Elective Surgery Without COVID-19 Testing Will Lead to Excess Morbidity and Mortality

June 2021: 63:5 Elective surgery Pages 193–228 without COVID-19 testing will lead to excess morbidity and mortality

IN THIS ISSUE Delay in diagnosis and management of adolescent ACL injuries in patients with lower socioeconomic status Impacts of the COVID-19 pandemic on the health and well-being of young adults Obesity as chronic disease Dr Jenn Tranmer: Proust questionnaire

bcmj.org June 2021 Volume 63 | No. 5 Pages 193–228

Emergency preparedness project in Kamloops. From left: Rhonda Eden, Graham Dodd, and Colin Swan. Article begins on page 220.

The BCMJ is published by Doctors of BC. The journal n provides peer-reviewed clinical and review articles 196 Editorials Re: On the nature of being a written primarily by BC physicians, for BC physicians, professional, Brian S. Pound, MBBS along with debate on medicine and medical politics in Rights and freedoms n editorials, letters, and essays; BC medical news; career David R. Richardson, MD Re: Managing vulnerable patients and CME listings; physician profiles; and regular columns. Roger Seldon, MBChB, MD Restrictions on private health n Print: The BCMJ is distributed monthly, Authors reply, Jennifer Laidlaw, MD, other than in January and August. insurance, Brian Day, MB Leanne Lange, MPA, Web: Each issue is available at www.bcmj.org. 198 Letters Erin Henthorne, MSW Subscribe to print: Email [email protected]. n Single issue: $8.00 Compliments to the artist Canada per year: $60.00 200 President’s Comment Foreign (surface mail): $75.00 Paul Thiessen, MD n Keeping you informed Subscribe to notifications: Value of family physicians To receive the table of contents by email, visit Robert H. Brown, MD during negotiations www.bcmj.org and click on “Free e-subscription.” n Re: Lost art of physical examination Matthew C. Chow, MD Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org Neil Finnie, MD n for submission requirements. Re: The gender pay gap in medicine Brenda Hardie, MD Rita McCracken, MD

Onc the over Editor Managing editor Proofreader Printing Elective surgery without COVID-19 David R. Richardson, MD Jay Draper Ruth Wilson Mitchell Press testing will lead to excess Editorial Board Associate editor Web and social media Advertising morbidity and mortality Jeevyn Chahal, MD Joanne Jablkowski coordinator Tara Lyon Assuming 37 000 planned surgeries David B. Chapman, MBChB Amy Haagsma 604 638-2815 are conducted per week in Canada Editorial and production Brian Day, MB [email protected] (excluding Quebec), and the prevalence coordinator Cover concept and Caitlin Dunne, MD of COVID-19 infection cases is 0.20%, the Tara Lyon art direction, Jerry Wong, ISSN: 0007-0556 David J. Esler, MD number of avoidable deaths that could Peaceful Warrior Arts Established 1959 Yvonne Sin, MD Copy editor occur is estimated to be 11.7 but could Cynthia Verchere, MD Tracey D. Hooper Design and production exceed 17.0. Article begins on page 208. Laura Redmond, Scout Creative

194 BC Medical Journal vol. 63 no. 5 | june 2021 ElECtivE surgEry without CoviD-19 tEsting 201 News WIll leAD TO exCeSS MOrbIDITy AnD MOrTAlITy n Book review: Dreamers, Skeptics, and Healers: The story of BC’s medical school We are not routinely testing patients for COVID-19 prior to surgery. n There are known morbidity and mortality dangers What is critical illness insurance? n to performing surgery on infected people. Grant to offset costs of recruiting into team-based care practices n Preventing symptom escalation among mild COVID-19 patients 204 BCMD2B 0.20% 77% Assumed active Risk of operating on at least Clicks, tweets, and likes case prevalence 1 person with COVID-19 Faizan Bhatia, MD, Arman for every 500 surgeries Mojtabavi, BSc, Azim Ahmed, BSc, As well as increased risk to patients, operating on COVID-19 patients risks transmission to hospital staff. Vishal Varshney, MD, Alana M. The authors recommend mandatory preoperative COVID-19 testing for planned operations. Flexman, MD TheA.A. authors Karimuddin, argue thatJ.M. Sutherland,patients should S.M. Wiseman be tested for COVID-19 prior to planned operations to prevent avoidable surgical 207 WorkSafeBC complicationsBCMJ 2021;63:208-210 and mortality. Article begins on page 208. Workers Compensation Act amended to include COVID-19 Michelle Vukelic 217 BCCDC 220 Shared Care CLINICAL Last in line: Impacts of the Emergency preparedness project COVID-19 pandemic on the health rises to the challenge with pandemic 208 Elective surgery without and well-being of young adults in response, Graham Dodd, MD COVID-19 testing will lead BC, Hasina Samji, PhD, Naomi 221 CME Calendar to excess morbidity and Dove, MD, Megan Ames, PhD, Meridith Sones, MPH, Bonnie mortality, Ahmer A. Karimuddin, Obituaries Leadbeater, PhD 222 MD, Jason M. Sutherland, PhD, Dr Robert Lachlan MacLeod Coupe Sam M. Wiseman, MD 218 College Library 223 Classifieds 211 Delay in diagnosis and Hidden gems on the bookshelves Karen MacDonell management of adolescent 226 Proust anterior cruciate ligament 219 Council on Health Promotion Dr Jen Tranmer injuries in patients with lower Obesity as chronic disease socioeconomic status Ilona Hale, MD, Priya Manjoo, MD Lise Leveille, MD, Tessa Ladner, BSc, Christopher Reilly, MD

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BC Medical Journal vol. 63 no. 5 | June 2021 195 Editorials

Rights and freedoms 4 May 2021

am writing this editorial as the provincial the powers that be made travel restrictions more receive increasingly suspicious glances thrown government just announced sweeping re- stringent with the threat of roadblocks and in my direction as the belief grows that maybe strictions preventing British Columbians fines. Tourism providers have been asked to I am part of “they.” Ifrom moving between three defined regions. cancel and refund customers who are from out- A quick evaluation of our elected officials Stuck between a rock and a hard place, the side their regions. All recreational vehicles have should be enough to doubt the government government made this difficult decision due to been banned on BC Ferries. conspiracy idea. In addition, if you have ever rising COVID-19 case numbers with hospi- As soon as these re- had to deal with any talizations and ICU admission levels reaching strictions were announced, government body, you’ll all-time pandemic highs. Despite pleas from angry comments began Despite pleas from recognize that the level our provincial health officer, people contin- to appear on social me- our provincial health of organization required ue to travel and are propagating viral spread dia about infringement of officer, people to form a secret agency through their actions, albeit often unknowingly. our basic rights and free- continue to travel seems an unobtainable Pandemic fatigue has led to the population doms. I even had some pa- goal. Furthermore, I am and are propagating craving some degree of normalcy and perhaps tients complain that this pretty sure Bill Gates has reducing their commitment to follow provin- was just another way that viral spread through enough money and access cial guidelines. “they” were trying to con- their actions, albeit without monitoring or re- Worried that this third viral wave has the trol us. These are often the often unknowingly. stricting the population’s potential to overwhelm our hospital resources, same individuals who are activities. against vaccines and mask Society already limits wearing. (I also suspect many of them have red many individual choices for the good of the MAGA hats hidden in their closets.) majority. For example, I’m not allowed to drive Secure cloud-based clinical I have often wondered who “they” are. I have drunk as a skunk without my seatbelt on at my even asked some of my patients, but I never chosen speed down the wrong side of the high- speech recognition seem to get a clear answer. As best as I can way with a baby smoking on my lap. tell, “they” is some secret level of government The current temporary travel restrictions are Dictate into your EMR from or a collection of sinister wealthy individuals no different and were created to buy time while almost anywhere (Bill Gates is often mentioned) who want to the vaccination process continues. track and control our movements. When I ask “They” are simply trying to save some Install within minutes across to what end would “they” want to restrict us, lives. n unlimited computers I do not get a definitive answer. I do, however, —David R. Richardson, MD One synchronized user profile Stunningly accurate with accents

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196 BC Medical Journal vol. 63 no. 5 | june 2021 Editorials

Restrictions on private health insurance

“ ithout a right of challenge through appearance remains vivid. The judge arrived accepted that harms and deaths were avoidable an independent body such as the in an escorted and chauffeured Rolls-Royce if doctors did their job properly. Government judiciary, our legislative and ex- limousine with a small Union Jack flag on the lawyers described desperate and suffering pa- ecutiveW bodies would be free to make arbitrary front. He wore impressive crimson and black tients accessing private clinics as “parasitic.” and discriminatory decisions respecting the robes. He and the barristers wore wigs and The world has seen changes since the lower health care benefits provided to Canadians with went through scenic and impressive court for- court hearings concluded, with the COVID-19 little or no consequence. Such a result would malities and rituals. All of pandemic being the most be contrary to the societal values upon which these experiences, togeth- impactful. Our already Canadian society is built.” Chief Justice Chris- er with our intervention We remain optimistic underperforming health topher Hinkson of the BC Supreme Court in the 2005 Chaoulli trial, that the higher system now faces even made this statement in November 2005. gave me some insight into courts will take some greater pressures. This month, Justice John Steeves’ 2020 BC our legal case. We will argue before Supreme Court decision supporting govern- Significant differenc- guidance from the the higher courts that ment restrictions on private health insurance es between Chaoulli and Chaoulli precedent. Canadian jurisdictions, and physicians’ dual practice will face a judi- our case included the which ban patient choice cial review by the BC Court of Appeal. This multiple patient plain- and exclude a safety valve, appeal will rely almost exclusively on the evi- tiffs and the fact that we had authenticated, violate human rights. Even government experts dence at trial, focusing on errors in law by the government-accepted, maximum wait times at trial gave evidence that Canada’s monopo- trial judge. Justice Steeves had, coincidentally, for thousands of procedures. Courts no longer listic system is unique, and that all countries received government-funded surgery at the had the burden of interpreting or defining what permit private sector participation. private False Creek Surgical Centre. was acceptable. Governments had done that for Chaoulli also lost at the lower-court level in Our legal challenge began in January 2009. them, and the trial judge acknowledged that, Quebec. We remain optimistic that the higher We had expected that government would want despite downplaying their relevance. courts will take some guidance from the Cha- a quick decision on whether its laws violated This data will, we hope and believe, prove to oulli precedent. In discussing the Chaoulli case, the Canadian Charter of Rights. However, be vitally important and pivotal in later hear- Canada’s most renowned constitutional scholar, the trial did not start until late 2016 and con- ings. For example, in 2017–2018, only 16% to the late professor Peter Hogg, QC, opined that sumed 194 court days going into a fourth year. 38% of patients needing treatment for serious no provincial government would risk arguing The 880-page written decision was unusually cancers of the bladder, ovary, prostate, lung, that their citizens deserved less freedom under lengthy. and colon were treated within the maximum the law than those living in Quebec. Like for many doctors, my courtroom expe- acceptable benchmark. Unfortunately, for the BC has proven him wrong. rience has mostly been as an expert in patient tens of thousands of BC patients waiting, suf- Hogg also wrote: “No one was watching the injury trials, but I had some previous informal fering, and sometimes dying on wait lists, the Chaoulli case as it bubbled on up, but people will legal education. In the early 1960s I enjoyed a government’s own self-incriminating data were be watching the second case very, very closely. I long-running and successful television show, largely ignored by the lower court. think in practical terms the ruling is extremely Boyd QC, and a decade later, Rumpole of the Government lawyers implied that private important even if not literally binding for the Bailey. More recently I watched Suits. Perhaps care was for the “wealthy and healthy,” despite rest of the country.” more impactful was my even earlier “hands-on” the fact that not one patient witness was either. I have no doubt he will be proven right on experience as a 5-year-old Crown witness (then The BC government did not call a single BC that. n one of the youngest in legal history) in a Liver- patient witness or a single BC physician as an —Brian Day, MB pool criminal trial. I gave evidence identifying expert. They focused on demonizing doctors for a thief I had witnessed stealing a watch (from not accurately “triaging” patients and foreseeing my own wrist). He was convicted and sentenced and forestalling any complications that wait- to jail time. My recollection of that courtroom ing patients might possibly suffer. The judge

BC Medical Journal vol. 63 no. 5 | June 2021 197 for the PMA and gender equity could be a value that is baked into the process. Imagine what we We welcome Letters to the editor might achieve if this were the case! original letters of less than 300 words; we may edit them for clarity I am excited that you have opened up this and length. Letters may be emailed to [email protected], submitted conversation in a meaningful way for Doctors online at bcmj.org/submit-letter, or sent through the post and must include of BC and all of us in the province. I look for- your mailing address, telephone number, and email address. Please disclose ward to reading more articles on what we are any competing interests. doing and how well we are making progress to reduce the gender pay gap. Thanks for taking this brave step, since we know you are likely to Compliments to the artist proceed to the OR, recognizing that it might experience significant backlash as a result of rarely end as an exploratory event. It’s now quite speaking out for gender equity. The April issue’s cover image is credited to Jerry —Brenda Hardie, MD kosher to listen to breath and heart sounds Wong (Peaceful Warrior Arts). I want to pay a North Vancouver compliment as this is truly one of the best and through clothing—it’s happened to me, by a most inspired covers I can recall. It truly illus- fine young physician. The world moves on, but I appreciate Dr Sin’s call to action in her April trates the story on ectopic pregnancy. I hope it practising the fine points of physical diagnosis editorial [BCMJ 2021;63:101]: “Ultimately, the is entered into some contest, as it’s a real winner! need not be a dying art. —Paul Thiessen, MD, FRCPC —Neil Finnie, MD question we should each be asking ourselves is Vancouver Victoria not whether a gender pay gap exists in medicine, but what can I do to help close it?” And I urge Re: The gender pay gap in Value of family physicians our professional representative body (Doctors medicine of BC) and our main payer (BC Ministry of Yesterday we were in need of a professional gas Thank you, Dr Sin, for your April editorial Health) to (1) engage experts to do a review of fitter to make a house call to fix a problem with on this important topic [BCMJ 2021;63:101]. processes and structures that are maintaining a gas line in our home. It was a simple problem Studies show that women also have increased the gender pay gap, despite intentions to have for him, requiring about 10 minutes. His fee rates of burnout compared with male colleagues. it change, and (2) start to publicly report what was $156 plus tax for a basic house call. I con- The pandemic has had an extra toll on women, this examination finds. trast that with a basic house call that I make —Rita K. McCracken, MD, PhD, CCFP (COE), FCFP making all of this much worse. as a physician. The last time I looked, the fee Vancouver You point out that there are some clear rec- was about $110. I am thankful that none of my ommendations that have been made to work five children have chosen family medicine as a to close this gap. We know this is a complex R e: On the nature of being a career. They are all in technical trades or engi- issue that will take many nuanced chang- professional neering. It is interesting that I am to conclude es, but a few broad strokes can happen now. that the services of a gas fitter are about 50% Bravo, Dr Chow! I’m retired from practice now Encouraging men to take parental leave is a more valuable to society than the services of a after 50 years as a GP/FP and found your ar- wonderfully achievable place to start, and is family physician based on the fees paid to these ticle in the April issue to be a breath of fresh air evidence-informed. Maybe we will see Doctors two respective professions. [BCMJ 2021;63:105]. The profession is facing —Robert H. Brown, MD, CCFP of BC promote this more widely. Doctors of decreasing numbers of physicians. Physician North Saanich BC could also be targeting and measuring its burnout has become a byword. Physicians are success in having women in leadership roles, losing the esteem from their patients, while R e: Lost art of physical and being transparent about what percentage other health care professionals are enjoying examination of stipends goes to men versus women might increasing popularity from their patients and be an enlightening project. The kind of encour- clients. To be a physician was once to also be I really appreciated Dr Walton’s germane reflec- agement needed for women to be in the places a trusted member of a patient’s and their fam- tion on the role the physical examination seems where decisions are made is often structural. ily members’ special circle, trusted as a car- to play in patient assessment these days [BCMJ This is not phoning, emailing, and telling them ing friend, but alas, the pressures of practice, 2021;63:102]. I’m one of those Neanderthal they would be great and should apply—not that bureaucracy, paperwork, and rules of conduct retired family docs who practised before CT kind of encouragement. We are talking about have disenfranchised us from the art of med- scans, MRIs, and other magical technologies. changing how we recruit, support, and retain icine, often creating a seemingly adversarial An acute appendix was first on a differen- women in leadership by making gender equity relationship with those we care for. Your phi- tial diagnosis as the result of history and spe- a priority through tangible goals, metrics, and losophy of medical practice illustrates a means cific physical examination. It was okay to then system improvements. This is negotiation time to bring back the very real joy of being that

198 BC Medical Journal vol. 63 no. 5 | june 2021 letters caring professional friend to those we care for. Authors reply Thought must also be given to how using Thank you for the wise encouragement. Regarding use of the Adult Guardianship Act a support and assistance plan can modify the —Brian S. Pound, MBBS, LRCP, MRCS, LMCC identified risks of using substances, recognizing Victoria (AGA) for individuals with chronic substance use, it should be clarified that the Act allows that we cannot typically force individuals to abstain from substances alone. Exceptions to this R e: Managing vulnerable patients involuntary admission in hospital to investigate whether a person meets full criteria for Section do occur, rarely, for individuals with significant I was interested to read the April 2021 article, 59. Section 59 allows ongoing hospitalization vulnerabilities; for example, a neurocognitive “Management of vulnerable adult patients seek- until a support and assistance plan can be put disorder rendering them at risk of regular and ing to leave hospital: Understanding and using in place to try to mitigate the risks of, in your significant substance abuse causing self-neglect. relevant legislation,” having had just such a co- example, self-neglect. The first criterion of the However, these cases typically exist after less nundrum during my shift the previous evening. AGA is that the adult is unable to seek sup- intrusive measures have failed and are likely to Unfortunately, the article did not specifically ad- port and assistance when needed.1 Such assess- involve a court-ordered support and assistance dress a certain common situation. Any insights ments are conducted by a designated responder, plan that restricts an individual’s access to sub- from the authors would be much appreciated. typically a social worker, once an individual is stances due to residing in a care facility. no longer intoxicated. Assessments for AGA Regarding the issue of “alcohol-induced Incapacity due to addiction eligibility will often incorporate information incapacity,” it is important to answer the ques- By my reading of the article, my patient (whose or assessments from other disciplines, such as tion, capacity for what kind of decision? It is parents were strongly advocating be involun- occupational therapy, psychiatry, or geriatric certainly reasonable to question an individual’s tarily admitted due to severe and progressive medicine to assess for factors that increase vul- capacity to make decisions about how they live self-neglect as a result of alcoholism) fulfills nerability while not intoxicated, such as neu- their life when they are living at significant risk. the criteria to allow treatment under the Adult rocognitive disorders. For many individuals For example, does the patient have capacity to Guardianship Act (AGA) (1. self-neglect, 2. without baseline cognitive impairment, the pa- make decisions about being homeless, or using risks, already experienced—e.g., loss of li- tient will demonstrate an ability to seek support substances? However, housing or substance cence to drunk driving, assault charges etc., and assistance when not under the influence of use are not medical treatments and, therefore, and 3. incapacity due to chronic unremitting substances, rendering them ineligible for Sec- don’t fall under the Health Care (Consent) and intoxication). tion 59. However, if a patient shows that they Care Facility (Admission) Act. Therefore, say- It is not regular practice to force treatment are unable to seek support and assistance even ing that an individual is incapable of making due to addictions. This patient was kept under once they are no longer intoxicated, for example decisions regarding substance use or housing the Health Care (Consent) and Care Facility because of a neurocognitive disorder secondary does not permit us to take any action in the (Admission) Act until sober enough to ambulate to alcohol use, they may meet the criteria for way of appointing a substitute decision maker safely and have a discussion regarding his situ- Section 59 if the other criteria are also satisfied, as we would for medical treatment. Further- ation, at which point he could voluntarily con- as outlined in Figure 1 of our article.2 more, even if someone fails to see the negative foreseeable consequences of their substance use, tinue treatment or leave against medical advice. Continued on page 201 Is this sober window (reportedly the only such window in a very long time) enough to allow the patient to voluntarily proceed back into his state of chronic alcohol-induced incapacity (not withstanding that the illness of addiction renders the patient incapable of avoiding further intoxication)? If it is not, should we be using the AGA routinely in cases of addicted vulnerable adults? Also, the fictional case of Ms Safe was a useful illustration. I imagine the statement that she’d “be fine” was explored in more detail. What if she’d meant: (1) I’ll be fine because I wish to die from this illness, or (2) I understand the risks you’re telling me but I’ll be fine with the natural medicines I’m using, or my faith that God will heal me? —Roger Seldon, MBChB, MD Campbell River

BC Medical Journal vol. 63 no. 5 | June 2021 199 president’s comment

Keeping you informed during negotiations

s I write this at the end of April, the steps in preparing for and conducting the Negotiations Update, which will include as our province is facing a surge of PMA negotiations. much information as we are able to disclose COVID-19 cases. My neighborhood We have reached out to members in nu- and that will be updated regularly. hasA been designated a high-transmission com- merous ways to determine your key priorities. Phases two and three of negotiations will munity, and I have been encouraging, cajoling, These have included our negotiations survey, come into play if phase one is not successful. and even pleading with all my neighbors to get meetings with the sections and other physician We would move into mediation and potential- vaccinated. Perhaps shouting, “Get your shot!” groups, Zoom webinars, ly into conciliation, which out my car window to pedestrians was a bit and a Representative As- ends with the release of a much, but perhaps not. While I cannot claim sembly workshop. We will be more report from a neutral con- any prescient ability, what I do know is that Among a number of proactive about ciliator. This is where we doctors—wherever you are and whatever you priorities important to communicating with take the public foundation do—will have given your very best and fought you, which will be brought members during the we have built and increase hard for your patients. I, and every person in to the table, are two spe- it, along with a number of this province, thank you for this. cific ones that were shared negotiations process. other possible measures. And now turning to something different: by a large majority of We have not had to do negotiations. The 2019–2022 Physician Mas- members: addressing the this in recent times, but it ter Agreement between Doctors of BC and continually increasing cost of running a prac- will come as no surprise to you that we expect a the government will end on 31 March 2022. tice and the funding and provision of virtual challenging negotiation given the general state Formal negotiations for our next agreement services on a permanent basis. These, among of society as it emerges from the pandemic. begin in June. others, will be considered by the Board as its Bottom line, we want our communications In the past, members have said they want to sets the mandate for the PMA negotiations. to you to demonstrate that you are being heard, be better informed as we go through the pro- While we are in negotiations, public opinion that we understand your concerns, and that the cess, which we will do to the best of our ability. is important because it will affect government negotiations team is doing its best to take your n Doctors of BC and the government have agreed priorities. We will continue to promote the requests into account. not to speak publicly about our bargaining posi- value doctors bring to the health care system, —Matthew C. Chow, MD tions, the status of negotiations, and how talks their patients, and communities, and the effects Doctors of BC President are going. This is not unusual—bargaining that of a shortage of doctors in several critical areas. takes place in the public domain often signals During this pandemic year, we are able to talk a serious problem. Still, we know you want to about how doctors showed leadership provin- understand what is going on and how it will cially and in their communities, how quickly affect you. doctors were able pivot to virtual care, and the To this end, we will be more proactive about invaluable contribution of doctors to main- communicating with members during the ne- taining capacity within the health care system. gotiations process, within the limits of bargain- Our negotiations communications to mem- ing rules. This will be a multiphased approach. bers will mostly be via the In Circulation elec- We are currently in phase one, our lead-up tronic newsletter. For those who have not yet to and moving through formal negotiations. signed up for it, I encourage you to do so at Our goal during this stage, which could last www.doctorsofbc.ca/account/subscriptions (log up to a year, is to keep members informed of in required). There is now a special section titled

200 BC Medical Journal vol. 63 no. 5 | june 2021 letters

Continued from page 199 which suggests incapacity, existing legislation We welcome news items of less than 300 words; we may does not address forcing individuals to abstain News edit them for clarity and length. News items should be emailed to journal@ from substances alone if they are incapable of doctorsofbc.ca and must include your mailing address, telephone number, and making a decision to use them. Instead, it is best to focus on whether an individual meets email address. All writers should disclose any competing interests. criteria for the AGA, or in some cases, the Mental Health Act. Regarding the case of Ms Safe, she had communicated that she thought her health I arrived in Vancouver in 1947 as an would remain unchanged or stable without IV 18-year-old immigrant, full of hope that I antibiotics. Therefore, Ms Safe failed to ap- might be able to enter medical school here. I preciate the foreseeable negative consequences learned with considerable anxiety that there and risk of death if she refused treatment, was no medical school in BC, and that the rendering her incapable of making a deci- likelihood of one opening soon was not very sion to decline medical treatment. In reply good. Only 4 years later, I was in UBC Medi- to another of your examples, such as if the cine’s second graduating class of 60 students, patient said she wished to die from her illness, when the school was still located in former that suggests she understands the foreseeable army barracks. Skeptics were abundant from consequences of declining treatment, which is before the school opened and throughout its one of several important criteria of capacity. early years; it was the dedicated deans, scien- In our experience, that kind of response could tists, and healing practitioners who brought signal a potential desire for hastened death, the dreams to reality. which would trigger a psychiatric consult to This very handsome, easy-to-read book rule out an underlying mood disorder. For the includes wonderful pictures of many of the other examples, capable patients may have doctors, healers, scientists, and administra- spiritual beliefs or preferences for nonconven- tors who made the school what it is today. tional treatments. The test of capacity would The book is divided into seven parts. It starts be whether the patient understands the nature Book review: Dreamers, with Dr John Sebastian Helmke’s ideas for and anticipated effects of the proposed investi- Skeptics, and Healers: The a health service, for a then fledgling popula- gation or treatment and available alternatives, tion, in the 1870s. And it ends with a proud 3,4 story of BC’s medical school including the consequences of refusing. celebration of the research and innovation that —Jennifer Laidlaw, MD, FRCPC By Wendy Cairns; John Cairns, MD; Da- has taken place over the past 70 years, with —Leanne Lange, MPA vid Ostrow, MD; Gavin Stuart, MD. Van- ideas for the future. —Erin Henthorne, MSW, RSW couver: Page Two Books, 2021. ISBN In between are accounts of how the school 978-1-989603-89-5. Hardcover, 224 pages. took off after years of arguments and disap- R eferences The mastermind behind this history of pointments, the unavoidable growing pains, 1. Province of British Columbia. Adult guardianship UBC Medical School was UBC graduate act. Victoria, BC; 2020. Accessed 25 August 2020. and how it came into a respected early ma- www.bclaws.ca/civix/document/id/complete/ Wendy Elizabeth Cairns. After her premature turity, with some unexpected turnarounds, to statreg/96006_01. death in 2018, her husband and former dean become a world famous medical school (the 2. Laidlaw J, Lange, L, Henthorne, E. Management of of the medical school, Dr John Cairns, along Faculty of Medicine is now home to more vulnerable adult patients seeking to leave hospital: with Dr David Ostrow and Dr Gavin Stuart, Understanding and using relevant legislation. BCMJ than 4500 undergraduate, graduate, and post- 2021;63:106 -111. took up the pen to expand on and complete graduate students), with students learning the 3. Canadian Medical Protective Association. Is the process of turning Wendy’s rich research art and science of medicine in almost every this patient capable of consenting? 2021. Ac- materials into this book. The title, Dreamers, district of BC. cessed 11 May 2021. www.cmpa-acpm.ca/en/ Skeptics, and Healers, accurately reflects the advice-publications/browse-articles/2011/ I had the feeling of reliving my student is-this-patient-capable-of-consenting. history of a medical school that admitted days as I read the sections on how Dr Kerr 4. Canadian Medical Protective Association. Aid to its first class in 1950 after years of contro- and Dr Walters conducted our oral exams at capacity evaluation. 1996. Accessed 11 May 2021. versy and is now counted among the largest the bedside, how Dr Friedman, the head and www.cmpa-acpm.ca/static-assets/pdf/education- and most respected medical schools in North and-events/resident-symposium/aid_to_capacity_ professor of anatomy drew his diagrams on evaluation-e.pdf. America. the blackboard with two hands at the same

BC Medical Journal vol. 63 no. 5 | June 2021 201 news time, or how Dr John William Boyd, head and up with a plan for increasing the number of insurers, should you want additional features professor of pathology, entertained us with his medical students and a plan for a campus hos- beyond what the group plan offers, such as pre- witty lectures. pital or lose out on an unclaimed federal fund mium refund upon cancellation. Each dean’s vision and legacy for the school that was about to be closed. Student numbers Critical illness insurance provides protection over 70 years is sensitively explained. Some have were increased. against expenses that can come with a serious come to life; some have not. For example, Dr The book will rekindle memories for some illness, and it can give you peace of mind that, McCreary’s vision for an “if they learn togeth- and bring an understanding to nonmedical if you are diagnosed with one of the covered er, they will work together” teaching program readers of the extreme complexity of gathering conditions, you will not derail your retirement for all health professionals, for the purpose of and maintaining the enthusiasm of dedicated savings plan or be faced with increasing debt strengthening integrated patient care by health practitioners, scientists, students, and other to assist with recovering. Proof of good health sciences teams, is still not a reality. health-related professionals with the goal of is required at time of application to determine Each section also introduces the leading understanding nature and serving mankind. eligibility. Doctors of BC advisors are avail- figures in the various basic science and clinical —George Szasz, CM, MD able to discuss coverage options that best suit faculties. The pictures of Dr Copp of physi- your needs. ology, Dr Williams of dermatology, Dr Bry- What is critical illness —Hali Stus ans of obstetrics and gynecology, Dr Slade of insurance? Insurance Advisor, Members’ Products family practice, and many others will evoke and Services warm memories in former students. And, of As one of the licensed, noncommissioned course, there is the politics. I was at the tense insurance advisors with Doctors of BC, I Grant to offset costs of locked-door meeting described in the book with meet with physicians every day to talk about recruiting into team-based Dr Pat McGeer, a graduate of the school, ac- member-exclusive insurance offerings. Critical care practices complished neuroscientist, UBC faculty mem- illness insurance is now part of every discus- ber, and BC’s Minister of Education at the time. sion, though it is less understood than life or A new team-based care grant provides $15 000 He issued an ultimatum to the university: come disability insurance. to eligible family practices that have onboarded Critical illness insurance was introduced interprofessional team (IPT) members. The to the insurance industry on 6 October 1983. grant will help to address the costs of recruit- The founder, South African cardiac surgeon, Dr ing and onboarding into a practice, and it is just Marius Barnard, identified a gap in the insur- one of the resources provided by the GPSC to ance industry through the care of his patients. help break down barriers and provide supports British Columbia Since then, critical illness insurance has been for practices to implement team-based care. Medical Journal @BCMedicalJournal accepted into insurance markets around the world. These policies provide the insured with How does it work? British Columbia Medical Journal a tax-free, one-time predetermined lump-sum The grant provides a lump sum payment of @BCMedicalJournal payment in the event you are diagnosed with $15 000 for each FTE of net new eligible IPT Systemic racism and medicine: A commentary one of the 25 illnesses covered under the policy. positions filled by the family practice applying A reflection on historical mistakes that we must You may wonder how this is different from for the grant. An eligible IPT position may be recognize and learn from to catalyze positive change. disability insurance. While disability insurance filled by a staff member employed by the fam- Read the Premise: bcmj.org/premise/systemic-racism is designed to replace your income, critical ill- ily practice or another organization, such as a -and-medicine-commentary ness insurance is designed to help with costs so health authority. Eligible family practices may you can focus on your health. These costs may apply for the grant for net new eligible IPT include medical treatment not covered by MSP positions filled on or after 1 April 2019. An end or your extended health benefits policy, in-home date has not yet been established for this grant. care, modifications to your home, equipment to assist with mobility, or replacement of income What are the requirements? from a spouse who is caring for you. If you are A minimum of 0.5 FTE of IPT position is fortunate to have a speedy recovery, you can use required to apply for this grant. To claim this the money to pay down debt or top up savings. grant, a group of family doctors must submit Doctors of BC offers a group term plan an online application form together after an that is available to members, their spouses, and IPT position has been filled. Doctors and clinic dependent children. In addition, our insurance owners may agree on how the funding is dis- Follow us on Facebook for regular updates advisors can offer policies from major Canadian tributed among the parties.

202 BC Medical Journal vol. 63 no. 5 | june 2021 news

What does it cover? These are some examples of what family doctors can do with the grant: • Cover the cost of setting up and upgrading EMR software and licensing and office hardware to enable interprofessional care. • Compensate physicians or clinic staff for time spent: • Reviewing and implementing changes to office capacity to accommodate new IPT members. • Recruiting, interviewing, hiring, and onboarding new IPT members. • Reviewing medicolegal requirements relevant for particular IPT members.

Are you eligible? To be eligible, family doctors of the group practice applying for the grant must: • Work within a group practice consisting of two or more physicians that has added an eligible IPT member to the group practice. The physicians working together in a group practice may or may not be co-located and may have an arrangement to jointly fund Preventing symptom escalation among mild an IPT position. COVID-19 patients • Meet the definition of a community longi- With several treatments available to care for the most urgent and severe cases of COVID-19, tudinal family physician as per the GPSC researchers are now investigating whether a common anti-inflammatory drug, ciclesonide, preamble. could help speed recovery in mild cases and put a stop to disease progression and potential • Have completed phase two of the GPSC hospitalization. When inhaled, the medication is directed to the nose and airways, the phases of panel management. areas of the body most affected by the COVID-19 virus. While the long-term effects of • Commit to participating in quality im- the virus are not fully understood, studies have found that any level of disease severity can provement activities related to team-based result in persistent physical and psychological symptoms. Ciclesonide has been shown to care such as services offered through the prevent viral activity against SARS-CoV-2 in some lab-based studies, and researchers GPSC Practice Support Program, in- hypothesize that giving it to patients early in the course of the disease could prevent the cluding team-based care coaches. Quality virus from replicating further and causing an increased inflammatory response. improvement activities should be aligned Ciclesonide was approved by the US Food and Drug Administration in January 2008 with the National Interprofessional Com- for use in humans to treat asthma, rhinitis, and other nasal and airway conditions. The petencies Framework. CONTAIN study team selected ciclesonide as a possible treatment option because of its • o Agree t work collaboratively with the low rate of side effects and drug interactions, as well as evidence linking this particular Ministry of Health, the primary care net- steroid with antiviral effects. work (if applicable), and other partners to- Dr Sara Belga, a clinical assistant professor in the Division of Infectious Diseases at ward implementing the attributes of the the University of British Columbia, is the principal investigator in the province of the patient medical home and primary care CONTAIN study, headed by Dr Nicole Ezer from the McGill University Centre for network. Health Outcomes Research. The study is recruiting individuals living in Quebec, Ontario, For more information, visit https://gpscbc or British Columbia. Adults 18 years and older can qualify to participate if they apply via .ca/news/news/grant-announced-gpsc-offset the CONTAIN study’s online portal within 5 days of being diagnosed with COVID-19. -costs-of-recruiting-team-based-care-practices. Eligible participants must also be recovering at home with a mild fever, shortness of breath, and/or symptomatic cough. Visit www.contain-covid19.com for more information about the study and how to participate.

BC Medical Journal vol. 63 no. 5 | June 2021 203 BCMD2

Clicks, tweets, and likes

Social media use by medical journals.

Faizan Bhatia, MD, Arman Mojtabavi, BSc, Azim Ahmed, BSc, Vishal Varshney, MD, FRCPC, Alana M. Flexman, MD, FRCPC

ABSTRACT: Medical literature is expanding at an level of engagement with Twitter (100%), YouTube Methods astonishing rate and physicians are increasingly (94.3%), Facebook (64.5%), and Instagram (62.5%). This analysis did not require ethics approval as using social media professionally. Currently, we lack General (versus specialty) medical journals had all information was publicly available. The rank- a comprehensive understanding about the use of higher H-indices and a larger numbers of followers ing of medical journals was obtained through social media by medical journals. We included the on Twitter and Facebook. Higher-impact journals SCImago Journal and Country Rank database top 100 medical journals by H-index, and analyzed were more likely to have social media accounts, (www.scimagojr.com). We selected the most 88 journals after excluding nonmedical journals. although this finding was not observed when con- recent ranking (2019) of the top 100 journals We described the use of social media platforms trolling for journal type. The use of social media to by H-index. We excluded journals that were not and followers stratified by H-index and journal facilitate education and knowledge dissemina- primarily focused on clinical medicine. type (general versus specialty). We found a high tion is increasingly common and requires further We classified journals as having either a research to determine the effectiveness. specialty or general medical focus by consensus Dr Bhatia was a fourth-year medical student and noted the most recent H-index and im- in the Vancouver Fraser Medical Program Background pact factors available. We collected information at the University of British Columbia when Social media activity has been associated with on social media engagement across four social he submitted this article for publication increased visibility of published articles, in- media platforms: Twitter, Facebook, Instagram, 1,2 consideration. He graduated from UBC cluding downloads and citations. As a result and YouTube. To optimize fast and accurate Medicine in May 2021. He is also a co- of the perceived benefits to and engagement data collection, we developed a program to founder of the UBC medical student podcast with readers, medical journals are increasingly web-scrape data using Selenium Webdriver MEDamorphosis (https://medamorphosis- using social media such as Twitter, Facebook, 3.141.0 on Python. All data from Instagram podcast.simplecast.com). Mr Mojtabavi is a Instagram, and YouTube to share content. Many and Facebook were gathered on 16 February recent graduate with an integrated science physicians are also engaging with journals in 2020, while all Twitter and YouTube data were degree in physiology, psychology, and this context and increasingly using social me- gathered on 2 March 2020. For each account, 3,4 pharmacology from the University of British dia as an avenue for CME. Despite an in- when available, we noted followers, likes, and Columbia and is a co-founder and director of crease in activity over the past decade, little is number of posts. the not-for-profit Campus Nutrition (https:// known about the frequency of social media Data were described using percentage and campusnutrition.ca). Mr Ahmed is a recent use by medical journals, including engagement median (interquartile range [IQR]). Normal graduate with an integrated science degree with specific social media platforms, number of distribution of continuous variables was de- in pathophysiology and kinesiology from the followers, and the relationship between these termined using the Shapiro-Wilk test for nor- University of British Columbia. Dr Varshney activities and objective measures of journal im- mality. Specialty and general medical journals (@VarshneyMD) is a staff anesthesiologist pact such as the H-index. The journal H-index were compared using a Wilcoxon rank sum and and pain medicine physician at St. Paul’s is defined as the number of articles (H) that Fisher’s exact test for continuous and categorical Hospital and Providence Health Care, and a have received at least H citations and, there- data, respectively. Multivariable linear regression clinical instructor at the University of British fore, combines an assessment of both quantity was used to explore the relationship between Columbia. Dr Flexman (@alanaflex) is a staff (number of papers) and quality (impact). H-index and the social media activity. P values anesthesiologist and research director at St. Our primary study objective was to describe less than .05 were considered significant. Statis- Paul’s Hospital and Providence Health Care, a the use of various social media platforms by tical analysis was completed in R version 3.6.3 clinical associate professor at the University high-impact medical journals. Our second- and STATA 12.1 (StataCorp, Texas, USA). of British Columbia, and an associate editor ary objectives were to analyze the relationship at the Canadian Journal of Anesthesia. between social media engagement and journal Results type (specialty versus general), the impact factor, We identified the top 100 journals by H-index This article has been peer reviewed. and the H-index. and excluded 12 journals that were found to not

204 BC Medical Journal vol. 63 no. 5 | june 2021 Q1 Q2 Q3 Q4

1.0

0.8

0.6

0.4 Frequency 0.2

0.0 Twitter Instagram Facebook BYouTubeCMD2 Social media platforms be primarily medical after further review, leav- Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 ing 88 journals for the analysis. Missing data were minimal and included only the YouTube 1.0 1.0 channel subscribers and views from three jour- 0.8 0.8 nals. We classified 84% (n = 74) of journals as 0.6 0.6 specialty and 16% (n = 14) as general. Charac- 0.4 0.4 Frequency teristics of included medical journals are sum- Frequency marized in Table 1. Included journals (n = 88) 0.2 0.2 had a median H-index of 278 (IQR 245, 332) 0.0 0.0 Twitter Instagram Facebook YouTube Twitter Instagram Facebook YouTube and a median journal impact factor of 9.6 (IQR Social media platforms Social media platforms 6.1, 19.1). All journals had associated Twitter accounts, while 94.3%, 64.8%, and 62.5%, of Figure 1. Frequency of social media platforms used Figure 2: Frequency of social media platforms used journals had associated YouTube, Facebook, by medical journals, stratified byH -index quartiles. by medical journals, stratified by impact factor quartiles. Q1 Q2 Q3 Q4 and Instagram accounts, respectively. Follow- ers were the highest on Facebook, followed 1.0 by Twitter, Instagram, and YouTube. General Table0.8 1: Characteristics of included medical journals. medical journals had higher H-indices and 0.6 Overall Specialty General impact factors than specialty journals. Both P value 0.4 (N = 88) (N = 74) (N = 14) types of journals used social media platforms Frequency at similar frequency, although general medical H-index0.2 278 (245, 332) 270 (238, 326) 353 (289, 497) 0.0016 journals had more Twitter and Facebook fol- Impact0.0 factor 9.6 (6.1, 19.1) 9.0 (6.1, 16.6) 22.5 (7.8, 51.3) 0.0277 Twitter Instagram Facebook YouTube lowers, and specialty journals had more Insta- Twitter (N, %) Social media platforms88 (100) 74 (100) 14 (100) — gram followers. Figure 1 and Figure 2 display a general increase in the frequency of available Twitter followers 10 776 (3529, 29 689) 9006 (3212, 25 898) 82 956 (12 486, 331 681) 0.0054 social media accounts for medical journals from Total tweets 3900 (2023, 7819) 3650 (1744, 7198) 12 134 (3531, 20 624) 0.0188 the lowest to highest H-index and impact factor quartile. From left to right, the bars under YouTube (N, %) 83 (94.3) 69 (93.2) 14 (100) 0.411 each category in Figure 1 signify quartile 1 to YouTube subscribers 3705 (549, 12 000) 2950 (527, 11 600) 6845 (1960, 20 500) 0.1506 4: Q1 (< 244.5), Q2 (244.5 < < 278), Q3 (278 YouTube videos 265 (77, 527) 265 (74, 527) 316 (88, 516) 0.8593 < < 332), Q4 (> 332), while those in Figure 2 signify quartile 1 to 4: Q1 (< 6.08), Q2 (6.08 Facebook (N, %) 57 (64.8) 46 (62.2) 11 (78.6) 0.193 < < 9.5765), Q3 (9.5765 < < 19.1305), Q4 (> Facebook followers 27 858 (8359, 99 880) 24 260 (4480, 74 045) 99 880 (46 489, 498 408) 0.0223 19.1305). Presence of an Instagram account predicted H-index (coefficient 56.8, 95% CI 9.5 Facebook likes 26 853 (8012, 98 452) 23 500 (4402, 71 431) 98 452 (45 753, 492 594) 0.0223 to 104.1, P = 0.019) but not Facebook (coef- Instagram (N, %) 55 (62.5) 44 (59.5) 11 (78.6) 0.146 ficient 39.9, 95% CI -8.89 to 88.6, P = 0.108) Instagram followers 5893 (1695, 87 979) 8483 (2478, 87 980) 2021 (162, 13 796) 0.0626 or YouTube (coefficient 60.1, 95% CI -41.2 to 161.5, P = 0.241). When controlling for journal Instagram posts 276 (110, 771) 343 (158, 753) 114 (18, 925) 0.1779 type, the presence of social media accounts did All values are median (interquartile range) unless otherwise indicated. not predict H-index [Table 2]. Since all journals had associated Twitter accounts, the presence of this account was not included in the model. Tabl. e 2 Linear regression model to predict journal H-index.

Discussion Ct oefficien 95% CI P value Our analysis provides a contemporary snap- Facebook 20.9 -24.0 to 65.7 0.358 shot and formal analysis of social media use by high-impact medical journals in 2020. We Instagram 36.6 -7.8 to 81.0 0.105 found that all journals included in our study YouTube 33.3 -57.7 to 124.2 0.469 used some form of social media, with universal use of Twitter and frequent use of You- General (vs specialty) 127.6 69.8 to 185.4 < 0.001 Tube. Facebook and Instagram were used by R2 = 0.2613 p < 0.001

BC Medical Journal vol. 63 no. 5 | June 2021 205 BCMD2

media coverage of scientific articles immediately after a majority of journals but less frequently than social media platforms may drive traffic toward 14 publication predicts subsequent citations - #SoME_Im- other platforms. General medical journals had CME initiatives, and that social media cov- pact Score: Observational analysis. J Med Internet Res 2,15 higher H-indices, impact factors, followers, and erage predicts citations of articles, although 2020;22:e12288-e12288. higher engagement with social media compared greater social media attention may simply reflect 3. Wray CM, Auerbach AD, Arora VM. The adoption of an to specialty journals. Of the four platforms an- higher-quality articles that are more likely to be online journal club to improve research dissemination and social media engagement among hospitalists. J alyzed, journals had the greatest number of cited. Two randomized trials have found that Hosp Med 2018;13:764-769. interactions on Facebook (such as followers tweeting articles increased Altmetric scores 4. Ghanem O, Logghe HJ, Tran BV, et al. Closed Facebook™ and likes). Our data offer a unique perspec- and citations over time compared to those that groups and CME credit: A new format for continuing tive that quantifies the use of social media by were not shared on Twitter.16,17 In contrast, an- medical education. Surg Endosc 2019;33:587-591. 5. El Bialy S, Jalali A. Go where the students are: A com- high-impact medical journals, and describes a other randomized study did not find that social parison of the use of social networking sites between high level of engagement, particularly by general media exposure increased article citations or medical students and medical educators. JMIR Med medical journals. downloads.18 A recent systematic review found Educ 2015;1:e7. The use of social media in medical publish- “suggestive yet inconclusive” evidence that the 6. Guraya SY. The usage of social networking sites by medical students for educational purposes: A meta-analysis ing to disseminate research and information use of social media increases article citations, and systematic review. N Am J Med Sci 2016;8:268-278. has evolved relatively rapidly over the last de- with notable limitations and inconsistent find- 7. Lopez M, Chan TM, Thoma B, et al. The social media cade. Social media itself has been introduced ings in the literature.1 editor at medical journals: Responsibilities, goals, bar- relatively recently (Facebook was founded in Our analysis has several limitations. Al- riers, and facilitators. Acad Med 2019;94:701-707. 8. Siau K, Lui R, Mahmood S. The role of a social media 2004, YouTube in 2005, Twitter in 2006, and though we described the use of social media and editor: What to expect and tips for success. United Eu- Instagram in 2010). The adoption of social me- the relationship with journal impact (H-index), ropean Gastroenterol J 2020;8:1253-1257. dia is uneven, and its use varies among different we cannot establish a causative effect of social 9. Oska S, Lerma E, Topf J. A picture is worth a thousand generations of medical professionals.5 Uptake media engagement on the journal’s performance views: A triple crossover trial of visual abstracts to ex- amine their impact on research dissemination. J Med is high among medical students; as many as or research. Furthermore, our results represent Internet Res 2020;22:e22327. 90% of medical students are active on social a snapshot in time that will continue to evolve, 10. Thamman R, Gulati M, Narang A, et al. Twitter-based 6 networking sites. Many journals now formal- and further research to establish trends over learning for continuing medical education? Eur Heart ly appoint a social media editor, a role which time would be valuable. Finally, we included J 2020;41:4376-4379. encompasses a range of responsibilities from only the top 100 medical journals by H-index; 11. Topf JM, Sparks MA, Phelan PJ, et al. The evolution of the journal club: From Osler to Twitter. Am J Kidney disseminating new publications via social me- the use of social media by lower-impact jour- Dis 2017;69:827-836. dia, summarizing articles, and managing social nals may vary. 12. Tunnecliff J, Weiner J, Gaida JE, et al. Translating evi- media accounts.7,8 Sharing visual abstracts (vi- Our study findings clarify the current state dence to practice in the health professions: A random- sual summaries of an article’s content) on social of social media use by high-impact medical ized trial of Twitter vs Facebook. J Am Med Inform Assoc 2017;24:403-408. media is increasing and may improve an article’s journals and indicate these journals are highly 13. Chan WS, Leung AY. Facebook as a novel tool for visibility and engagement compared to sharing engaged with these platforms. General medi- continuous professional education on dementia: Pi- citations only.9 Twitter is increasingly embraced cal journals have a greater impact and reach on lot randomized controlled trial. J Med Internet Res as a CME tool, encompassing activities such social media compared to specialty journals, as 2020;22:e16772. 14. Flynn S, Hebert P, Korenstein D, et al. Leveraging social as online journal clubs and virtual networking. measured by followers and subscribers. The use media to promote evidence-based continuing medi- These formats offer several advantages such as of social media to facilitate medical education cal education. PLoS One 2017;12:e0168962. lower cost, accessibility, and innovative methods and knowledge dissemination is increasingly 15. Chau M, Ramedani S, King T, Aziz F. Presence of social of engagement.3,10,11 An open label randomized common and future research should address media mentions for vascular surgery publications is associated with an increased number of literature ci- trial found that CME practice tips provided questions about whether social media can in- tations. J Vasc Surg 2021;731096-1103. by Twitter and Facebook can improve clinical crease article citation, improve CME, and ef- 16. Luc JGY, Archer MA, Arora RC, et al. Does tweeting 12 n knowledge and promote behavior change, and ficiently disseminate knowledge. improve citations? One-year results from the TSS- another study found Facebook more effective MN prospective randomized trial. Ann Thorac Surg 2021;111:296 -300. than email at delivering medical education.13 Competing interests Dr Flexman is an associate editor of the Canadian 17. Ladeiras-Lopes R, Clarke S, Vidal-Perez R, et al. Twitter Our study results suggest that the majority of promotion predicts citation rates of cardiovascular Journal of Anesthesia and the Journal of Neurosurgi- medical journals perceive these benefits and articles: A preliminary analysis from the ESC Journals have now embraced these platforms. cal Anesthesiology. Randomized Study. Eur Heart J 2020;41:3222-3225. Social media may offer several benefits to 18. Tonia T, Van Oyen H, Berger A, et al. If I tweet will you cite? The effect of social media exposure of ar- journals in promoting knowledge dissemina- References 1. Bardus M, El Rassi R, Chahrour M, et al. The use of so- ticles on downloads and citations. Int J Public Health tion and article engagement, although the evi- cial media to increase the impact of health research: 2016;61:513-520. dence supporting an effect on citation is mixed. Systematic review. J Med Internet Res 2020;22:e15607. There is some evidence to suggest that use of 2. Sathianathen NJ, Lane III R, Murphy DG, et al. Social

206 BC Medical Journal vol. 63 no. 5 | june 2021 worksafebc

Workers Compensation Act amended to include COVID-19

o be compensable under the Work- compensation jurisdiction with presumptive to proceed.) If exposure-only claims—those ers Compensation Act, an occupa- legislation for COVID-19 infections. (New- where the worker was potentially exposed, test- tional disease must be due to the foundland does not have a specific COVID-19 ed, and/or required to self-isolate, but didn’t natureT of any employment in which the worker presumption, but it does have a more general develop the illness, as confirmed with a nega- was employed (the work presumption for infectious tive test result or absence of symptoms—are causation requirement). diseases “contracted in an excluded from the disallowed claims, then the Where no presumption There are two general ap- occupation where there allow rate is approximately 95%. This better proaches to establishing applies, WorkSafeBC is a particular risk of con- represents the allow rate on claims where the work causation: where a must determine tamination,” which could worker developed COVID-19. presumption applies and whether the evidence apply to COVID-19.) Currently, the majority of COVID-19 where one does not. in the specific case The presumption re- claims are from workers in the health care, so- Where a presumption quires the infections to be cial services, and education subsectors (e.g., applies, the starting point shows the occupational subject to a BC-specific acute care, long-term care, and public school is that work causation is disease is due to the emergency declaration districts). n presumed. This means that worker’s employment. or notice under the BC —Michelle Vukelic a claim can be accepted Public Health Act, BC Research Analyst, WorkSafeBC even though no specific Emergency Program evidence of work causation is produced. How- Act, or Vancouver Charter. Limiting the pre- R eference 1. WorkSafeBC. Rehabilitation services and claims ever, the presumption is rebutted if the evidence sumption in this way ensures it applies only manual, volume II. Accessed 20 April 2021. www shows the occupational disease was not due to in exceptional circumstances. Other common .worksafebc.com/en/resources/law-policy/rehabili the worker’s employment. outbreaks (e.g., the common cold) continue to tation-services-and-claims-manual-volume-ii/rehabili Where no presumption applies, Work- be adjudicated on a case-by-case basis using tation-services-and-claims-manual-volume-ii/rehabili tation-services-and-claims-manual-volume-ii?lang=en. SafeBC must determine whether the evidence existing law and policy. in the specific case shows the occupational Under this presumption, work causation is disease is due to the worker’s employment. presumed (unless the contrary is proved) if both: In making this determination, WorkSafeBC • The worker’s employment involves a risk of Further information decision-makers apply guidance found in exposure to source(s) of infection signifi- WorkSafeBC’s Contagious Diseases policy.1 cantly greater than the public at large. • Schedule 1 of the Workers Com- • The exposure risk occurs during the time pensation Act: www.bclaws.gov. Schedule 1 presumption period and within the geographical area of bc.ca/civix/document/id/complete/ On 20 August 2020, Schedule 1 of the Act the BC-specific emergency or notice. statreg/19001_09. was amended to add a work causation pre- The second requirement further ensures • WorkSafeBC’s current policies sumption for infections caused by communi- the presumption applies only in exceptional on compensation and reha- cable viral pathogens, including COVID-19. circumstances. bilitation for injured workers: The presumption refers to infections caused www.worksafebc.com/en/ by communicable viral pathogens, rather than COVID-19 claims statistics law-policy/claims-rehabilitation/ COVID-19 specifically, to ensure it will apply As of 19 March 2021, 4314 claims have been compensation-policies/ to similar infections that may arise in the future. submitted to WorkSafeBC related to a work- rehab-claims-volumeii. At this time, BC is the only Canadian workers’ place COVID-19 exposure. Of the COVID-19 • COVID-19 claims statistics on claims that proceeded to an allow/disallow de- WorkSafeBC’s website (up- cision, 71% have been allowed to date. (Not all dated weekly): www.work- This article is the opinion of WorkSafeBC claims registered receive an allow or disallow safebc.com/en/covid-19/claims/ and has not been peer reviewed by the decision; some are suspended when insufficient covid-19-claims-by-industry-sector. BCMJ Editorial Board. information is available or a worker decides not

BC Medical Journal vol. 63 no. 5 | June 2021 207 Clinical

Ahmer A. Karimuddin, MD, FRCSC, Jason M. Sutherland, PhD, Sam M. Wiseman, BSc, MD, FRCSC Elective surgery without COVID-19 testing will lead to excess morbidity and mortality

Patients should be tested for COVID-19 prior to planned operations to prevent avoidable surgical complications and mortality.

ABSTRACT: Countless surgical procedures have been canceled worldwide due to the COVID-19 ElECtivE surgEry without CoviD-19 tEsting pandemic. As surgical volumes increase globally to WIll leAD TO exCeSS MOrbIDITy AnD MOrTAlITy address unmet surgical need, consideration must be given to how to navigate surgical risk during We are not routinely testing patients for COVID-19 prior to surgery. this pandemic. Using current COVID-19 prevalence There are known morbidity and mortality dangers rates, the risk of operating on COVID-19–infected to performing surgery on infected people. patients in the absence of routine mandatory testing was modeled. Assuming 37 000 planned surgeries are conducted per week in Canada (excluding Quebec), and the prevalence of COVID-19 infection cases is 0.20%, the number of avoidable deaths 0.20% 77% that could occur is estimated to be 11.7 but could Assumed active Risk of operating on at least case prevalence 1 person with COVID-19 exceed 17.0. Given the risk of increased morbidity for every 500 surgeries and mortality after elective surgery in asymptomatic COVID-19-infected patients, preoperative test- As well as increased risk to patients, operating on COVID-19 patients risks transmission to hospital staff. ing should be considered mandatory. The authors recommend mandatory preoperative COVID-19 testing for planned operations.

A.A. Karimuddin, J.M. Sutherland, S.M. Wiseman BCMJ 2021;63:208-210 Dr Karimuddin is a surgeon in the Department of Surgery, St. Paul’s Hospital, and a clinical associate professor at the University of British ased on global experiences during the prepandemic surgical volumes, and even in- Columbia. Dr Sutherland is a professor early days of the COVID-19 pan- creasing volumes to catch up with delayed or at the Centre for Health Services and demic, most elective operations were canceled procedures.3 Whether in public health Policy Research, School of Population canceled to create capacity for an anticipated care systems, where surgical access was previ- and Public Health, University of British B surge in pandemic-related hospitalizations. ously constrained and now is further exacerbat- Columbia. Dr Wiseman is a surgeon in Cancelation of elective surgeries reduced the ed by the pandemic, or in mixed public–private the Department of Surgery, St. Paul’s risk of hospitals serving as transmission sites health care models like those in the United Hospital, and a professor at the University and avoided a significantly increased risk of States, where providers view surgical services of British Columbia. postoperative complications and death.1,2 as a business, there will be increasing demands As the pandemic begins to ebb in many on surgical capacity and a need for increasing This article has been peer reviewed. countries, there is a focus on returning to surgical volumes.4,5

208 BC Medical Journal vol. 63 no. 5 | june 2021 Karimuddin AA, Sutherland JM, Wiseman SM Clinical

Preoperative testing with COVID-19 were completely asymptom- April 2019, approximately 475 000 operations, Faced with pressure to increase surgical volumes, atic; however, even the asymptomatic patients or 37 000 per week, were performed in Canada, hospitals should understand their options and suffered from a higher incidence of postsurgical excluding Quebec. While it is not known what the risks of inaction regarding COVID-19 in- pulmonary complications than would otherwise proportion of these planned operations were 11 fection. The first decision is whether to preop- be expected. Based on similar observations, considered emergent and had to be performed eratively test all asymptomatic elective surgical researchers from Italy concluded that surgery regardless of patient COVID-19 infection sta- patients for infection. The feasibility and utility should be postponed in COVID-19–infected tus, based on our assumption of a 0.20% active 12 of testing varies from centre to centre and is in- patients whenever possible. Thus, the possibil- case prevalence in Canada and extrapolating fluenced by many factors, including the test itself ity of patients undergoing elective surgery when from 2019 Canadian surgical volumes, more (availability, practicality, performance metrics), unknowingly infected with COVID-19 repre- than 70 patients with COVID-19 are likely type of proposed operation (risk of aerosoliza- sents a critically important preoperative concern. to be operated on weekly. tion), preferences of the surgical team (surgeons, COVID-19 has been shown to significantly anesthesiologists, and nurses), centre-specific Modeling risk increase morbidity and mortality among surgi- 6 characteristics (policies, facility size, surgical We modeled the likelihood of operating on cal patients. Fifty-three percent of COVID- volumes, availability of personal protective a COVID-19–infected patient based on as- 19–infected patients are assumed to have pul- equipment), and surgical population (age, co- sumptions regarding COVID-19 prevalence in monary complications, and their death rate morbidities, COVID-19 prevalence rate). the population. Current prevalence data from is assumed to be 25%; among COVID-19– Recent research has raised concerns about Canada and other countries, which ranged from infected patients who do not experience pulmo- increased risks of pulmonary complications a low of 0.01% to a high of 0.30% prevalence, nary complications, the death rate is assumed and mortality in COVID-19–infected patients, were used to form the model’s assumptions. to be 9%. These outcomes are compared with whether they are asymptomatic or presymp- These rates reflect current findings from mem- the assumption that 15% of operative cases tomatic at the time of elective surgery.6,7 Al- ber countries of the Organisation for Economic have pulmonary complications, and pulmonary though many infected patients are completely Co-operation and Development, whereas ac- complication-related deaths account for 5%, asymptomatic or have a few minor symptoms, cording to the Worldometer, as of 12 January whereas the death rate among patients without they have significantly increased perioperative 2021, the prevalence of active cases was 0.20% pulmonary complications is 1%. The difference morbidity and mortality. Furthermore, they in Canada and 2.74% in the United States. At between the two models represents the “excess” pose an infection risk to all hospital personnel a local active case prevalence of 0.20%, for ev- deaths attributable to increased morbidity and and other patients they come into contact with ery 500 surgeries conducted in a hospital, the mortality of COVID-19–infected patients who during their hospitalization. Recently, the Mi- risk of operating on at least one person with have undergone surgery. sericordia Community Hospital in Alberta had COVID-19 is 77%. The Figure illustrates the excess, or avoid- to be closed and all elective surgeries were can- According to the Canadian Institute for able, deaths in a non-testing environment, as- celed for a second time due to a hospital-wide Health Information, between 1 February and 30 suming 37 000 planned surgeries per week in COVID-19 outbreak. Direction from public health, specifically in Canadian centres, has not included mandatory COVID-19 testing of asymptomatic patients 20 Prevalence who are considered low risk on screening prior 0.10% to elective surgery.8 While prescreening can 0.20% 0.30% identify some people who are at increased risk 15 0.40% of harboring COVID-19 infection and warrant preoperative testing, it has not been shown to 10 be effective or to protect patients or their health care providers when compared with mandatory

testing. Routine preoperative testing of elec- Number of excess deaths 5 tive surgical patients has been recommended in guidelines issued by many surgical organiza- 0 tions.9,10 At the height of the pandemic in New York City, 99 orthopaedic surgical patients were 0 5000 10000 15000 20000 25000 30000 35000 screened and also underwent nasopharyngeal Number of surgeries (weekly) swab testing for COVID-19. Seven of 12 pa- F Estimatedigure. number of excess deaths of COVID-19–infected surgical patients in the absence of tients (58.3%) who were found to be infected preoperative testing.

BC Medical Journal vol. 63 no. 5 | June 2021 209 Clinical Elective surgery without COVID-19 testing will lead to excess morbidity and mortality

4. Kruse FM, Jeurissen PPT. For-profit hospitals out of busi- Canada (excluding Quebec). Assuming the analyses, we recommend that provinces and ness? Financial sustainability during the COVID-19 epi- prevalence of COVID-19 infection cases is hospitals mandate preoperative testing for demic emergency response. Int J Heal Policy Manag 0.20%, the number of excess deaths is estimated planned operations to prevent avoidable sur- 2020;9:423-428. to be 11.7. It is important to note that the num- gical complications and patient mortality. n 5. Nepogodiev D, Omar OM, Glasbey JC, et al. Elective ber of excess deaths is an underestimation be- surgery cancellations due to the COVID-19 pandemic: Global predictive modelling to inform surgical recov- cause surgical case volumes for Quebec were not ery plans. Br J Surg 2020;107:1440-1449. included, and COVID-19 preoperative testing 6. COVIDSurg Collaborative. Mortality and pulmonary methodologies are currently evolving and may We recommend that complications in patients undergoing surgery with not diagnose all infected cases. Further, if the provinces and hospitals perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38. true Canadian prevalence rate is higher (e.g., mandate preoperative 7. Nahshon C, Bitterman A, Haddad R, et al. Hazardous 0.40%) due to variable testing practices or a lack testing for planned postoperative outcomes of unexpected COVID-19 of testing among asymptomatic Canadians, it infected patients: A call for global consideration of is expected that the number of excess deaths operations to prevent sampling all asymptomatic patients before surgical treatment. World J Surg 2020;44:2477-2481. will exceed 23.5. The impact of vaccination, and avoidable surgical 8. British Columbia Centre for Disease Control, British the presence of viral variants, on perioperative complications and Columbia Ministry of Health. Infection prevention and COVID-19–related mortality and morbidity, patient mortality. control (IPC) protocol for surgical procedures during and whether it should influence preoperative COVID-19: Adult. Coronavirus COVID-19. 21 May 2020. Accessed 25 February 2021. www.bccdc.ca/Health testing protocols, is not established and war- -Professionals-Site/Documents/COVID19_IPCProtocol rants further study. SurgicalProceduresAdult.pdf. Competing interests 9. Dowdy S, Fader AN. Surgical considerations for gyne- Summary None declared. cologic oncologists during the COVID-19 pandemic. Society of Gynecologic Oncology. Accessed 25 Febru- Government policymakers, hospitals, surgeons, ary 2021. www.sgo.org/wp-content/uploads/2020/03/ other medical personnel, and patients must References 1. Aminian A, Safari S, Razeghian-Jahromi A, et al. COVID-19 Surgical_Considerations_Communique.v14.pdf. reckon with the knowledge that even at the outbreak and surgical practice: Unexpected fatality in 10. American College of Surgeons. Local resumption lowest COVID-19 prevalence rates, without perioperative period. Ann Surg 2020;272:e27-e29. of elective surgery guidance. 17 April 2020. Acces preoperative testing, infected people will un- 2. Li Y-K, Peng S, Li L-Q, et al. Clinical and transmission sed 25 February 2021. www.facs.org/covid-19/clinical -guidance/resuming-elective-surgery. dergo elective surgery and have an increased risk characteristics of Covid-19 – A retrospective study of 25 cases from a single thoracic surgery department. 11. Gruskay JA, Dvorzhinskiy A, Konnaris MA, et al. Uni- of avoidable morbidity and mortality; they will Curr Med Sci 2020;40:295-300. versal testing for COVID-19 in essential orthopaedic also present an avoidable risk of transmission 3. British Columbia Ministry of Health. A commitment to surgery reveals a high percentage of asymptomatic to hospital staff. surgical renewal in BC. Coronavirus COVID-19. 7 May infections. J Bone Joint Surg Am 2020;102:1379-1388. 12. Doglietto F, Vezzoli M, Gheza F, et al. Factors associat- Currently, no province has a mandate to 2020. Accessed 25 February 2021. www2.gov.bc.ca/ assets/gov/health/conducting-health-research/ ed with surgical mortality and complications among routinely test elective surgical patients for surgical-renewal-plan.pdf. patients with and without Coronavirus disease 2019 COVID-19 preoperatively. Based on our (COVID-19) in Italy. JAMA Surg 2020;155:1-14.

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Lise Leveille, MD, MHSc, Tessa Ladner, BSc, Christopher Reilly, MD Delay in diagnosis and management of adolescent anterior cruciate ligament injuries in patients with lower socioeconomic status

Reconstructive surgery for anterior cruciate ligament injuries in adolescents with lower socioeconomic status may have been delayed because their families had less capacity to seek multiple medical opinions and were less likely to be able to afford privately funded services such as physiotherapy and private advanced imaging.

ABSTRACT Methods: A retrospective chart review was con- lateral meniscal tear or articular cartilage damage, Background: Anterior cruciate ligament (ACL) injur- ducted for adolescents undergoing primary ACL most patients had experienced delayed treatment ies are common in physically active adolescents. reconstruction at a tertiary care pediatric hospital. and had meniscal or articular cartilage damage at Delayed treatment of these injuries is associated Data on patient demographics, physiotherapy, the time of ACL reconstruction. Income was the with increased intra-articular pathology. This study income, and intraoperative status of cartilage only variable that had a significant effect on time aimed to identify the patient factors associated were collected, and time from injury to ortho- to ACL reconstruction. For every $10 000 increase with delayed ACL reconstruction in adolescents, the paedic referral, consult, and ACL reconstruction in income, time to ACL reconstruction was reduced relationship between time to ACL reconstruction were calculated. Federal census data were used by 20.9% (43 days). and frequency of intra-articular pathologies, and to determine the patients’ socioeconomic status. the barriers to timely access to treatment of ACL A multivariate linear regression model was used Conclusions: Most adolescent patients are hav- injuries in a publicly funded health care system. to identify the association between time to ACL ing delayed ACL reconstruction, potentially con- reconstruction and the patient’s sex, age, family tributing to increased frequency of intra-articular income, and distance to hospital. The model was pathology. Increased income was associated with run for each of the four time variables: injury to a significant decrease in time to ACL reconstruc- ACL reconstruction, injury to orthopaedic referral, tion. Further research is needed to determine why referral to orthopaedic consultation, and consulta- patient socioeconomic status was associated with tion to ACL reconstruction. A logistic regression differential access to ACL reconstruction within a Dr Leveille is a pediatric orthopaedic model was used to determine whether delayed publicly funded health care system. surgeon at BC Children’s Hospital and reconstructive surgery led to higher likelihood a clinical assistant professor at the of intra-articular pathology. Delayed time to ACL University of British Columbia. Ms Ladner Background reconstruction was considered to be more than is a medical student at the University of Anterior cruciate ligament (ACL) rupture is 180 days after injury. British Columbia. Dr Reilly is a pediatric a common sporting injury in physically active 1 orthopaedic surgeon at BC Children’s adolescents. The incidence of this injury has Results: Eighty-three patients were identified. Mean 2 Hospital and an associate professor at been increasing over the last 20 years, likely due time from injury to reconstruction was 286 days. the University of British Columbia. to increased sporting involvement among ado- Although no association was found between time lescents and improved diagnostic techniques.3,4 This article has been peer reviewed. to ACL reconstruction and frequency of medial or ACL rupture is frequently associated with

BC Medical Journal vol. 63 no. 5 | June 2021 211 Clinical Delay in diagnosis and management of adolescent anterior cruciate ligament injuries articular cartilage damage and meniscal tears, the relationship between time to ACL recon- A logistic regression model was used to deter- which contribute to degenerative changes in the struction and frequency of intra-articular pa- mine whether delayed reconstructive surgery joint over time.5,6 Historically, there was con- thologies, and describe barriers to timely access led to a higher likelihood of intra-articular siderable concern that ACL reconstruction in to care for ACL injuries in a publicly funded pathology. A P value of < .05 was considered skeletally immature patients could damage the health care system. Identifying and clearly de- significant. Delayed time to ACL reconstruc- physis and cause associated growth abnormali- fining risk factors that contribute to late pre- tion was defined as more than 180 days after ties.7 However, more recent evidence has shown sentation and reconstruction of ACL ruptures injury. All analyses were conducted using SAS that ACL reconstruction in adolescents will aid in (version 9.4). can be done safely and ef- Often the delay screening, detection, and fectively with techniques improvement of patient Results that protect the actively from injury to ACL outcomes. Eighty-three patients were identified and had a growing physis.8-10 Sur- reconstruction is related mean age of 14.7 years (range 9–17) [Table 1]. gical reconstruction for to a delay in diagnosis, Methods Fifty-five patients were female (66.3%). adolescent and pediatric access to specialist This was a retrospective Fifty-three patients (63.9%) had meniscal or ACL rupture is now con- case series. Following in- articular cartilage damage at the time of ACL 11,12 consultation, or access sidered standard care. stitutional review board reconstruction. Twenty-one patients (25.3%) In young, active patients, to operating room time. approval, consecutive pa- had medial meniscal tears; 36 (43.4%) had lat- nonoperative manage- tients who had undergone eral meniscal tears. Forty-six patients (55.4%) ment or planned delayed ACL reconstruction at a had received physiotherapy prior to reconstruc- ACL reconstruction often results in recurrent single tertiary care pediatric hospital were iden- tion, and 5 (6.0%) had not; history was missing episodes of instability due to a lack of adher- tified. Inclusion criteria were children and youth for the remaining 32 (38.6%) patients. At the ence to activity modifications and bracing.13 A less than 18 years of age who had undergone time of injury, 76 patients (91.6%) were playing delayed ACL rupture diagnosis similarly leads ACL reconstruction between 2014 and 2018. sports: the most common sports included soccer to recurrent episodes of instability due to a lack Patients were excluded if they had undergone a (23, 27.7%), basketball (12, 14.4%), skiing (5, of knowledge that activity modification, brac- revision ACL reconstruction during that period. 6.0%), volleyball (4, 4.8%), running (3, 3.6%), ing, or surgical reconstruction is needed. With Information collected included the patients’ and trampoline (3, 3.6%). Of the remaining each episode of instability, the patient is at risk date of birth, sex, sport involvement, side of patients, 6 were involved in non-sport activities of causing further damage to intra-articular involvement, history of prior injury, and his- at the time of injury, and for one patient, the structures, including the meniscus and articular tory of physical therapy prior to orthopaedic mechanism of injury was unknown. cartilage.14 Thus, delaying ACL reconstruction consult. Presence of articular cartilage damage Mean time from injury to reconstruction in adolescents leads to higher incidence and se- or meniscal pathology was determined by re- was 286 days, injury to referral (W0) was 80 verity of medial meniscal tears5 and irreparable view of the intra-operative surgical report. To chondral damage at the time of surgery.10,14 assess socioeconomic status, federal census data Table 1. Demographics. A family may elect to delay ACL recon- were used to estimate mean after-tax individual Study cohort Variable struction due to a variety of patient consider- income by postal code. Time variables recorded (N = 83) ations. However, often the delay from injury to included date of injury, referral for orthopaedic ACL reconstruction is related to a delay in diag- consult, MRI, orthopaedic consult, and surgery. Sex (no.) nosis, access to specialist consultation, or access Descriptive statistics were used to analyze to operating room time. Patient factors, injury differences between patients who had presented Female 55 (66.3%) mechanism, and model of health care delivery early after ACL injury and those with a delayed Male 28 (33.7%) can all contribute to the timing of diagnosis and presentation. A multivariate linear regression 15,16 definitive management after ACL rupture. model was used to determine the association Mean age (years) 14.7 Socioeconomic status has also been found to be between time to reconstructions (log trans- an important factor in the use of orthopaedic formed) and the patient’s sex, age, family in- Side of involvement resources and access to treatments.17-19 Specific come, and distance to hospital. The model was patient factors that contribute to delayed ACL run for each of the four time variables: injury Right 43 (51.8%) reconstruction and the consequences of this de- to reconstruction, injury to orthopaedic refer- Left 40 (41.2%) lay in a publicly funded health care system are ral (W0), referral to orthopaedic consult (W1), and consult to reconstruction (W2). A P value Mean after-tax poorly understood. The aim of this study was to $40 092 (SD 9590) identify patient factors associated with delayed of < .0125 was considered significant to correct individual income ACL reconstruction in adolescents, understand for the four independent models evaluated.

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Table 2. Wait time variables. days, referral to consult (W1) was 30 days, and consult to reconstruction (W2) was 161 days Variable Mean SD Range [Table 2]. Fifty patients (60.2%) were treated more Injury to reconstruction 286 days 240.62 51–1623 than 180 days after injury. There was no signifi- Injury to referral (W0) 80 days 145.95 0–1030 cant effect of patient sex, age, or distance from Referral to consult (W1) 30 days 34.45 0–230 home address to hospital on time to reconstruc- Consult to reconstruction (W2) 161 days 143.50 16–759 tion, but individual income did have a significant effect [Table 3]. For every $10 000 increase in individual income, time to reconstruction was reduced by 20.9%. Using the median time Table 3. Effect of sex, age, income, and distance to hospital on time variables. to reconstruction of 223 days, this represents Injury to reconstruction (total wait) a decrease of 47 days for every $10 000 incremental increase in income. When time from Variable Comparison Time ratio 95% CI P value injury to reconstruction was divided into W0, Sex M > F 1.1207 0.8013 1.5674 0.5010 W1, and W2, individual income showed a sig- Age per year 0.9938 0.9019 1.0950 0.8983 nificant effect on time from injury to referral Individual after-tax income* per 10 k 0.7914 0.6739 0.9292 0.0048 (W0) [Table 3], with a decrease of 43.8% for every $10 000 incremental increase in individual Distance per 100 km 1.0329 0.9765 1.0926 0.2544 income. No association was found between in- Injury to referral (W0) come and W1 or W2 [Table 3]. No association Variable Comparison Time ratio 95% CI P value was found between time to ACL reconstruction Sex M > F 0.6987 0.3266 1.4945 0.3475 and odds of medial or lateral meniscal tear or articular cartilage damage [Table 4]. Age per year 0.9823 0.7984 1.2084 0.8627 Individual after-tax income per 10 k 0.5619 0.3852 0.8197 0.0036 Interpretation Distance per 100 km 1.1592 1.0187 1.3190 0.0259 Most ACL reconstructions conducted at the Referral to consult (W1) publicly funded pediatric tertiary care hospital Variable Comparison Time ratio 95% CI P value in this study were delayed. In 60.2% of patients, ACL reconstruction was performed more than Sex M > F 0.7569 0.3965 1.4447 0.3912 6 months after the initial injury. This type of Age per year 1.0229 0.8669 1.2070 0.7848 delay was previously documented at another Individual after-tax income per 10 k 0.8022 0.5940 1.0833 0.1470 Canadian centre, where mean time from injury Distance per 100 km 1.0901 0.9449 1.2576 0.2316 to ACL reconstruction was 342 days (range 42–1637).20 This is similar to our mean of 286 Consult to reconstruction (W2) days (range 51–1623). Times from injury to Variable Comparison Time ratio 95% CI P value reconstruction at American medical centres Sex M > F 1.1025 0.7474 1.6264 0.6187 are considerably shorter than those reported Age per year 0.9950 0.8892 1.1134 0.9302 at Canadian medical centres. One US study reported a mean time to ACL reconstruction Individual after-tax income per 10 k 0.8489 0.7047 1.0225 0.0836 of 101 days;5 other studies reported that 65% Distance per 100 km 1.0305 0.9655 1.0998 0.3610 21 of patients were treated in less than 150 days, *Red text indicates significance (P < 0.0125). and 59% were treated within 90 days.14 We were able to better understand the discrepancy in access to ACL reconstruction Table 4. Effect of time to anterior cruciate ligament reconstruction on odds of intra-articular damage. between Canada and the United States by ana- lyzing the time from ACL injury to reconstruc- Variable Odds ratio 95% CI P value tion in our study based on three separate time Odds intra-articular damage: Total wait 0.698 0.368 1.325 0.271 segments: injury to orthopaedic referral (W0), Odds meniscal tear: Total wait 0.825 0.443 1.539 0.546 referral to orthopaedic consultation (W1), and Odds articular cartilage tear: Total wait 0.462 0.211 1.013 0.054 consultation to ACL reconstruction (W2). The

BC Medical Journal vol. 63 no. 5 | June 2021 213 Clinical Delay in diagnosis and management of adolescent anterior cruciate ligament injuries longest mean wait times and standard devia- findings suggest that children and adolescents the patients at risk of experiencing those delays, tions were recorded in W0 (80 [146] days) and from families with lower socioeconomic status attention can be focused on initiatives to ad- W2 (161 [144] days) [Table 2]. The long W0 may have less support or capacity to seek mul- dress those gaps in care. Improving W0 for all time may suggest a delay in presentation, in di- tiple medical opinions, private physiotherapy, patients could be achieved without significant agnosis by the initial health care provider, or in or private advanced imaging, which can con- increased cost of care or health care resources. obtaining advanced imaging. The large standard tribute to a delay in diagnosis and an increase Education on ACL injuries in adolescents that deviation for this variable suggests that some in W0. These patients are also less likely to have is aimed at parents, coaches, and primary care patients were accessing health care resources parental support or capacity for multiple out- health practitioners would likely improve W0 better than others. The long W2 time may re- patient visits, which require time off work, or by reducing the time to diagnosis and improving flect a variation in management due to physi- the insurance and/or money necessary to pay the quality of orthopaedic referrals, which could ologic differences (swelling, stiffness, skeletal for privately funded services. lead to an additional decrease in W1. Educa- immaturity, concomitant injuries), availability tional initiatives for primary care physicians of operating room time, scheduling conflicts would help them recognize the importance due to the child’s schooling, or lack of surgeon Our analysis showed of accurate and timely diagnosis of adolescent availability. The large standard deviation for that an increase in acute knee injuries. This would result in an in- this variable was likely related to differences in individual income crease in appropriate referral for advanced im- clinical patient factors. We did not identify any aging and specialist care after an initial patient was associated with a discrepancies in access to health resources based presentation. Likely, these initiatives would have on socioeconomic status that would explain significant decrease the greatest effect if they were implemented the variability in W2 among patients. Many in time from injury to during medical training and provided easily of those delays can be attributed to insuffi- ACL reconstruction. accessible resources for knowledge acquisition cient funding or resources within the Canadian and skill development (physical examination). health care system. However, the discrepancies There is a discontinuity between the amount of in access to health resources in W0 suggest Discrepancy in access to health care based time spent on musculoskeletal teaching during there was systematic discrimination against on socioeconomic status has also been found medical training and the volume of musculo- patients with lower socioeconomic status. in American adolescent patients with ACL in- skeletal pathology seen in a typical primary Our analysis showed that an increase in juries. Patel and colleagues found that children care practice. Although a large proportion of individual income was associated with a sig- in the United States who had no private health visits to primary care providers involve mus- nificant decrease in time from injury to ACL insurance coverage and relied on government culoskeletal issues, many physicians feel this reconstruction. When neighborhood-level in- health care had delayed ACL reconstructive is not adequately addressed in their medical dividual income was used to reflect patient so- surgery compared to children with private cov- undergraduate training.22 A summary of current cioeconomic status, every $10 000 increase in erage.15 Individual income was also a significant recommendations for the diagnosis of adoles- income was associated with a 20.9% reduction and independent predictor of ACL reconstruc- cent ACL injuries for primary care providers in time to ACL reconstruction. However, so- tion timing, with patients with lower socioeco- is provided in Table 5.23-26 cioeconomic status affected only the W0 time nomic status experiencing delays in treatment. Several studies have shown an associa- variable: for every $10 000 incremental increase In contrast to our study, Patel and colleagues tion between increasing time from injury to in individual income, time from injury to refer- found an association between socioeconomic reconstruction and frequency and severity of ral decreased by 43.8%. Delay in referral to a status and time from initial orthopaedic evalu- intra-articular pathology.5,12,14,19-21,27 A system- specialist was often related to missed diagnosis ation to surgical reconstruction. The authors atic review and meta-analysis of ACL recon- of ACL tear after initial injury, failure to present speculated that this was due to reduced access struction and associated medial meniscal and to a medical practitioner, or reduced access to to care, familial resources, and social support.15 articular cartilage damage in children and ado- advanced imaging modalities. We hypothesize In our publicly funded health care system, all lescents that was conducted in 2018 showed a that the effect of income on time to orthopae- patients have equal access to specialist consul- significant reduced risk of concomitant medial dic referral was due to reduced access to mus- tation (time to consultation from referral) and meniscal injury in patients with early ACL culoskeletal specialists (e.g., sports medicine surgical reconstruction (time to reconstruction reconstruction (26%) compared to those with clinics), health care resources, privately funded from consultation) independent of socioeco- delayed ACL reconstruction (47%). There was physiotherapy, or private MRI. In a publicly nomic status; however, further work is needed also a reduced risk of chondral damage in the funded system that is often functioning at or to address discrepancies in access to resources early versus late ACL reconstruction groups.11 above capacity, patient advocacy from the family for early diagnosis of injuries. We did not find an association between time to and medical practitioner is often necessary to By understanding the timing of delay in ACL reconstruction and odds of intra-articular obtain appropriate care in a timely fashion. Our management of adolescent ACL injuries and pathology. However, treatment of most of our

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Table 5. Adolescent anterior cruciate ligament injury diagnosis recommendations for primary care providers. with a delay in diagnosis and definitive manage-

Provide injury Certain injury prevention programs have been well established in the pediatric ment of ACL injuries. Any interaction between prevention education population, including FIFA 11+.23 These programs should target athlete geographic location and access to health care is to highly active biomechanics, using strength, plyometric, and sports-specific agility exercises.24 likely a complex interaction among availability adolescents, their of local resources, proximity to higher level care, parents, and coaches and family socioeconomic status. Acute knee injury History: Future research is needed to provide more diagnosis • Twisting or contact acute knee injury obtained during high-risk sports (skiing or cutting sports such as soccer, football, volleyball, etc.). insight on the discrepancy between income • Recurrent episodes of instability/giving way with activity. and surgical wait time. A prospective cohort • Acute period of knee swelling with stiffness and possible difficulty weight- would provide more accurate information on bearing. Physical examination: income levels, as well as any other patient fac- • Large effusion/hemarthrosis within 24 hours. tors (such as ethnicity) related to delayed injury • Decreased range of motion—loss of terminal extension suggestive of large presentation and reconstruction. Additionally, meniscus tear. • Ligamentous laxity—Lachman, pivot shift,25 and anterior drawer test. communicating with primary health care providers about possible gaps in education on mus- Imaging Begin with plain knee radiographs (findings suggestive of ACL tear include culoskeletal injuries in pediatric populations presence of hemarthrosis, Segond fracture). These will also assist in ruling out other intra-articular pathology/fractures. An MRI should be obtained in may help identify where to target educational all adolescent patients presenting with an acute hemarthrosis or recurrent resources. episodes of instability.26 Referral to specialist Urgent referral to a musculoskeletal specialist should be made for all adolescent Conclusions patients with an acute hemarthrosis or loss of terminal extension after an At a pediatric tertiary care hospital in a public acute knee injury, recurrent episodes of instability/giving way, or concern of ligamentous knee injury. health care system, most adolescent patients experienced delays in ACL reconstruction, which contributed to a high rate of intra-articular pathology. Increase in parental income was patients was delayed (60.0% to 87.0% depend- reconstruction. However, no association was associated with a significant decrease in time 5,21,28 ing on the definition of delayed), and the found between access to physiotherapy and time to orthopaedic referral, which suggests there frequency of meniscal tears and articular car- to ACL reconstruction. This possibly is related was differential access to health care resources tilage damage was reflective of this finding: 53 to the inherent challenges of retrospective data based on patient socioeconomic status. Further patients (63.9%) had meniscal or articular carti- collection, as no history on access to physio- research is needed to determine the specific lage damage at the time of ACL reconstruction. therapy was available for 39% of patients. We factors that caused this discrepancy in access to This is further support for what has already been similarly hypothesized that access to private health care within a publicly funded system. n established in the literature: delayed reconstruc- MRI would reduce time to ACL diagnosis and tion leads to increased intra-articular pathology, reconstruction. However, due to incomplete Competing interests likely due to ongoing instability. It is impor- MRI data, we were unable to investigate this Dr Leveille received a clinical research stimulus tant to advocate for more medical resources for further. This is an area that will be assessed in award from the BC Children’s Hospital Research adolescent acute knee injuries to try to reduce future prospective studies. Institute to help cover research-related costs. None the time to ACL reconstruction for all patients Geographic-based census data were used to of the authors received financial support for the and prevent irreversible intra-articular damage estimate patient socioeconomic status, which completion of this project. when access to resources is delayed. contributed to an ecological fallacy. A number of studies have used census data to predict so- R eferences 1. Frobell RB, Roos EM, Roos HP, et al. A randomized trial cioeconomic status.12,15,18,29 Limitations and future directions However, it is pos- of treatment for acute anterior cruciate ligament tears. Due to the retrospective nature of our study and sible that incomes estimated using this method N Engl J Med 2010;363:331-342. gaps in our data, we were unable to identify a were not always reflective of patient socioeco- 2. Werner BC, Yang S, Looney AM, Gwathmey FW. relationship between access to private health nomic status. The estimates are based on aver- Trends in pediatric and adolescent anterior cruciate care services and time to ACL reconstruction. age income for a given geographic region. It is ligament injury and reconstruction. J Pediatr Orthop 2016;36:447-452. We hypothesized that history of access to phys- possible that some of the delay in treatment of 3. Beck NA, Patel NM, Ganley TJ. The pediatric knee: Cur- iotherapy could be used as a surrogate for so- ACL injuries could be related to challenges in rent concepts in sports medicine. J Pediatr Orthop Part cioeconomic status and overall family support. accessing health care resources in a given geo- B. 2014;23:59-66. More than half the patients (55%) in this study graphic region. However, distance to the tertiary 4. Jaremko JL, Guenther ZD, Jans LBO, MacMahon PJ. Spec- trum of injuries associated with paediatric ACL tears: An had access to a physiotherapist prior to surgical care hospital in our study was not associated

BC Medical Journal vol. 63 no. 5 | June 2021 215 Clinical Delay in diagnosis and management of adolescent anterior cruciate ligament injuries

MRI pictorial review. Insights Imaging 2013;4:273-285. a diagnosis of an anterior cruciate ligament tear: Is 21. Dumont GD, Hogue GD, Padalecki JR, et al. Meniscal 5. Millett PJ, Willis AA, Warren RF. Associated injuries in there harm in delay of treatment? Am J Sports Med and chondral injuries associated with pediatric ante- pediatric and adolescent anterior cruciate ligament 2011;39:2582-2587. rior cruciate ligament tears: Relationship of treatment tears: Does a delay in treatment increase the risk of 15. Patel AR, Sarkisova N, Smith R, et al. Socioeconomic time and patient-specific factors. Am J Sports Med meniscal tear? Arthroscopy 2002;18:955-959. status impacts outcomes following anterior cruciate 2012;40:2128-2133. 6. Friel NA, Chu CR. The role of ACL injury in the develop- ligament reconstruction status. Medicine (Baltimore) 22. Pinney SJ, Regan WD. Educating medical students ment of posttraumatic knee osteoarthritis. Clin Sports 2019;98:e15361. about musculoskeletal problems. Are community Med 2013;32:1-12. needs reflected in the curricula of Canadian medical 7. Calvo R, Figueroa D, Gili F, et al. Transphyseal anteri- schools? J Bone Joint Surg Am 2001;83:1317-1320. or cruciate ligament reconstruction in patients with Further research is 23. Thorborg K, Krommes KK, Esteve E, et al. Effect of open physes: 10-year follow-up study. Am J Sports specific exercise-based football injury prevention Med 2015;43:289-294. needed to determine programmes on the overall injury rate in football: A 8. Dunn KL, Lam KC, Valovich McLeod TC. Early operative the specific factors that systematic review and meta-analysis of the FIFA 11 versus delayed or nonoperative treatment of anterior and 11+ programmes. Br J Sports Med 2017;51:562-571. cruciate ligament injuries in pediatric patients. J Athl caused this discrepancy 24. Lauersen JB, Bertelsen DM, Andersen LB. The effective- Train 2016;51:425-427. in access to health ness of exercise interventions to prevent sports injuries: 9. Kocher MS, Heyworth BE, Fabricant PD, et al. Outcomes A systematic review and meta-analysis of randomised of physeal-sparing ACL reconstruction with iliotibial care within a publicly controlled trials. Br J Sports Med 2014;48:871-877. band autograft in skeletally immature prepubescent funded system. 25. Mall NA, Paletta GA. Pediatric ACL injuries: Evalua- children. J Bone Joint Surg Am 2018;100:1087-1094. tion and management. Curr Rev Musculoskelet Med 10. Henry J, Chotel F, Chouteau J, et al. Rupture of the an- 2013;6:132-140. terior cruciate ligament in children: Early reconstruc- 26. Ardern CL, Ekås G, Grindem H, et al. 2018 International tion with open physes or delayed reconstruction to 16. McCarthy M, Dodwell E, Pan T, Green DW. Long term Olympic Committee consensus statement on preven- skeletal maturity? Knee Surg Sports Traumatol Arthrosc follow up of pediatric ACL reconstruction in New York tion, diagnosis and management of paediatric ante- 2009;17:748-755. state: High rates of subsequent ACL reconstruction. rior cruciate ligament (ACL) injuries. Knee Surg Sports 11. Kay J, Muzammil M, Shah A, et al. Earlier anterior cru- Orthop J Sports Med 2015;3:2325967115S00129. Traumatol Arthrosc 2018;26:989-1010. ciate ligament reconstruction is associated with a de- 17. Pandya NK, Wustrack R, Metz L, Ward D. Current con- 27. Sommerfeldt M, Goodine T, Raheem A, et al. Relationship creased risk of medial meniscal and articular cartilage cepts in orthopaedic care disparities. J Am Acad Or- between time to ACL reconstruction and presence of damage in children and adolescents: A systematic re- thop Surg 2018;26:823-832. adverse changes in the knee at the time of reconstruc- view and meta-analysis. Knee Surg Sports Traumatol 18. Jones MH, Reinke EK, Zajichek A, et al. Neighborhood tion. Orthop J Sports Med 2018;6:2325967118813917. Arthrosc 2018;26:3738-3753. socioeconomic status affects patient-reported out- 28. Hagino T, Ochiai S, Senga S, et al. Meniscal tears asso- 12. Vavken P, Murray MM. Treating anterior cruciate liga- come 2 years after ACL reconstruction. Orthop J Sports ciated with anterior cruciate ligament injury. Arch Or- ment tears in skeletally immature patients. Arthroscopy Med 2019;7: 2325967119851073. thop Trauma Surg 2015;135:1701-1706. 2011;27:704-716. 19. Newman JT, Carry PM, Terhune EB, et al. Delay to recon- 29. Ko G, Shah P, Kovacs L, et al. Neighbourhood income 13. Reid D, Leigh W, Wilkins S, et al. A 10-year retrospective struction of the adolescent anterior cruciate ligament: level and outcomes of extremely preterm neonates: review of functional outcomes of adolescent anterior The socioeconomic impact on treatment. Orthop J Protection conferred by a universal health care system. cruciate ligament reconstruction. J Pediatr Orthop Sports Med 2014;2:2325967114548176. Can J Public Health 2012;103(6):e443-7. 2017;37:133-137. 20. Guenther ZD, Swami V, Dhillon SS, Jaremko JL. Menis- 14. Lawrence JTR, Argawal N, Ganley TJ. Degeneration cal injury after adolescent anterior cruciate ligament of the knee joint in skeletally immature patients with injury: How long are patients at risk? Clin Orthop Relat Res 2014;472:990-997.

216 BC Medical Journal vol. 63 no. 5 | june 2021 bcCDC

Last in line: Impacts of the COVID-19 pandemic on the health and well-being of young adults in BC

rior to the COVID-19 pandemic, young being last in line for the COVID-19 vaccina- mobility of young adults have also been signifi- adults age 18 to 30 years in British tion. Indeed, according to the BCCDC, as of cantly disrupted by the COVID-19 pandemic.3 Columbia faced a challenging social, April 2021, young adults represented 31% of There is an urgent need to monitor health Peconomic, and employment landscape due to BC individuals infected during the pandemic trends, characterize health trajectories, and changing norms around key life transitions, but only 17% (892 543) of the BC population. identify key determinants of health through increasing income inequality, and declining Young adults experienced peak rates of men- ongoing, timely, and targeted longitudinal mon- housing affordability. The prevailing character- tal health and substance use disorders prior to itoring. Data are severely lacking for historically ization of young adults as healthy, highly social, the COVID-19 pandemic underserved populations and irresponsible is inaccurate and detrimen- and are now experiencing (e.g., Indigenous and ra- tal to pandemic recovery planning. Emerging substantial increases in Many young adults with cialized groups; those liv- data forecast serious impacts of pandemic re- mental health concerns mental illness report ing in rural, remote, and sponse measures on the social determinants of and stress. In a BC survey disruptions in mental northern communities; young adult health while intensifying existing of almost 400 000 partici- and gender-diverse peo- downstream effects on their health behaviors, pants in May 2020, more health services they ple). Engaging youth to care, and outcomes.1 The BCCDC COVID-19 than half (54%) of young had accessed prior speak to their needs and Young Adult Task Force was commissioned in adults reported worsen- to the pandemic. experiences will be criti- response to concerning impacts to highlight ing mental health at the cal in both guiding and areas for action to mitigate those impacts. onset of the pandemic evaluating policy, educa- Young adults in BC are experiencing a se- compared to 46% of the general BC population, labor, and health-service interventions for vere economic crisis: the unemployment rate tion.3 Many young adults with mental illness this age group. A better understanding of the has more than doubled in this age group dur- report disruptions in mental health services they unique needs and impacts of the pandemic on ing the pandemic and has not yet recovered to had accessed prior to the pandemic.5 Although young adults will enhance the ability for health prepandemic levels.2,3 Young adults have been there has been an increase during the pandemic care practitioners to support this population. n more likely than others to lose their job dur- in access to crisis-oriented virtual counseling, —Hasina Samji, PhD, MSc ing the pandemic and many report increased in-person access to continuing mental health BCCDC and Simon Fraser University difficulty meeting household financial needs.3 services is limited, stigmatized, expensive, or —Naomi Dove, MD, MPH, FRCPC Education and job training have been disrupted difficult for young adults to find.3,5 Office of the Provincial Health Officer of BC or delayed for many. Students report delays in Declining physical activity, escalating sed- —Megan Ames, PhD, RPsych program completion and challenges securing entary behavior, disruptions in sleep and nu- University of Victoria work experience (e.g., co-op opportunities).4 trition, and increased substance use (alcohol —Meridith Sones, MPH Poor housing affordability contributes to over- and cannabis), with repercussions on emotional Simon Fraser University crowded living conditions and increased risk and physical well-being, have been reported —Bonnie Leadbeater, PhD, FRSC of COVID-19 exposure. Risk of exposure is by young adults during the pandemic.3 The University of Victoria also increased due to frontline work in grocery lack of structure created by work and educa- For the BCCDC COVID-19 Young Adult Task stores, restaurants, and retail stores, as well as tion contribute to these problems, along with Force decreased access to settings, resources, and opportunities that promote healthy behaviors. For R eferences 1. Samji H, Dove N, Ames M, et al. British Columbia Centre This article is the opinion of the BC Centre example, restrictions on parks and other public for Disease Control Young Adult Task Force. Impacts of for Disease Control and has not been spaces particularly impact young adults, who are the COVID-19 pandemic on the health and well-being of young adults in British Columbia. 2021. peer reviewed by the BCMJ Editorial more dependent on them for socializing and 6 References continued on page 218 Board. recreation. Social networks, daily routines, and

BC Medical Journal vol. 63 no. 5 | June 2021 217 college library BCCDC

Continued from page 217 2. Statistics Canada. Unemployment rate, participation rate, and employment rate by type of stu- Hidden gems on the dent during school months, monthly, unadjusted for seasonality. Accessed 30 April 2021. www150 .statcan.gc.ca/t1/tbl1/en/tv.action?pid=1410002 bookshelves 101&pickMembers%5B0%5D=1.11&pickMembers %5B1%5D=4.1&pickMembers%5B2%5D=5.2& cubeTimeFrame.startMonth=02&cubeTimeFrame ibraries are normally quiet, and they A Guide to Improving the Lives of Patients .startYear=2020&cubeTimeFrame.endMonth =03&cubeTimeFrame.endYear=2021&reference have been even more so during the and Families Affected by Neurologic Disease. Periods=20200201%2C20210301. pandemic. The physical College Li- 2019, e-book. 3. BC Centre for Disease Control. BC COVID-19 R1 2020 brary is closed and staff are working mainly • “Culturally Appropriate Care,” chapter in: SPEAK Survey. 2020. L 4. Toronto Science Policy Network. COVID-19 gradu- from home. However, the Library has had Adolescent Nutrition: Assuring the Needs of ate student report: The early impacts of COVID-19 a virtual aspect even from its beginnings in Emerging Adults. 2020, e-book. on graduate students across Canada. 2020. Ac- 1906—BC physicians could access librarian • “Oppression and Mental Health,” chapter cessed 24 February 2021. www.toscipolicynet.ca/ support and books through the mail. Now, in: Oppression: A Social Determinant of covid19-report. e-books have made the book collection all the Health. 2012, physical book. 5. Hawke LD, Barbic SP, Voineskos A, et al. Impacts of COVID-19 on youth mental health, substance use, more accessible. In the past year, 70% of new and well-being: A rapid survey of clinical and com- books purchased are in electronic form. Why munity samples: Répercussions de la COVID-19 not 100%? Several reasons: most people prefer Regardless of format, sur la santé mentale, l’utilisation de substances et reading physical books1 and have deeper read- books often hold le bien-être des adolescents : un sondage rapide d’échantillons cliniques et communautaires. Can J ing experiences, especially with longer tracts of chapters that are gems, 2 Psychiatry 2020;65:701-709. narrative, and electronic books are not always not necessarily heralded 6. Dewis G. Access and use of parks and green spac- reasonably priced: e-books can be the same es: The potential impact of COVID-19 on Canadi- by a book’s title. price as the physical item but are sometimes an households. Statistics Canada; 2020. Accessed even 10 times more expensive. Generally, li- 24 February 2021. www150.statcan.gc.ca/n1/pub/ 45-28-0001/2020001/article/00031-eng.htm. brarians weigh the anticipated use as educational or in-depth research material (physical The College Library’s online catalogue book) versus use as a reference tool (e-book), (https://szasz.cpsbc.ca) lists almost 1000 elec- and select the format accordingly. tronic and 3000 physical books. Simply use a Doctors Regardless of format, books often hold CPSBC login to view e-books, and contact the Helping chapters that are gems, not necessarily her- library to request physical books through the Doctors alded by a book’s title. Here’s a selection from mail at www.cpsbc.ca/library/services-hours n 24 hrs/day, recent acquisitions: (return postage is included). • “Hypoglycemia in the Toddler and Child,” —Karen MacDonell 7 days/week chapter in: Sperling Pediatric Endocri- Director, Library Services nology. 2021, e-book. The Physician Health Program of • “Thyroid Imbalance and Subfertility,” R eferences 1. Espresso. Economist. Why printed books are still pop- British Columbia offers chapter in: Subfertility: Recent Advances in ular. 2016. Accessed 22 April 2021. https://espresso help 24/7 to B.C. doctors Management and Prevention. 2021, e-book. .economist.com/21e8cadba9839cd22bc29597866 and their families for a • “Nutritional Support in Esophageal 632e3. wide range of personal and Cancer,” chapter in: Esophageal Cancer: 2. Mangen A, Olivier G, Velay J-L. Comparing compre- hension of a long text read in print book and on Kin- professional problems: physical, Prevention, Diagnosis and Therapy. 2020, dle: Where in the text and when in the story? Front psychological and social. e-book. Psychol 2019. doi: 10.3389/fpsyg.2019.00038. If something is on your mind, give • “Parkinson’s Disease and Related Dis- us a call at 1-800-663-6729 or visit orders,” chapter in: Neuropalliative Care: www.physicianhealth.com.

This article is the opinion of the Library of the College of Physicians and Surgeons of BC and has not been peer reviewed by the BCMJ Editorial Board.

218 BC Medical Journal vol. 63 no. 5 | june 2021 coHp

Obesity as chronic disease

he term chronic disease has been defined obesity as a disease, not an individual lifestyle may seek expensive treatments that are not by several public health agencies, in- choice, helps us shift the deeply held societal evidence-based and are potentially harmful. cluding the CDC and WHO. While belief that people with obesity simply lack will- The WHO recognized obesity as a chronic somewhatT varied, the definitions generally agree power and just need to eat less and exercise disease in 1948. The Canadian Medical Asso- that chronic diseases have complex etiologies, more. Even among health professionals, this ciation recognized obesity as a chronic disease are of long duration, and progress slowly. They intrinsic belief is preva- in 2015, and several other are associated with functional impairment or lent and leads to bias and provinces have followed disability and while they cannot be cured, they stigma despite extensive Understanding obesity suit (Yukon in 2019, Sas- can be managed. evidence that obesity is as a medical condition katchewan in 2015, On- The 2020 “Obesity in Adults: A Clini- no more an individual like any other will tario in 2020, and Alberta cal Practice Guideline” states that obesity is choice than cancer or de- help relieve patients in 2021). British Colum- a complex chronic disease in which abnormal mentia.4 Understanding bia has not yet taken this of the typical shame or excess adiposity impairs health, increases obesity as a medical con- important step. A resolu- the risk of long-term medical complications, dition like any other will and blame they tion recognizing obesity and reduces lifespan.1 Many adiposity-related help relieve patients of the regularly experience. as a chronic disease within conditions, such as diabetes, hypertension, and typical shame and blame our province will help us cardiovascular disease, are recognized as chronic they regularly experience. advocate for safe, effective, diseases. The guideline emphasizes the limita- It will also help them understand that their sustainable management that focuses on the tions of using BMI to define obesity and advo- condition is not the result of personal failure, root causes and management of complications cate for novel approaches that incorporate the but rather the result of a complex interplay of with the intent to improve overall quality of life requirement that individuals not only have an genetics, physiology, environment, and early for people living with obesity. n elevated BMI but also experience health conse- life experiences; it is not their fault. This un- —Ilona Hale, MD quences (metabolic, physical, and psychological derstanding would help alleviate the underly- —Priya Manjoo, MD parameters) as a result of excess adiposity.2 The ing mental health problems related to the guilt guideline also clarifies that obesity manage- or shame associated with repeated failures to R eferences ment is primarily about the improvement of maintain weight loss, often unwittingly exacer- 1. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: A clinical practice guideline. CMAJ 2020;192:E875-E891. the health and well-being of patients, not just bated by medical professionals. The fear of being 2. Sharma AM, Kushner RF. A proposed clinical staging about weight loss. It acknowledges that many shamed or humiliated in the doctor’s office can system for obesity. Int J Obes (Lond) 2009;33:289-295. individuals with elevated BMI are physically result in patients with obesity avoiding care 3. Scarpelli DG, Burrows W. Disease. Encyclopedia Britan- and mentally healthy, and not at the same risk altogether, leading to yet other health issues. nica, 2020. Accessed 9 April 2021. www.britannica.com/ science/disease. for complications. This aligns with the standard Recognizing obesity as a chronic disease 4. Fruh SM, Nadglowski J, Hal HR, et al. Obesity stigma definition of the term disease, which refers to has important implications for patients. Until and bias. J Nurse Pract 2016;12:425-432. “any harmful deviation from the normal struc- obesity is recognized as a chronic disease, health tural or functional state of an organism.”3 systems will not allocate resources to prevent Although many will recoil at the idea of and manage obesity as they do for other chronic labeling individuals with obesity as having a diseases. This can increase the out-of-pocket disease, the words we use are important in how costs that patients pay for evidence-based obe- they influence our understanding. Recognizing sity treatments and wait times to access publicly funded treatments. Until obesity is recognized as a chronic dis- This article is the opinion of the Nutrition ease, health care professionals will not receive Committee, a subcommittee of Doctors of adequate obesity training, leading to delays in BC’s Council on Health Promotion, and is not screening, diagnosis, and treatment, and need- necessarily the opinion of Doctors of BC. This less progression of illness with deepening nega- article has not been peer reviewed by the tive effects on quality of life. There is also the BCMJ Editorial Board. concern that patients having no other options

BC Medical Journal vol. 63 no. 5 | June 2021 219 shared care

Emergency preparedness project rises to the challenge with pandemic response

From left: Rhonda Eden, project lead, Dr Graham Dodd, family physician lead, and Colin Swan, Interior Health emergency management coordinator, in Sahali Terrace Nature Park overlooking Royal Inland Hospital in Kamloops.

n recent years, we’ve grown increasingly Colin Swan, Interior Health emergency man- expertise between its partners throughout the accustomed to emergency situations in BC. agement coordinator (Kamloops, Thompson health authority. Forest fires, flooding, and other natural Cariboo Region). Collectively, we began explor- This response was its own form of prepared- Idisasters are on the rise, and the province’s hos- ing how to integrate community care providers ness. The division created geographical group- pitals have been developing their responses to into emergency planning in collaboration with ings of its primary care providers—forming these events and their effects on public health. the health authority. community-wide “division member” networks As the physician lead for the Thompson Then COVID-19 hit, and it became clear that included family physicians and nurse prac- Region Division of Family Practice (TRDFP) that not only was the crisis a threat to the ef- titioners, medical office assistants, and partners with a special interest in emergency disaster ficient operation of our hospitals, it was also such as community specialists, allied health care management, I began thinking that the bur- unsafe for panicked communities to gather professionals, and Interior Health and govern- den of such crises should not fall entirely on in emergency wards en masse for everything ment representatives. hospitals when there are community primary from COVID-19 testing to asthma attacks. No Each network identified a physician and an care providers that can share that burden. Di- matter the emergency, hospitals must continue administrative lead, which allowed for efficient viding the load would allow hospitals to treat with their work, from delivering babies to do- communication both upstream and downstream. emergency patients when appropriate, while ing heart surgery. The theme of our Shared When a call went out for personal protective freeing them from tasks that might be handled Care project became all the more relevant, be- equipment (PPE) early in the COVID crisis, for by others, such as respiratory ailments caused cause its objective was to distribute the load instance, health authority supplies were rapidly by forest fire smoke. more equitably, preventing Interior hospitals directed to those most in need. The TRDFP agreed and embarked on an and medical facilities from being swamped by The problem with emergency disaster man- Emergency Preparedness and Response Project people who could readily be helped elsewhere agement is that when you’re in the midst of a in 2019 with funding from the Shared Care in the community. community crisis, you don’t have time to plan Committee. In addition to me, the project team The team immediately rallied to shift the for a better response in the future, and imme- included Dr Joslyn Conley, community special- focus of the project to a community emergen- diately afterward you’re exhausted from having ist lead; Ms Rhonda Eden, project lead; and Mr cy response. We seized the chance provided responded as best you could. Emergencies are by the pandemic to help develop community usually short-lived as well—they’re resolved and resilience in real time, fostering partnerships, then the community moves on. However, as a The Emergency Preparedness and building networks, and facilitating effective long-term public health emergency, the pan- Response Project is funded by the Shared communications. Meanwhile, the division fa- demic has been an eye-opener. While terrible Care Committee. This article has not been cilitated the sharing of emergency management on so many fronts, it has left a positive legacy in peer reviewed by the BCMJ Editorial Board.

220 BC Medical Journal vol. 63 no. 5 | june 2021 the aforementioned improvements—channels are open throughout the health care commu- Rates: $75 for up to 1000 characters nity, and the importance of integrating com- CME calendar (maximum) plus GST per month; there is no partial rate. If the course or event munity providers into emergency planning is now abundantly clear. is over before an issue of the BCMJ comes out, there is no discount. Deadlines: When the dust settles on the pandemic, Online: Every Thursday (listings are posted every Friday). Print: The first of the our team hopes to bring together emergency month 1 month prior to the issue in which you want your notice to appear; e.g., 1 response providers from across the province, February for the March issue. The BCMJ is distributed by second-class mail in the even from across Western Canada, for a sym- second week of each month except January and August. Planning your CME posium. The lessons we’ve learned over the listing: Advertising your CME event several months in advance can help improve past year, within our Shared Care project and attendance; we suggest that your ad be posted 2 to 4 months prior to the event. beyond it, are that collaboration, integration, Ordering: Place your ad at www.bcmj.org/cme-advertising. You will be invoiced innovation, education, and funding are key upon publication. Payment is accepted by Visa or MasterCard on our secure online to emergency management success. Ideally, payment site. BC will establish an ongoing province-wide network with a solid organizational structure and the backing of the divisions and the health authorities, merging the skills of clinical PSYCHOLOGICAL PPE, PEER SUPPORT Providence Health Care, and Vancouver champions of emergency planning with those BEYOND COVID-19 Coastal Health. This course can be taken any- of community health care providers, among Online (Wednesdays) time and is divided into four lessons: (1) Social n and Political Context of gbMSM health, (2) other crucial players. In response to physician feedback, the Phy- —Graham Dodd, MD Epidemiology & Life Course, (3) Safer Spaces, sician Health Program’s online drop-in peer Physician Lead, Emergency Preparedness and Language, and Communication, and (4) Case support sessions, established 7 April, are now Response Project Studies. For more information visit https:// permanently scheduled for Wednesdays at Thompson Region Division of Family Practice ubccpd.ca/course/gbmsm-online. noon. The weekly sessions are cofacilitated by psychiatrist, Dr Jennifer Russel, and manager GP IN ONCOLOGY EDUCATION of clinical services, Roxanne Joyce, and are Vancouver (27 Sept–29 Oct) drop-in with no commitment required. The focus is peer support, not psychiatric care. All par- BC Cancer’s Family Practice Oncology Net- ticipants have the option to join anonymously. work offers an 8-week General Practitioner in To learn more about the sessions and the pro- Oncology education program beginning with a 2-week introductory session every spring BC Medical Journal gram, visit www.bcmj.org/news-covid-19/ Follow and fall at BC Cancer–Vancouver. This pro- @BCMedicalJrnl psychological-ppe-peer-support-beyond-covid gram provides an opportunity for rural family The BC Medical Journal provides continuing medical -19. Email [email protected] education through scientific research, review articles, and for the link to join by phone or video. physicians, with the support of their com- updates on contemporary clinical practice. #MedEd munity, to strengthen their oncology skills so #Vaccine toolkit for physicians. @DoctorsOfBC OPTIMIZING CARE FOR GAY, BISEXUAL, that they can provide enhanced care for local has developed an information toolkit to support cancer patients and their families. Following doctors and their teams in conversations with AND OTHER MEN WHO HAVE SEX WITH patients about #COVID19 vaccines. MEN the introductory session, participants com- Read the article: bcmj.org/news-covid-19 Online (ongoing) plete a further 30 days of clinic experience /vaccine-toolkit-physicians at the cancer centre where their patients are This is a short online CME course designed referred. These are scheduled flexibly over 6 for family physicians and primary care pro- months. Participants who complete the providers in Canada. This course will introduce gram are eligible for credits from the College you to gbMSM health issues and implica- of Family Physicians of Canada. Those who are tions with the intent to provide you with the REAP-eligible receive a stipend and expense knowledge and skills to improve the care of coverage through UBC’s Enhanced Skills your gbMSM patients. Designed in partner- Program. For more information or to apply, ship by UBC CPD and Community-Based visit www.fpon.ca, or contact Dilraj Mahil at Research Centre, Health Initiative for Men, [email protected]. Follow us on Twitter for regular updates Interior Health, Island Health, Fraser Health, Northern Health, Men’s Health Initiative,

BC Medical Journal vol. 63 no. 5 | June 2021 221 Obituaries We welcome original tributes of less than 500 words; we may edit them for clarity and length. Obituaries may be emailed to [email protected]. Include birth and death dates, full name and name deceased was best known by, key hospital and professional affiliations, relevant biographical data, and a high-resolution head-and-shoulders photo.

Robert was one of the first full-time clinician SFU Library Special Collections. Late in life, scientists in dermatology in Vancouver, with Robert expanded his inner horizons by writ- his work supported by the Medical Research ing five novels. Council of Canada. He later transitioned to Robert was a man of principle, adhering to a community dermatology practice in Burnaby life-long vegetarian diet. He also had a discrimi- as a clinical faculty member while providing nating taste for fine wine and good honey. As consulting services at both Vancouver General in his professional career, he insisted on preci- and Burnaby Hospitals. He became an expert in sion in everything, doing complex mathemati- clinical hair disorders and also ran our pediatric cal calculations in his head down to the last hair clinic at BC Children’s Hospital. Robert decimal point. Robert and his wife Rosemary enthusiastically shared his clinical expertise were a perfect team in their large garden, she with residents and medical students, and we all planting and he trimming back. He was a wise marveled at his astute and meticulous attention and kind father and grandfather. Many friends, to the morphologic details of skin lesions as well colleagues, students, and patients held him in as his kind and reassuring manner. great affection and admiration. For many years Robert was the only der- —Harvey Lui, MD, FRCPC matologist in Burnaby, and many Burnaby resi- Vancouver dents were his patients. They might have been —Rosemary Coupe surprised to see him walking home through Burnaby Deer Lake Park before the days of the board- walk. When the lake flooded he rolled up his Dr Robert Lachlan MacLeod trousers and pushed on through the mud, care- Coupe Recently deceased physicians fully balancing his briefcase above it. After di- If a BC physician you knew well is 1935–2021 minishing eyesight forced him into retirement, recently deceased, please consider many patients still greeted him on the street. submitting an obituary. Include Robert died peacefully after a long and rich He remained the volunteer librarian for the the deceased’s dates of birth and life, 1 day short of his 86th birthday in January university department’s dermatology collec- death, full name and the name the 2021. He was born in Manchester, England, tions, some of which he personally donated. deceased was best known by, key and attended Merchant Taylors’ School, where Robert’s energy, acute intelligence, and sharp hospital and professional affiliations, he won a state scholarship with a distinction in memory led to many interests. He climbed relevant biographical data, and a biology, going on to take his medical degree at many BC mountains, although the Cuillin high-resolution photo. Please limit the University of Liverpool. In 1958 he came mountain range on the Isle of Skye was his your submission to a maximum of 500 to Canada, interning in St. John’s, doing an “spiritual home.” These roots led him to en- words. Send the content and photo internal medicine residency in Halifax, and joy Scottish country dancing and do exten- by e-mail to [email protected]. his dermatology fellowship in Montreal. His sive research on his ancestors. Robert was an last years of specialty training were in Min- accomplished scholar of William Morris, the neapolis, leading to an FRCPC in 1963 and 19th-century poet, designer, publisher, and so- MSc 2 years later. cialist, and published his own definitive book His passion for mountaineering then on illustrated editions of Morris’ works. That brought him to Vancouver, initially to a re- interest lives on in the Robert Coupe Collection search position in skin tissue culture at UBC. of Works by and about William Morris, now in

222 BC Medical Journal vol. 63 no. 5 | june 2021 Classifieds Advertisements are limited to 700 characters. Rates: Doctors of BC members: $50 + GST per month for each insertion of up to 350 characters. $75 + GST for insertions of 351 to 700 characters. Nonmembers: $60 + GST per month for each insertion of up to 350 characters. $90 + GST for insertions of 351 to 700 characters. Deadlines: Ads must be submitted or canceled by the first of the month preceding the month of publication, e.g., by 1 November for December publication. Visit www.bcmj.org/classified-advertising for more information. Ordering: Place your classified ad online at www.bcmj.org/classified -advertising. Payment is required at the time that you place the ad.

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BC Medical Journal vol. 63 no. 5 | June 2021 223 Classifieds for a population of 3500 in four hospital. This beautiful commu- days per week. Clinic with eight seeking psychiatrists to work 1–3 communities across the tradi- nity offers outstanding outdoor exam rooms, two physio rooms, days per week in a well-estab- tional Nisga’a Territory. A team recreation. For more information and pharmacy on site. lished reproductive mental of three physicians works contact Laurie Fuller: Competitive split. For more health program based at BC together to provide full-scope 604 485-3927, email: information please contact Women’s Hospital. Great team services (excluding obstetrics) in [email protected], website: Anand at wecaremedical and excellent support staff. concert with other services such powellrivermedicalclinic.ca. [email protected] or Please send your CV and cover as home care, public health, and SOUTH SURREY/WHITE 778 888-7588. letter outlining your interest to mental wellness and addictions. ROCK—FP SURREY CITY CENTRE— [email protected]. The health and wellness centrer Busy family/walk-in practice in SPECIALISTS, RMTs, PHYSIO, VANCOUVER/RICHMOND—FP/ are staffed with full-time RNs DIETITIANS SPECIALIST who take first call after hours. South Surrey requires GP to Soaring mountains, picturesque build family practice. The The Mercer Clinic at City We welcome all physicians, from fjords, dramatic lava beds, natural community is growing rapidly Centre 2 is inviting specialists, new graduates to semi-retired, hot springs, and thriving rivers and there is great need for family registered massage therapists, part time or full time. Virtual, offer outstanding recreation year physicians. Close to beaches and physiotherapists, and dietitians walk-in, or full-service family round. Excellent remuneration. recreational areas of Metro to join our team in a part-time medicine and all specialties. Contact Jeremy Penner at md@ Vancouver. OSCAR EMR, or full-time capacity. Our current Excellent splits at the busy nisgaahealth.bc.ca. nurses/MOAs on all shifts. medical team includes two South Vancouver and Richmond CDM support available. endocrinologists and an internist. Superstore medical clinics. NORTH VAN—FP LOCUM Competitive split. Please contact Our clinic is a brand new, Efficient and customizable Busy, established physicians with Carol at Peninsulamedical@live well-equipped modern facility OSCAR EMR. Well-organized stellar support staff seek part- .com or 604 916-2050. and has plenty of examination clinics. Contact Winnie at time or full-time associates. SURREY—GPs AND SPECIALIST rooms and offices for physicians. [email protected]. Doctors currently needed to fill OPPORTUNITIES We use Accuro EMR and have VANCOUVER—LOCUM very busy telemedicine and highly trained staff, which allows Considering a change of location COVERAGE, BEAUTIFUL CLINIC in-office shifts. Oscar EMR with for no administrative burdens. STEPS FROM VGH technical support. Part-time or practice? Or considering We are conveniently located associates will be on a 70/30 split merging? Whether you are in steps away from Surrey A beautiful clinic (steps from for weekend and evening shifts. family practice or a specialist we Memorial Hospital, LifeLabs, VGH) is looking for locum Option of working from home. have opportunities in a beauti- and West Coast Imaging. For coverage for booked appoint- For further information contact fully appointed clinic in the more information please contact ments with a variety of shifts Kim at 604 987-0918 or heart of Central City in Surrey Jessie at [email protected] available. The clinic is open 7 [email protected]. close to all new development at or 236 427-1088. days per week, 9 a.m. to 8 p.m. City Hall. Free parking, close to on weekdays and 10 a.m. to 4 NORTH VANCOUVER—FP buses, trains, and very easy SURREY/DELTA/ p.m. on weekends. The clinic LOCUM location to drive to, this practice ABBOTSFORD—GPs/ functions as a walk-in clinic and SPECIALISTS Come practice on the North is fully computerized using family practice hybrid clinic Shore in a busy, friendly clinic of OSCAR EMR and is close to Considering a change of practice serving the local neighborhood/ three doctors. Excellent staff and recreational areas in an afford- style or location? Or selling your community, with a very welcom- remuneration without OB or able part of the Lower Mainland. practice? Group of seven ing and warm atmosphere. The hospital work. Looking for Full- or part-time, room rental, locations has opportunities for patient demographics of the area 3 months of locum cover per or full admin support, the family, walk-in, or specialists. include a wide spectrum with a year, starting with September flexibility and choice can be Full-time, part-time, or locum mix of families from newborn to and October 2021. discussed. Contact Priti doctors guaranteed to be busy. geriatric. It is also a resident Please reply to clinic manager at at 604 788-3649 or We provide administrative teaching site. In general, [email protected] email [email protected]. support. Paul Foster, appointments are booked every for more details. SURREY (BEAR CREEK AND 604 572-4558 or pfoster@ 10 minutes (4 hours booked and POWELL RIVER—LOCUM NEWTON)—FAMILY PRACTICE denninghealth.ca. two spots for walk-in). However, VANCOUVER—PSYCHIATRISTS there is an opportunity for some The Medical Clinic Associates is We are looking for part-time/ WANTED flexibility. Contact looking for short- and long-term full-time physicians for walk-in/ [email protected]. locums. The medical community family practice to work on the Are you a psychiatrist looking to offers excellent specialist backup flexible shifts between 9 a.m. and join a team of perinatal special- and has a well-equipped 33-bed 6 p.m.; option to work 7 or 5 ists in Vancouver? We are

224 BC Medical Journal vol. 63 no. 5 | june 2021 Classifieds

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