FEATURE Using digital health interventions to improve access to sexual and reproductive health services in British Columbia

COMMENTARY Medicine and the media: a synergistic combination?

REVIEW All fun and games? Exploring the positive effects educational video games can have on medical learners

NEWS AND LETTERS Mixed reviews: critiques and compliments of physician-rating websites The University of British Columbia Medical Journal (UBCMJ) is a On the cover peer-reviewed, student- driven academic journal with the goal of engaging students in medical dialogue and contributing meaningful discourse to the scientific community.

FEATURE Using digital health interventions to improve access to sexual and reproductive health services in British Columbia

COMMENTARY Medicine and the media: a synergistic combination?

REVIEW All fun and games? Exploring the positive effects educational video games can have on medical learners

NEWS AND LETTERS Mixed reviews: critiques and compliments of physician-rating websites

www.ubcmj.com ISSN: 1920 -7425

9 771920 742004

edia has long been an integral part of how the medical Mcommunity communicates with the public. Technological advances have made creating and consuming media content easier than ever before. In this issue, we explore how physicians can use digital media to make healthcare more accessible for the community as well as how media can change the way we study and practice medicine. To subscribe, advertise or submit, see our website. ubcmj.med.ubc.ca Rachel Zhao, MD Program, Faculty of Medicine, University of British Mailing Address: Columbia, Vancouver, BC, Canada UBC Medical Journal c/o Student Affairs, UBC Faculty of Medicine 2775 Laurel Street, 11th Floor Vancouver, BC V5Z 1M9

DISCLAIMER: Please note that views expressed in the UBCMJ do not necessarily reflect the views of the editors, the Faculty of Medicine or any organizations affiliated with this publication. They are solely the authors’ opinion and are intended to stimulate academic dialogue. Contents VOLUME 11 ISSUE 2 | Spring 2020

EDITORIAL COMMENTARIES

3 Medicine and media: opposites attract 30 Medicine and the media: a synergistic Hur S.A., Wang C. combination? Dean P.H., Zou V.Z.

32 Caution and guidance for the social media FEATURE savvy physician Khan W.I. 4 Using digital health interventions to improve access to sexual and reproductive health 34 The role of the public on physician services in British Columbia remuneration in Canada: the cases of British Pedersen H., Gilbert M., Smith L., Ogilvie G. Columbia and Ontario McNeely B. 6 Social media impacts on the dissemination of health-related information and patient- 36 An analysis of current trends in multimedia physician relationships platform usage and surgery Goobie G.C. Udwadia F.R., Khan H.M.

9 SmartMom: teaching by texting 38 Young physicians on YouTube: helping Janssen P.A., Pennington S. patients connect with health care Rietchel L.

ACADEMIC RESEARCH 40 Launching resident-led simulations to augment the undergraduate medical school 11 Gender/sex disparity in self-reported sleep curriculum Moroz P.A., Douglas S.L.M., Gill D.D. quality among Canadian adults Rich A.J., Koehoorn M., Ayas N.T., Shoveller J.

NEWS AND LETTERS REVIEWS 43 Mixed reviews: critiques and compliments of 17 Climate change and human health physician rating websites Paul B.R. Dayan Z., Suleman R., Kapoor V.

20 All fun and games? Exploring the positive effects educational video games can have on medical learners Chow R., Cheung M.

23 A review of wilderness patient transport: a British Columbian perspective Stanley A., Buhler H.

27 Backcountry triggered avalanches: a summary of risk factors, causes of death, and wilderness medical management Stich A., Blanco J.

UBCMJ Volume 11 Issue 2 | Spring 2020 2 EDITORIAL

Medicine and media: opposites attract Seo Am Hur1, Christine Wang1 Citation: UBCMJ. 2020: 11.2 (3)

re medicine and media a compatible pair? Medicine, at its core, BC Centre for Disease Control, which discusses the development of Avalues privacy, confidentiality, and professionalism. On the other two digital health interventions aimed to improve access to sexual and hand, most forms of media thrive on transparency, dissemination of reproductive health screening, as well as the realistic opportunities and knowledge, and—at times—informality, especially with the rise of challenges of incorporating such resources in today’s care. Lastly, this social media. Despite (or perhaps due to) these differences, medicine issue features a discussion of a text message-based prenatal education has been a longstanding subject of interest in the media and the two program developed by Dr. Patricia Janssen and her team at the UBC work closely alongside each other. Newspapers and scientific journals School of Population and Public Health. This mobile health program report on the latest medical breakthroughs and rare disease case for expecting mothers again underscores the fact that multiple reports shared by healthcare professionals and researchers. Television healthcare resources facilitated by media are currently being used to and radio programs disseminate a variety of health-related messages, serve various populations in British Columbia. from advertisements of health products to public health campaigns Despite their seemingly conflicting values, medicine and media such as Stop Overdose BC.1 The internet contains a wealth of may be inseparable in this interconnected society. As you read this information that is just a click away. issue, we invite you to reflect on the impact of media in your life The impact of media on medicine has been magnified in the last as a medical student, healthcare professional, researcher, or everyday decade with the surge of social media. Platforms such as Facebook, consumer of information. Twitter, and YouTube that began as means for social networking and content sharing have now developed into ubiquitous media giants Conflict of interest with billions of active monthly users,2 including patients as well as The authors have declared no conflict of interest. current and future healthcare professionals. According to national References surveys conducted in the United States and Canada, approximately 1. Stop Overdose BC [Internet]. Victoria BC: Government of British Columbia; 2019 40% of practicing physicians reported using Facebook or other forms [cited 2019 Dec 11]. Available from: https://www.stopoverdose.gov.bc.ca/stop- overdose of online social media, with markedly higher usage rates of 79% and 2. Facebook. Facebook Newsroom [Internet]. Menlo Park CA: Facebook; 2019 [cited 93% among the younger cohorts of resident physicians and medical 2019 Dec 4]. Available from: https://about.fb.com/news/ 3,4 3. Bosslet GT, Torke AM, Hickman SE, Terry CL, Helft PR. The patient-doctor students, respectively. The pervasiveness of social media makes it relationship and online social networks: results of a national survey. J Gen Intern a convenient and powerful tool that can affect healthcare decisions Med. 2011;26(10):1168–74. 4. College of Family Physician of Canada. 2014 National physician survey. Mississauga made by patients, doctors, and policymakers. When used appropriately, ON: National Physician Survey; 2014. 13 p. social media can increase awareness and share knowledge among the 5. Cystic Fibrosis Canada [Internet]. Toronto ON: Cystic Fibrosis Canada; 2019 [cited 2019 Dec 11]. Available from: https://www.cysticfibrosis.ca lay and medical audience, as exemplified by the Movember initiative 6. National Kidney Foundation [Internet]. New York NY: National Kidney or Twitter hashtags used by researchers at major scientific meetings Foundation, Inc.; 2019 [cited 2019 Dec 4]. Available from: https://www.kidney.org to garner peers’ attention for their work. However, the interaction between social media and medicine can blur the professional boundary of patient-physician relationships and raise concerns of patient privacy and confidentiality. The ease of accessibility to social media can also be abused to spread misinformation and propagate false beliefs, as seen by the anti-vaccination movement today. In this issue’s feature articles section, clinician investigator program fellow Dr. Gillian Goobie discusses the impact of social media on dissemination of information and patient-physician relationships in the context of specific illnesses. Certain healthcare fields and their patients have embraced different forms of media to improve care and service accessibility. Patients living with chronic diseases, such as cystic fibrosis and chronic kidney disease, make use of social media groups to connect, find peer and medical support, and build advocacy programs for new treatments or patient engagement.5,6 This topic is explored in a joint feature by Dr. Mark Gilbert, Dr. Gina Ogilvie, and their teams from

1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada Correspondence to Seo Am Hur ([email protected]) Christine Wang ([email protected])

3 UBCMJ Volume 11 Issue 2 | Spring 2020 FEATURE

Using digital health interventions to improve access to sexual and reproductive health services in British Columbia Heather Pedersen1, Mark Gilbert1,2, Laurie Smith3,4, Gina Ogilvie1,2,3 Citation: UBCMJ. 2020: 11.2 (4-5)

Sexual and reproductive health service barriers information accessed.7 Digital health interventions are appealing ncreasing rates of sexually transmitted and blood borne infections for their convenience and reduce the need for interactions with the I(STBBI) are of significant public health concern. Rates of healthcare setting or providers. Digital sexual health tools such as chlamydia (317.6 per 100,000 population in 2016), gonorrhea (68.8 internet-based testing offer low-barrier approaches with the potential per 100,000 population in 2016) and syphilis (18.4 per 100,000 to improve access for priority populations, and increase efficiencies population in 2018) have increased in British Columbia (BC) over within primary care.8,9 In BC, partnerships within the Provincial Health the last two decades.1 These infections are often asymptomatic, but Services Authority including the BC Centre for Disease Control if detected early through screening, can be easily managed or treated. (BCCDC), BC Cancer, and the BC Public Health Laboratory, along Another very common STBBI is human papillomavirus (HPV), with regional health authorities, have led to the development of two which is the primary cause of cervical cancer. More than 75% of all digital health interventions, GetCheckedOnline and CervixCheck, to sexually active adults will have had an HPV infection at some point address barriers to SRH screening in BC. in their lifetime.2 Through cervical cancer screening, cell changes GetCheckedOnline (GCO) is an internet-based testing service caused by HPV can usually be detected and treated early, preventing for STBBIs developed by BCCDC that lets individuals test for progression to cervical cancer. However, approximately 30% of the chlamydia, gonorrhea, syphilis, HIV, and hepatitis C without needing BC population is under-screened for cervical cancer—an enduring to see a clinician in person.10 GCO users create their own laboratory gap that standard practice has yet been unable to address.3 As a result, requisitions on the website, visit a participating lab to provide it comes as no surprise that those who face barriers or lack access to specimens, and receive results online (if negative) or by phone (if sexual and reproductive health (SRH) services and screening (Table positive). All users are offered gonorrhea and chlamydia urine testing, 1) also experience a higher burden of STBBI and cervical cancer.3–5 plus HIV and syphilis serology testing. Some are additionally offered This article discusses two internet-based testing services developed gonorrhea and chlamydia throat and/or rectal swabs, or hepatitis C to improve access to SRH care in BC, and the opportunities for and serology if indicated by the assessment. Clients can opt out of any challenges to implementation in a primary care context. of the recommended tests if they choose to. Testing through GCO is done centrally through the BC Public Health Laboratory, and Table 1 |Access barriers to SRH services in BC, adapted from a multi-level framework for testing barriers and facilitators.6 treatment and follow up is managed by the Provincial STI Clinic at the BCCDC. To reduce barriers related to concerns about confidentiality Barrier Level Examples of testing, clients do not need to use their real name and are not asked Individual-level Lack of awareness of the need for screening to provide their personal health number (PHN) when they register Provider-level Not having a primary care provider, not wanting for GCO, with tests conducted using a unique alphanumeric code. to discuss SRH with available healthcare GCO launched in Vancouver in September 2014, and in February provider for fear of judgement, or preference 2016 expanded to Island Health (Victoria, Langford, Duncan) and for another provider (e.g., a female provider, or Interior Health (Kamloops, Nelson), with over 800 test episodes per one who specializes in sexual health) month since January 2018. Research has demonstrated that GCO Healthcare system Inconvenient clinic hours or location reaches people at a higher risk of STBBI and helps to mitigate known barriers to accessing traditional clinic-based testing. Compared to Social and structural Stigma, embarrassment, cultural taboo, trauma, STI clinic clients, people who used GCO were more likely to report or mistrust of the healthcare system that they previously delayed testing due to distance and wait times, felt discomfort discussing sexual health issues, and feared judgement Digital health solutions in BC to improve access to services from any healthcare provider.6 GCO also may facilitate a higher rate There is increasing public interest in, access to, and use of health of repeat testing, which in individuals at ongoing risk of STBBI can services online in Canada.7 The number of Canadians who accessed facilitate earlier diagnosis and treatment.11 A recent chart review found their medical records online in the last year doubled from 2016 that 98.8% of GCO users completed treatment, which is comparable to 2018, with lab testing being the most common type of health to the treatment uptake among BCCDC STI clinic clients. CervixCheck is an online service for at-home cervical cancer screening for women who do not regularly attend screening. It was 1BC Centre for Disease Control, Clinical Prevention Services developed by BC Cancer and UBC researchers in partnership with the 2University of British Columbia, Faculty of Medicine, School of Population and Public Health team that developed GCO, and builds on the GCO platform by being 3Women’s Health Research Institute integrated within primary care (i.e., results are returned to primary 4BC Cancer, Cancer Control Research care providers). CervixCheck uses HPV testing, which is an evidence- Correspondence to based, effective way to screen for cervical cancer. Compared to cervix Heather Pedersen ([email protected]) screening with the Pap test, HPV testing allows the opportunity for

UBCMJ Volume 11 Issue 2 | Spring 2020 4 FEATURE self-sampling, where women can collect their own vaginal specimens. Conflict of interest To use CervixCheck, participants must be registered with MSP and The authors have declared no conflict of interest. be a patient of a collaborating healthcare provider. The participants’ References screening results are available online for the participant, in addition 1. BC Centre for Disease Control. STI in British Columbia: Annual Surveillance Report 2016 [Internet]. Vancouver, British Columbia: BC Centre for Disease to being sent to a pre-identified primary healthcare provider to help Control; 2018 [cited 2019 Oct 28]. Available from: http://www.bccdc.ca/ ensure linkage to care in the event of an abnormal or positive result. search?k=sti%20annual%20report/. 2. The Society of Obstetricians and Gynaecologists of Canada. HPVInfo [Internet]. CervixCheck launched in May 2019, and is being piloted as a research Ottawa, Ontario: HPVInfo.ca; 2019 [cited 2019 Feb 12]. Available from: https:// project in select communities with low screening rates in the Fraser www.hpvinfo.ca/. 3. BC Cancer Cervix Screening 2017 Program Results [Internet]. Vancouver, and Northern Health regions, with plans for eventual scale up to British Columbia: BC Cancer Cervix Screening Program; 2019 [cited 2019 Nov other areas. CervixCheck will evaluate uptake of self-collected cervical 5]. Available from: http://www.bccancer.bc.ca/screening/Documents/Cervix_ ProgramResults2017_FINAL.pdf/. cancer screening and acceptability of the service. Attendance among 4. Nanditha NGA, St-Jean M, Tafessu H, Guillemi SA, Hull MW, Lu M, et al. those that were recommended follow-up care will be a key outcome Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: a retrospective cohort study. PLoS One. 2019;14(3):e0214012. that will be measured to determine whether the CervixCheck model 5. Mitchell K, Roberts A, Gilbert M, Homma Y, Warf C, Daly KL, et al. Improving the can support participants throughout the full continuum of care. accuracy of Chlamydia trachomatis incidence rate estimates among adolescents in Canada. Can J Hum Sex. 2015;24(1):12–8. Opportunities and challenges for integration with 6. Gilbert M, Thomson K, Salway T, Haag D, Grennan T, Fairley CK, et al. Differences primary care in experiences of barriers to STI testing between clients of the internet-based diagnostic testing service GetCheckedOnline.com and an STI clinic in Vancouver, These innovative digital health solutions hold great potential for Canada. Sex Trans Infect. 2019;95(2):151–6. improving SRH, and there is even more potential for further 7. Connecting Patients for Better Health: 2018 [Internet]. Toronto, Ontario: Canada Health Infoway; 2018 [cited 2019 Oct 28]. Available from: https://infoway- adaptation to improve access (e.g., incorporating telemedicine services inforoute.ca/en/component/edocman/3564-connecting-patients-for-better- for prescribing HIV pre-exposure prophylaxis, and incorporating health-2018/view-document?Itemid=101/. 8. Rietmeijer CA, McFarlane M. STI prevention services online: moving beyond the 12 digital tools for notifying sexual partners to get tested). However, proof of concept. Sex Trans Dis. 2008;35(8):770–1. bringing these innovations to scale across BC has many challenges, not 9. McFarlane M, Bull SS. Use of the Internet in STD/HIV Prevention. In: Aral SO, Douglas JM, editors. Behav Interv Prev Cont of Sex Trans Dis. Boston, MA: Springer least of which is rising costs due to increasing utilization. In smaller US; 2007. p. 214–31. cities and rural and remote communities, there may be limited or no 10. Gilbert M, Salway T, Haag D, Fairley CK, Wong J, Grennan T, et al. Use of GetCheckedOnline, a comprehensive web-based testing service for sexually access to laboratories for specimen collection. People may also have transmitted and blood-borne infections. J Med Internet Res. 2017;19(3):e81. inconsistent or multiple healthcare providers, which can be a challenge 11. Gilbert M, Salway T, Haag D, Elliot E, Fairley C, Krajden M, et al. A cohort study comparing rate of repeat testing for sexually transmitted and blood-borne infections for follow-up of lab results. There are also concerns that services like between clients of an internet-based testing programme and of sexually transmitted GCO and CervixCheck risk creating a parallel or siloed system of infection clinics in Vancouver, Canada. Sex Trans Infect. 2019;95(7):540–6. 12. Doull M, Haag D, Bondyra M, Lee C, Dinner K, Wong T, et al. Similarities and care that exacerbates health inequities by reaching people who are differences in perceptions of models for online partner notification for sexually already engaged in existing in-person primary care health services. It transmitted infections: potential users versus care providers. Poster session presented at: World STI & HIV Congress; 2015 Sept 13–16; Brisbane. is reassuring that early evidence suggests that this is likely not the case, 13. Ablona A, Korol E, Gauthier B, Campeau L, Bannar-Martin S, Karlsson M, et al. and that these programs may instead connect people to the healthcare Regional differences in use of GetCheckedOnline and client characteristics across British Columbia, Canada. Poster session presented at: STI & HIV World Congress; system who might otherwise not be engaged. For example, up to one 2019 July 14–17; Vancouver. in five GCO clients report never having previously tested for STBBI, 14. B.C. government’s primary health-care strategy focuses on faster, team-based care [Internet]. Vancouver, British Columbia: Government of British Columbia Office a high proportion of whom live in suburban or rural areas.13 of the Premier; 2018 [cited 2019 Nov 28]. Available from: https://news.gov.bc.ca/ With the BC government’s renewed prioritization and funding releases/2018PREM0034-001010/. 15. Gomez-Ramirez O, Thomson K, Grace D, Salway T, Grennan T, Haag D, et al., towards improving primary care,14 ensuring that digital health tools editors. Tensions in how potential users and service providers perceive the utility are integrated with primary care networks and useful to the practice and acceptability of online HIV/STI Risk Self-Assessment tools. Poster session presented at: Canadian Association of HIV Research Conference; 2018 April 26– of primary care physicians will be key to their successful scale-up. 29; Vancouver. Both GCO and CervixCheck programs continue to consider how 16. Ablona A. Descriptive analysis from GetCheckedOnline client survey 2015–2019 (internal communication). 2019. best to do this through iterative cycles of evaluation and adaptation. 17. BC Health Information Management Professionals Society, editor Province of BC One approach currently planned for GCO that will facilitate this is Digital Health Strategy: Transforming our health system so all British Columbians can achieve optimal health and wellness. BCHIMPS Conference Keynote; 2019 adopting the CervixCheck model of giving users the option to use March 1, 2019; Vancouver, BC. their PHN for testing and to identify their primary care provider for receipt of test results—an option valued by providers in early research15 and which does not pose a barrier for a majority of GCO clients surveyed.16 The team is also looking at ways to offer CervixCheck to under-screened women who do not have a primary healthcare provider, and offer access to clinics or clinicians who can support them through follow-up. Indeed, the importance of digital technologies to accelerate primary and community care while empowering patients in their own care are core pillars of digital health strategies in BC.17 As digital health services for SRH continue to evolve in BC, it will be important to continue evaluating their impact to ensure that they are reaching individuals facing the greatest barriers to access.

5 UBCMJ Volume 11 Issue 2 | Spring 2020 FEATURE

Social media impacts on the dissemination of health-related information and patient-physician relationships Gillian C. Goobie1,2 Citation: UBCMJ. 2020: 11.2 (6-8)

Introduction YouTube n our increasingly interconnected society, healthcare professionals YouTube is the second most frequented website on the internet, Ishould be aware of the impacts of social media on the health and surpassed only by Google.5 A 2019 survey found that YouTube is wellness of their patients. Social media has a number of positive used by 73% of U.S. adults, making it the most popular social media attributes for patients, including greater access to health information, platform.3 YouTube has also been used in medical education, especially increased support networks, and avenues for healthcare policy- to promote procedural skill attainment.6 The accuracy and reliability related messaging.1 Similarly, social media can be used in medical of patient-directed health information on YouTube has been assessed education to engage learners, enhance professional development, for a variety of conditions. Many of these studies raise concerns about and provide networking communities.2 Despite these advantages, the propagation of misinformation, including the promotion of pro- concerns have been raised regarding the potential for dissemination anorexia and anti-vaccination perspectives.7–9 of misinformation through these platforms. Healthcare professionals The accuracy and quality of medical information on YouTube need to be cognizant of their role on social media and remain aware may be affected by the source producing the videos.10,11 For idiopathic of professionalism issues that can arise across these domains. pulmonary fibrosis, information produced by foundations or While social media usage is often perceived to be limited to medical organizations, news organizations, and independent medical “Millennials” and younger generations, there has been a steady professionals had higher accuracy and quality compared to videos increase in its usage among all age groups in the U.S. since 2006 (Figure produced by for profit organizations or independent non-medical 1).3 Regarding health-relevant social media usage, a 2013 survey of users.11 Non-recommended or potentially harmful therapies were obstetrics and gynaecology patients found that 99% of respondents endorsed in 17% of all videos, with the potential for producers to used one or more forms of social media, with 32% of these patients directly profit from consumer investment. These videos had higher using social media for health-related reasons.4 This highlights the viewership and user interaction than videos that did not support increasingly important role that social media plays in society and non-recommended therapies, thereby increasing the propagation of emphasizes the importance of evaluating the impact of these inaccurate information to patient audiences. platforms on patient education and patient-physician relationships. Despite these concerns, YouTube has the potential to provide This article seeks to summarize the major forms of social media accurate and reliable health information to patient audiences. Health used by patients, as well as explore the literature surrounding social on the Net (HON) is an organization that evaluates the accessibility media education and effective use of these platforms by healthcare and trustworthiness of health information on the internet. The HON professionals. Code tool has been used to assess the quality of information available on the internet and YouTube for several medical conditions.10–12 The widespread implementation of this type of assessment tool for medically-relevant social media could help patients and healthcare providers identify informative resources for health-related content. Furthermore, the identification and professional endorsement of quality information could assist policy makers and investors in improving the accuracy of medical information on YouTube. Facebook After YouTube, Facebook is the second most popular form of social media,3 with numerous patient support groups available for many conditions.13–15 There is increasing public interest in using Facebook to engage with healthcare professionals and medical organizations.14,16 Figure 1 | The percentage of U.S. adults who use at least one social media site (2006- A 2016 study surveyed members of Facebook groups focused on 2019), by age group. Reproduced with permission from the Pew Research Center. congenital anomalies and found that 84% of respondents would like healthcare professionals to engage in their groups and 97% would like to join groups developed by their primary hospital.14 Healthcare professionals and medical organizations can harness this interest, along with the vast networks of Facebook, to engage patients in 1Clinician Investigator Program Fellow, University of British Columbia supportive and educational dialogues. One example of this approach 2PhD Student, Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh is the Manchester Adult Cystic Fibrosis (CF) Centre Facebook page, which was created to improve healthcare communication and patient Correspondence to 17 Gillian C. Goobie ([email protected]) interactions in a large adult CF centre. This page has been successful

UBCMJ Volume 11 Issue 2 | Spring 2020 6 FEATURE in engaging patients in both supportive and educational dialogues respondents had received friend requests from patients within the past about CF. year.16 Of these physicians, only 10% had received formal social media Although there are many useful and supportive pages on training. This highlights the possibility of professionalism and privacy Facebook, there is also increasing concern about the content and issues that may arise for healthcare professionals using social media. quality of some health-related information on the site. A 2014 study Patients who use social media for health-related purposes have evaluated the source and content of 522 Facebook pages pertaining reported that their primary motives are to increase knowledge, to the top 20 health conditions searched on Google.15 The most exchange advice, and obtain social support.4 In contrast, the motives frequently found pages focused on marketing and promotion (32%), of health professionals for using health-related social media are largely followed by information and awareness (21%), with fewer pages related to communication with colleagues, marketing, and to a lesser focusing on patient support (9%). The high proportion of marketing- extent, patient-physician communication.4 It is important to consider related pages indicates that patients may be susceptible to advertising these differing motives when navigating the challenging landscape of of non-recommended therapies on pages that are run by industry social media as a health professional. or for-profit organizations. Despite advertising concerns, there is a Conclusions demand for more professional-driven content on social media.14 This While there are numerous potential benefits from patients engaging avenue should be further developed by the healthcare system to offset in social media, there is also the possibility of harm from the the proliferation of misinformation across these platforms. dissemination of misinformation. Tools like the HON Code are being Twitter implemented in research to evaluate the quality of information on The majority of publications evaluating health-related information websites and YouTube, but these tools need to be more widely applied on Twitter have been descriptive in nature.18–20 A smaller body of across various forms of social media. Wider application of these tools literature supports Twitter as a beneficial platform for patient support would help to ensure that medical information propagated across and education.21,22 Participation in the Breast Cancer Social Media these platforms is accurate and not exploitative. Equally important Twitter support community was found to be associated with reduced is the recognition of how medical information received through anxiety levels among patient respondents in a 2015 survey.21 Another these forums can impact the patient-physician relationship. The use evaluation of colorectal cancer-related tweets found that 85% of a of social media by both healthcare professionals and patients has the subset of tweets contained credible information, and that a higher potential to blur professional lines and introduce privacy issues. Social number of retweets was correlated with a greater likelihood of the media conduct training should be provided throughout continuing tweet containing accurate medical information.22 This preliminary medical education, as this is a constantly evolving domain. research indicates that health information disseminated on Twitter It is imperative that healthcare professionals and medical may be of higher quality than seen on other platforms like YouTube organizations recognize this new realm for communication of health and Facebook. information and counsel patients about the responsible use of social One potential reason for the higher quality of information on media. The possible benefits of social media in healthcare are vast, Twitter is that it is the most frequently used platform to disseminate but harnessing this potential requires health professionals to engage information about novel research.6 Twitter is frequently used by health social media investors and policymakers to achieve a common goal of professionals, especially at medical conferences and in residency providing accurate and accessible health information through these education.6 However, Twitter is less frequently used across the wider platforms. population, with only 22% of U.S. adults surveyed in 2019 using this platform.23 Further study is required to verify the observed benefits Conflict of interest of Twitter. These evidence-based conclusions may assist healthcare The author has declared no conflict of interest. professionals in developing effective approaches of communicating References health-related information using this platform. 1. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C, et al. A New dimension of health care: systematic review of the uses, benefits, and limitations of Social media and the patient-physician relationship social media for health communication. J Med Internet Res. 2013;15(4):e85. Social media is a new and important element in the patient-physician 2. Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education: a systematic review. Academic Medicine. 2013;88(6):893–901. relationship; however, the best methods of implementing social 3. Pew Research Center. Demographics of Social Media Users and Adoption in the media training into medical curriculum remain unclear.24 Social United States [Internet]. Pew Research Center, Washington D.C. 2019 [cited 2019 Nov 3]. Available from: https://www.pewresearch.org/internet/fact-sheet/social- media training in medical school has been shown to enhance and media/ maintain empathy and professionalism in medical students, aid in 4. Antheunis ML, Tates K, Nieboer E. Patients’ and health professionals’ use of social media in health care: Motives, barriers and expectations. Patient Educ Couns. career advancement and networking, and provide a novel platform 2013;92(3):426–31. for learner engagement.2 The University of British Columbia Faculty 5. Alexa. youtube.com Competitive Analysis, Marketing Mix and Traffic [Internet]. Alexa Internet, Inc. 2019 [cited 2019 Nov 3]. Available from: https://www.alexa. of Medicine Office of Professionalism and the College of Physicians com/siteinfo/youtube.com and Surgeons of British Columbia teaches medical students about 6. Sterling M, Leung P, Wright D, Bishop TF. The use of social media in graduate medical education: a systematic review. Acad Med. 2017;92(7):1043–56. social media and professionalism, but formal social media training 7. Syed-Abdul S, Fernandez-Luque L, Jian W-S, Li Y-C, Crain S, Hsu M-H, et al. is not currently mandated by The Committee on the Accreditation Misleading health-related information promoted through video-based social media: 25 anorexia on YouTube. J Med Internet Res. 2013;15(2):e30. of Canadian Medical Schools (CACMS). A 2012 study surveying 8. Keelan J, Pavri-Garcia V, Tomlinson G, Wilson K. YouTube as a source of psychiatry residents found that 96% had a Facebook account, but the information on immunization: a content analysis. JAMA. 2007;298(21):2482–4. 9. Ache KA, Wallace LS. Human papillomavirus vaccination coverage on YouTube. majority reported a lack of social media conduct training during their Am J Prev Med. 2008;35(4):389–92. medical education.25 A 2015 survey of family physicians and residents 10. Stellefson M, Chaney B, Ochipa K, Chaney D, Haider Z, Hanik B, et al. YouTube as a source of chronic obstructive pulmonary disease patient education: a social media found that 15% of resident respondents and 56% of senior physician content analysis. Chronic Resp Dis. 2014;11(2):61–71.

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11. Goobie GC, Guler SA, Johannson KA, Fisher JH, Ryerson CJ. YouTube videos as a source of misinformation on idiopathic pulmonary fibrosis. Ann Am Thorac Soc. 2019;16(5):572–9. 12. Fisher JH, O’Connor D, Flexman AM, Shapera S, Ryerson CJ. Accuracy and reliability of internet resources for information on idiopathic pulmonary fibrosis. Am J Resp Crit Care Med. 2016;194(2):218–25. 13. AlQarni ZA, Yunus F, Househ MS. Health information sharing on Facebook: an exploratory study on diabetes mellitus. J Infect Publ Health. 2016;9(6):708–12. 14. Jacobs R, Boyd L, Brennan K, Sinha CK, Giuliani S. The importance of social media for patients and families affected by congenital anomalies: a Facebook cross- sectional analysis and user survey. J Ped Surg. 2016;51(11):1766–71. 15. Hale TM, Pathipati AS, Zan S, Jethwani K. Representation of health conditions on Facebook: content analysis and evaluation of user engagement. J Med Internet Res. 2014;16(8):e182. 16. Klee D, Covey C, Zhong L. Social media beliefs and usage among family medicine residents and practicing family physicians. Fam Med. 2015;47(3):222–6. 17. Dale C, Reid N, Cox K, Jones A, Williams H, Shawcross A, et al. Using social media to improve communication with people with cystic fibrosis. ERJ Open Res. 2016;2(1):00015. 18. Crannell WC, Clark E, Jones C, James TA, Moore J. A pattern-matched Twitter analysis of US cancer-patient sentiments. J Surg Res. 2016;206(2):536–42. 19. Tsuya A, Sugawara Y, Tanaka A, Narimatsu H. Do cancer patients tweet? Examining the twitter use of cancer patients in Japan. J Med Internet Res. 2014;16(5):1–8. 20. Weeg C, Schwartz HA, Hill S, Merchant RM, Arango C, Ungar L. Using Twitter to measure public discussion of diseases: a case study. JMIR Public Health Surveill. 2015;1(1):e6. 21. Attai DJ, Cowher MS, Al-Hamadani M, Schoger JM, Staley AC, Landercasper J. Twitter social media is an effective tool for breast cancer patient education and support: patient-reported outcomes by survey. J Med Internet Res. 2015;17(7):e188. 22. Park S, Oh H-K, Park G, Suh B, Bae WK, Kim JW, et al. The source and credibility of colorectal cancer information on Twitter. Medicine. 2016;95(7):e2775. 23. Vogels EA. Millennials stand out for their technology use, but older generations also embrace digital life [Internet]. Pew Research Center, Washington D.C. 2019 [cited 2019 Nov 3]. Available from: https://www.pewresearch.org/fact- tank/2019/09/09/us-generations-technology-use/ 24. Flynn L, Jalali A, Moreau KA, Flynn L V, Postgrad Med J MK. Learning theory and its application to the use of social media in medical education. Postgrad Med J. 2015;1080:556–60. 25. Ginory A, Sabatier LM, Eth S. Addressing therapeutic boundaries in social networking. Psychiatry. 2012;75(1):40–8.

UBCMJ Volume 11 Issue 2 | Spring 2020 8 FEATURE

SmartMom: teaching by texting Patricia A Janssen1, Shaina Pennington1 Citation: UBCMJ. 2020: 11.2 (9-10)

Health, or mobile health, leverages the use of cellular devices and Mdigital media to achieve health-related goals. It encompasses the use of mobile communication and multimedia, and their integration in wireless health care delivery systems. There is much evidence from randomized controlled trials that mobile health (mHealth) can change health behaviour, including smoking cessation, weight loss, physical activity, and stress management.1-5 The Health Belief Model of Behavior Change theorizes that recipients change their beliefs and attitudes as a result of information received at the point of decision making. Messages serve as a cue to action, essentially providing “just- in-time” salient tips to help motivate behaviour choices.1 Prenatal education is designed to teach women and their support persons about the physiological and psychological changes of pregnancy, what to expect during prenatal care, and how to prepare for labour, birth, and newborn care. Attendance at prenatal education classes has been associated with higher rates of attendance at prenatal care, compliance with prenatal screening, lower rates of preterm birth and low birthweight,2 and higher rates of vaginal births in Canadian3 and U.S.4 observational studies. In Canada, only 32% of pregnant women attend prenatal classes, and those in rural locations are even less likely to attend. Women are increasingly turning instead to the internet, especially smartphone pregnancy apps, to navigate the complexities and challenges of pregnancy and birth. However, there are concerns about the quality of this information. An overview of 370 apps found through the Google Play Store reported that only three apps documented having a scientific board.5 Furthermore, there are concerns about bias. A recent cross-sectional review reported that the most common sources of content for apps were either website portals for laypersons or commercial sites, rather than healthcare organizations.6 In Canada, the most popular pregnancy website is the Johnson & Johnson’s owned babycenter.ca. Sites driven by consumer-based advocacy organizations, such as mothersofchange. org, todaysparent.com, or forums such as parentscanada.com do not reference sources for their content. In addition, information available from the internet is potentially overwhelming in its sheer volume, exacerbating the difficulty of identifying accurate, relevant, evidence- based, and unbiased information. Finally, there are concerns about the completeness and timeliness of information that is not organized to provide the right information to the right person at the right time. For example, a study examining the content of two frequently used free U.S. apps, Text4Baby and My Pregnancy Today, reported that neither delivered comprehensive prenatal information.7 To address the need for accessible and reliable prenatal education, our research group (www.optimalbirthbc.ca) created “SmartMom,” Canada’s first prenatal education program delivered to cellphones by short message service (SMS) text messaging (Figure 1). Women enrolled in SmartMom receive three SMS text messages each

1School of Population and Public Health, University of British Columbia Correspondence to Patricia A Janssen ([email protected]) Figure 1 | SmartMom Landing Page for Cell Phone.

9 UBCMJ Volume 11 Issue 2 | Spring 2020 FEATURE week. These messages focus on accessing knowledge, undergoing them and that they would recommend it to a friend. They indicated assessment, and adopting behaviours to support healthy pregnancy that the reliability and comprehensiveness of the information were and physiologic birth. They provide information and links to online important factors in their satisfaction, as well as the fact that they sources of evidence-based topics such as discomforts of pregnancy, did not have to search for information online. These reasons were fetal development, exercise and activity in pregnancy, nutrition, closely followed by a desire to know about local resources and receive labour and birth, mental health, prenatal screening, and vaccinations. reminders related to their stage of pregnancy. Our evaluations to date Messages also suggest topics of conversation with healthcare have demonstrated significant improvements on knowledge tests and providers (Figure 2). standardized measures of anxiety, depression, and fear of childbirth at completion of the program. We will be evaluating perinatal outcomes including rates of preterm birth, fetal growth restriction, and stillbirth, based on comparisons of enrolled versus non-enrolled women. Personal health numbers, provided by participants in a secure fashion to Memotext via the SmartMom website, will be sent to health authorities who will link them to health outcomes and then send de- identified data back to the investigators for outcome analysis. Our findings indicate that SmartMom is reaching our target audience of young (76% of participants), lower educational attainment (18% with Figure 2 | Sample SmartMom message. high school education or less), Indigenous (9%), and visible minority populations (33%). The messages are consistent with current professional guidelines The future of health education is tied to advantages found 8 and peer reviewed prenatal education curricula, and have been in the use of digital media and mobile technology. SmartMom endorsed by the Society of Obstetricians and Gynaecologists of exemplifies use of mHealth to improve access to health education for Canada. They are brief (136 characters or fewer) and tested for health underserved populations to effect improvements in knowledge and literacy (grade eight reading level). Messages contain embedded links health outcomes. to more detailed information online. Consistent with Social Cognitive Theory, our links also take women to interactive learning tools Conflict of interest designed to enhance engagement and promote self-efficacy, critical Dr. Pennington reports grants from BC Children's Hospital Research elements in behaviour change.9,10 Our focus group findings11 and those Institute, Peter Wall Institute for Advanced Studies, and the Alva of others12 have reported that women want a “personalized touch” Foundation during the conduct of the study. in digital programs. SmartMom provides optional supplemental References streams for women who wish to have additional messages addressing 1. Ajzen I. The theory of planned behavior. Org Behav Human Decision Processes. special topics such as: reducing use of tobacco, alcohol or illicit drugs; 1991;50:179–211. 2. Fleming N, Tu X, Black A. Improved obstetrical otcomes for adolescents depression; obesity; maternal age over 35; violence in the home; and in a community-based outreach program: a matched cohort study. JOGC. vaginal birth after a prior cesarean section. 2012;34(12):1134–40. 3. Stoll K, Hall W. Childbirth education and obstetric interventions among low-risk The back-end software sending messages to subscribers was Canadian women: is there a connection? J Perinat Educat. 2012;21(4):229–37. developed by MEMOTEXT, a Canadian company with extensive 4. Afshar Y, Wang E, Mei J, Esakoff T, Pisarska M, Gregory K. Childbirth education class and birth plans are associated with a vaginal delivery. Birth. 2017;44(1):29–34. experience in mHealth. The message set is anchored to the woman’s 5. Bert F, Passi S, Scaioli G, Gualano M, Siliquini R. There comes a baby! What should due date so as to be relevant to each week of gestational age for I do? Smartphones' pregnancy-related applications: a web-based overview. Health Informatics J. 2016;22(3):608–17. individual participants. MEMOTEXT has developed an enrollment 6. Lee Y, Moon M. Utilization and content evaluation of mibile applications for portal to allow women to quickly, anonymously, and securely enroll pregnancy, birth and child care. Health Care Information Res. 2016;22(2):73–80. 7. O'Donnell B, Lewkowitz A, Vargas J, Zlatnik M. Examining pregnancy-specific in the program by texting from a cell phone. The company is based smartphone applications; what are patients being told? J Perinatol. 2016;36:802–7. in Toronto and encrypts and stores all data on Canadian servers. 8. Province of British Columbia Ministry of Health. Baby’s Best Chance: Parents’ Handbook of Pregnancy and Baby Care. 6th ed. Victoria, BC. 2011. Impact Mobile, a Canadian aggregation company, directs messages 9. Lagan B, Sinclair M, Kernohan W. Internet use in pregnancy informs women's sent by MEMOTEXT to subscribers via wireless carriers. The decision-making: a web-based survey. Birth. 2010;37(2):106–15. 10. Bandura A. Health promotion by social cognitive means. Health Ed Behav. Canadian Wireless Telecommunications Association, a trade group 2004;31:143–64. that represents the cellular carriers, has successfully negotiated on our 11. Munro S, Hui A, Salmons V, Solomon C, Gemmell E, Torabi N, et al. SmartMom text messaging for prenatal education: a qualitative focus group study to explore behalf with TELUS, Bell, Rogers, and other English-language carriers Canadian women’s perception. JMIR Public Health Surveill. 2017;3(1):e7. to allow our text messages to be delivered free of charge to users. In the 12. Goetz M, Müller M, Matthies L, Hansen J, Doster A, Szabo A, et al. Perceptions of patient engagement applications during pregnancy: a qualitative assessment of the unlikely event that participants live in areas without cellular coverage, patient's perspective. JMIR Mhealth Uhealth. 2017;5(5):e73. the program can be accessed via the internet at smartmomcanada.ca. SmartMom has been successfully launched in the Northern, Fraser, and Interior Health Authorities in British Columbia, with Vancouver Coastal Health and the Northwest Territories joining in early 2020. SmartMom initially launched in 2017 as a pilot. Since then, over 5000 women have enrolled and 500 currently join each month. To evaluate the program, women complete online surveys at enrollment and at completion of the program. Nearly all participants—99%—have indicated that the program was useful to

UBCMJ Volume 11 Issue 2 | Spring 2020 10 ACADEMIC

Gender/sex disparity in self-reported sleep quality among Canadian adults Ashleigh J. Rich1, Mieke Koehoorn1, Najib T. Ayas2, Jean Shoveller1 Citation: UBCMJ. 2020: 11.2 (11-16)

Abstract Objective: This study investigated gender/sex differences in sleep quality among Canadian adults in a population-representative survey. Methods: Data for this study was provided by the Canadian Community Health Survey (CCHS). For respondents who completed the 2011–12 CCHS sleep module, multinomial logistic regression was used to investigate the relationship between gender/sex and a composite sleep quality measure among adults ≥18 years old, adjusted for confounders. Results: Among the sample (n = 39,700), gender/sex was evenly distributed (49.3% men, 50.7% women). In the adjusted logistic model, being a woman was independently associated with higher odds of poor sleep quality at all levels of poor sleep quality (from ‘a little of the time’ AOR = 1.47, 95% CI: 1.24, 1.73 to ‘all of the time’ AOR = 2.10, 95% CI: 1.74, 2.54). This sleep quality disparity was progressively greater the more frequent the poor sleep quality reported, for all but the highest poor sleep quality level. Conclusions: This study provides population-level evidence of a sleep quality disparity between Canadian men and women. Using a mixed gender/sex population-based sample and a robust composite sleep quality measure, this study contributes to a growing understanding of poor sleep as a population health issue. Further research is needed to understand the mechanisms underlying the gender/sex-sleep relationship, as well as to investigate effective public health and policy interventions for addressing sleep-gender/sex population health disparities.

Introduction and cardiovascular disease-related death than men.8,9 In gender/ leep is increasingly recognized as a determinant of health at both sex-specific research, poor sleep among women is associated with Sindividual and population levels, as well as a symptom of other decreased neuroendocrine and metabolic function and increased risk underlying conditions (i.e., poor sleep).1 The Public Health Agency of metabolic syndrome, including diabetes,10 higher body mass index, of Canada recognizes “personal health practices and coping skills,” and incident obesity.11 under which sleep arguably falls, as one of the twelve key determinants Though there is growing evidence of gender-based sleep of health.2 Sufficient and high quality sleep is important for normal differences, gaps in the literature remain. For one, high rates of sleep daily functioning, while poor sleep is associated with increased use disorders known to be more prevalent among men have resulted of healthcare services and products, reduced workplace productivity, in the underrepresentation of women in clinical studies. This likely and high economic burden.3 Sleep problems have a range of health leaves women both undertreated and understudied. Furthermore, the consequences including increased risk of occupational injury,4 motor literature on gender/sex and sleep largely consists of clinical studies vehicle accidents,5 short-term and chronic morbidities, and early and gender/sex-specific samples. Much of the existing literature cause-specific and all-cause mortality.6 While the epidemiology of has focused on insomnia, the most prevalent sleep disorder in sleep problems is not well described in the Canadian context, 40% of Canada.7 In gender-specific research, much has focused on midlife Canadian adults experience insomnia symptoms.7 or menopausal women. There is a need for the investigation of Women disproportionately experience poor sleep quality. gender differences in sleep quality across age groups using population Gender/sex-based differences in sleep can be explained by underlying studies to inform public health strategies and focus resources. While neurochemical processes and anatomical differences, including some population health research has investigated the relationship less nonrapid eye movement, decreased delta activity, and higher between gender/sex and sleep, much of the literature is U.S.-based, prevalence of sleep apnea in women.8 Gender/sex-based differences where the healthcare system and sociopolitical environment differs in sleep can be explained by psychosocial and environmental factors, substantially from Canada and may impact gender/sex disparities in and include, for women, greater sleepiness, longer sleep latency, health outcomes. The Canadian Community Health Survey (CCHS) shorter sleep duration for older women (20 minutes or less per night), provides a unique opportunity to address these gaps in the literature, and poorer sleep quality.8 Sleep disorders are also more prevalent providing representative population-level data on sleep quality among among women—women experience higher rates of insomnia and Canadian adults across all age ranges. The objective of this study was twice the risk of restless leg syndrome.8 In the limited research to investigate gender differences in sleep quality among Canadian using mixed gender/sex samples that is able to examine gender/ adults. We hypothesized that there would be a gender disparity in sleep sex differences in sleep-related morbidity and mortality, it has been quality, with women experiencing poorer quality sleep. shown that women have a greater likelihood of both depression Data and Methods Study Design Data for this study were obtained from the 2011–12 CCHS public 1 School of Population and Public Health, University of British Columbia 12 2Department of Medicine and Sleep Disorders Program, University of British use microdata file. The CCHS is an ongoing, national, cross- Columbia sectional survey of the health status, service utilization, and related Correspondence to health determinants of the Canadian population. Conducted by Ashleigh J. Rich ([email protected]) Statistics Canada in two-year cycles, the CCHS is designed to provide

11 UBCMJ Volume 11 Issue 2 | Spring 2020 ACADEMIC reliable estimates at the health region level. Interviewer-administered potential confounders were included in the model, based on evidence questionnaire data are obtained from respondents aged 12 years of association with both the outcome and primary explanatory or older living in private homes across the 115 health regions in variables. These included age (younger adults: 18–39 years, midlife Canada based on a multistage, stratified cluster design, in person adults: 40–59 years, older adults: ≥60 years), educational attainment or via telephone, which is representative of 98% of the Canadian (< secondary school, ≥ secondary school, ≥ post-secondary school), population aged 12 years or older. Ethical approval of the study was visible minority status (yes/no), self-reported current mood disorder covered under the University of British Columbia Research Involving diagnosis (e.g., self-reported depression, bipolar, mania, or dysthymia Human Participants Policy (#89, item 7.1), governing use of publicly diagnosis) (yes/no), marital status (married, common-law, widowed/ available datasets.13 separated/divorced, single, never married), and presence of children Study Sample five years old or under in the household (none, ≥1).16-19 The overall CCHS 2011–12 sample included 124,929 respondents. Of Data Analysis those, 46,172 respondents (37.0%) lived in provinces that opted to Data analyses were conducted with SAS® University Edition include the optional sleep content survey module for their residents statistical software (SAS Institute Inc., Cary NC). Accounting (Nova Scotia, Quebec, Manitoba, Alberta, and Yukon). The 2011–12 for the nonrandom CCHS survey sampling design and uneven cycle was the most recent, most geographically representative cycle to probabilities of selection, CCHS survey weights were applied to all include the sleep module. The current study sample was restricted to analyses to provide appropriate variance estimates and meaningful respondents aged ≥18 years and without invalid responses (“Don’t population representative estimates.20 Following descriptive statistics, Know”, Refusal, Not Stated) to any study variable. Figure 1 illustrates a multinomial logistic regression model was built to examine the the selection process to achieve the final analytic sample (n = 39,700, independent effect of gender/sex on sleep quality, adjusted for 31.8% of the CCHS total sample and 93.8% of eligible respondents). confounders. Potential confounders were assessed via addition to the unadjusted model one at a time using a 10% shift in the point estimate Total CCHS 2011–12 respondents strategy.21 Despite no strong statistical evidence of confounding, n = 124,929 all were retained in the final analysis based on an a priori conceptual Excluded: Not offered Sleep Module: 78,757 model of potential confounders of the relationship between gender/ Total CCHS 2011–12 Sleep Module sex and sleep quality. respondents n = 46,172 Results

Excluded: Descriptive statistics profiling the overall study sample demographics Age <18 years: 3,829 are presented in Table 1. The study sample (n = 39,700) was comprised Sleep Module respondents age 18 of approximately equivalent proportions of men and women years or older n = 42,343 (49.32% and 50.78%, respectively). Almost half of all respondents Excluded: were in the older age category (43.68% aged ≥60 years), 35.43% Invalid response to sleep items: 794 were midlife adults (40–59 years), and 20.89% were younger adults Invalid response to gender: 0 Sleep Module respondents age 18 (18–39 years). Most of the sample had completed post-secondary with valid responses to outcome and education or higher (68.88%), 15.88% identified as visible minorities, primary explanatory variables n = 41,549 6.42% reported a current doctor-diagnosed mood disorder, almost

Excluded: half (45.23%) were married, and 13.83% reported children under five Invalid response to confounders: 1,849 years old in their household. Final analytic sample Overall, women reported poorer sleep quality than men. Further, n = 39,700 the difference in the proportion of women versus men reporting Figure 1 | Selection of analytic sample to investigate the relationship between poor sleep quality increased with each level of poor sleep quality. gender/sex and sleep quality, Canadian Community Health Survey, 2011–12. Specifically, 52.24% of women reported poor sleep quality “some of Measures the time” compared to 47.76% of men, 55.88% of women reported The main outcome for the analysis was sleep quality. A composite poor sleep quality “most of the time” compared to 44.12% of men, sleep quality outcome variable was created based conceptually on and 57.11% of women reported poor sleep quality “all of the time” the Pittsburgh Sleep Quality Index (PSQI), a commonly used sleep compared to 42.89% of men. quality measure.14 The outcome measure combined three CCHS In unadjusted bivariable analysis (Table 2), being a woman was items related to the PSQI components sleep latency, sleep disturbances, associated with increased odds of poor sleep quality from lowest and daytime dysfunction, respectively: “How often do you have trouble level (“a little of the time”, odds ratio (OR) = 1.40, 95% confidence going to sleep or staying asleep?”, “How often do you find sleep interval (CI): 1.19, 1.64) to highest level (“all of the time”, OR = 2.23, refreshing?”, and “How often do you find it difficult to stay awake 95% CI: 1.84, 2.70), compared to being a man. In the multivariable when you want to?”. The CCHS used a five-level response for all model adjusted for age, educational attainment, visible minority status, three questions: “none of the time”, “a little of the time”, “some of current doctor-diagnosed mood disorder, marital status, and children the time”, “most of the time”, and “all of the time”. For this study, in the household (Table 2), the progressively disproportionate respondents were assigned to the highest level of poor sleep based on relationship between being a woman and poor sleep quality remained their highest level of response to any one of the three CCHS sleep overall, though the adjusted odds of poor sleep were somewhat variables. The primary explanatory variable was gender/sex (men/ attenuated for the “all of the time” level (AOR = 2.10, 95% CI: 1.74, women).15 Informed by a review of the sleep-gender/sex literature, 2.54). The 95% confidence intervals for estimates of the association

UBCMJ Volume 11 Issue 2 | Spring 2020 12 ACADEMIC between being a woman and poor sleep quality excluded “1” at all by individual-level clinical and behavioural remedies such as sleeping levels of sleep quality, indicating a statistically significant effect. pill use and sleep hygiene training.8 While these options may improve Discussion sleep quality for individuals, they do not address population- This study makes important contributions to the Canadian level causes. Understanding sleep quality as a population health and international sleep-gender/sex literature, including use of issue rather than an individual issue brings into focus the need for epidemiological data from a large, population representative Canadian population-level interventions aimed at improving sleep quality, such sample. Strengths of the study include use of a mixed gender/sex as sleep-conducive employment schedules and incorporation of sleep sample of adults 18 years and older and employment of a robust optimization education into primary school curricula. While poor composite sleep quality outcome measure, rather than reliance on a individual autonomy and the uneven distribution of socioeconomic single sleep problem indicator, with potential for use in future research resources have been theorized as potential underlying causes of poor on sleep in the Canadian population. quality sleep, further research is needed to investigate effective public Results demonstrated that being a woman was independently health and social policy interventions for ameliorating root causes and associated with higher odds of poor sleep quality overall. Furthermore, ultimately addressing related population health disparities, including a progressively disproportionate effect was observed between being a gender/sex-specific efforts.1,28 woman and higher odds of poor sleep quality at each outcome level Limitations except the highest (sleep problems “all of the time”). The greatest There are a number of limitations to this study. Firstly, use of effect was a more than two-fold (AOR = 2.16) increased odds of cross-sectional self-report survey data restricts the ability to assess poor sleep quality “most of the time” for women versus men, in temporality and causality, limiting inferences to observation of the adjusted multivariable model. The results of the current study association. Though the composite sleep quality outcome is based are consistent with other research, including a U.S. based study of conceptually on the validated PSQI, it is not a validated measure socioeconomic impacts on sleep quality that found women had 1.55 itself nor as comprehensive a measure of sleep-related problems and times the odds of poor sleep quality compared to men, and a clinic- thus may have introduced information bias in this study.14 As a result, based European sample of multiple sclerosis patients that found men study findings may be a conservative estimate of sleep problems had 0.10 the odds of poor sleep quality compared to women.17,22 A among Canadian adults. Relatedly, as respondents were classified by higher prevalence of poor sleep quality in women was also noted in a the highest level of sleep problems reported for any of the three U.S. community-based sample of older adults (32.6% versus 16.3%)23 sleep quality items, the outcome effect may be dulled, though this is and a cross-sectional study of Korean young adults.24 likely non-differential by gender/sex. Selection bias may have been In this mixed age group study, younger and midlife women introduced as it is possible that those who opted to respond to the experienced poorer sleep quality compared to older women. Much of sleep questions experienced more sleep problems. In this event, the sleep-gender/sex research has been conducted among age group- findings of poor sleep quality in this study may be an overestimation, specific samples, with little prior evidence comparing age groups though likely non-differential by gender/sex. However, the number across the life span. While there is limited research utilizing mixed of non-respondents to the sleep module was relatively low, at less than age group and mixed gender/sex adult samples, a community-based 2% of eligible respondents. Further, this study is limited by an inability study of U.S. adolescents found a 2.75-fold increased risk of insomnia to control for a variety of known confounders of the relationship for girls at onset of menses compared to boys.25 The lack of gender/ between gender/sex and sleep in the CCHS (e.g., household division sex difference in insomnia risk prepuberty may point to a potential of labour), resulting in possible residual confounding. hormonal pathway for sleep disorders, and suggests maturational Potential misclassification of gender/sex may also bias this development may be related to the natural course of insomnia and study. Survey documentation instructs CCHS interviewers to input the onset of other sleep problems for women and girls.25 Relatedly, respondent sex and, if necessary, ask “is respondent male or female?” there is evidence that menstrual cycle, pregnancy, and menopause Though the term “sex” is used in the CCHS documentation, this can influence sleep in women.16 Gender/sex-based disparities in variable is more accurately a gender/sex measure. The survey sleep quality and other sleep problems may be further explained by question does not collect sex assigned at birth and thus likely captures gender/sex inequities in leisure time, caregiving responsibilities, and interviewer assessment of respondent gender/sex based on name, household labour at different life stages, as has been demonstrated in voice pitch, or other gendered signifiers. Though inconsistent with a study of gender/sex and sleep duration in U.S. adults.19 This finding best practices in the literature regarding measurement of sex and is consistent with confounding effects in this study, demonstrating gender, this item has been used to make both sex- and gender-related poorer sleep for married women and those with children five years old inferences in the CCHS.29 The binary male/female response options or younger in the household. While much of the sleep literature has also constitute a methodological erasure of transgender respondents shown poor sleep for older adults, finding greater sleep problems for and/or those with non-binary identities—an important consideration younger and midlife women in this study may be a function of age- both for future CCHS research and for Statistics Canada as the survey differential underreporting. Specifically, older adults may underreport instrument evolves. Though the resulting potential for misclassification sleep problems due to cultural normalization of sleep issues in older bias is an important limitation, this study used the best available CCHS age.26 gender/sex measure, and the number of any potentially misclassified Finding elevated odds of poor sleep quality for women using respondents is likely small, as to have minimal impact on results. population-based data adds to the evidence that poor quality sleep Despite oversimplification of gender/sex measurement, a meaningful is a population health issue, intersecting with larger social disparities gender/sex difference was detected in this study. in health.27 Currently, intervention for sleep problems is dominated

13 UBCMJ Volume 11 Issue 2 | Spring 2020 ACADEMIC

Table 1 | Descriptive statistics for the study sample to investigate the relationship between gender/sex and sleep quality, Canadian Community Health Survey, 2011–12 (n = 39,700). Overall Study Study Sample by Sleep Quality Sample A little of the Some of the Most of the All of the time 39,700 (100%) None (%) time (%) time (%) time (%) (%) Sleep Quality 2,484 (6.34) 10,671 (27.41) 14,184 (35.98) 8,276 (20.43) 4,085 (9.84) Gender Men 17,464 (49.32) 62.57 54.48 47.76 44.12 42.89 Women 22,236 (50.78) 37.43 45.52 52.24 55.88 57.11 Age Older (≥60) 22,191 (43.68) 53.96 42.50 43.52 40.84 46.83 Midlife (40–59) 10,846 (35.43) 32.07 35.77 35.45 36.33 34.68 Younger (18–39) 6,663 (20.89) 13.97 21.74 21.03 22.83 18.49 Educational Attainment < Secondary 7,758 (14.94) 20.42 12.39 13.82 16.06 20.34 Secondary 6,629 (16.18) 14.54 14.82 15.89 17.84 18.64 Post-secondary 25,313 (68.88) 65.14 72.79 70.29 66.10 61.01 Visible Minority Status Visible Minority 3,983 (15.88) 21.79 13.42 16.49 16.82 14.77 White 35,717 (84.12) 78.21 86.58 83.51 83.18 85.23 Current Mood Disorder No 36,745 (93.58) 98.39 97.49 94.28 90.39 83.69 Yes 2,955 (6.42) 1.61 2.51 5.72 9.61 16.31 Marital Status Married 16,595 (45.23) 45.86 46.52 45.24 43.01 45.75 Common-law 5,395 (17.10) 15.93 18.79 16.79 17.06 14.40 Widowed/ 8,417 (13.56) 17.77 11.54 13.44 12.95 18.19 Separated/ Divorced Single/Never 9,293 (24.11) 20.44 23.15 24.53 26.97 21.70 Married Children under 5 None 35,010 (86.17) 89.40 85.25 86.39 85.25 87.77 1 or more 4,690 (13.83) 10.60 14.75 13.61 14.75 12.23

Conflict of interest 4. Kling RN, McLeod CB, Koehoorn M. Sleep problems and workplace injuries in Canada. Sleep. 2010 May;33(5):611–8. The authors have declared no conflict of interest. 5. Léger D, Bayon V, Ohayon MM, Philip P, Ement P, Metlaine A, et al. Insomnia and accidents: cross-sectional study (EQUINOX) on sleep-related home, work and References car accidents in 5293 subjects with insomnia from 10 countries. J Sleep Res. 2014 1. Hale L, Hale B. Treat the source not the symptoms: why thinking about sleep Apr;23(2):143–52. informs the social determinants of health. Health Educ Res. 2010 Jun;25(3):395–400. 6. Alvarez GG, Ayas NT. The impact of daily sleep duration on health: a review of the 2. Federal Provincial and Territorial Advisory Committee on Population Health. literature. Prog Cardiovasc Nurs. 2004 Mar 1;19(2):56–9. Toward a healthy future: second report on the health of Canadians [Internet]. 7. Morin CM, LeBlanc M, Bélanger L, Ivers H, Mérette C, Savard J. Prevalence of Ottawa, ON: Minister of Public Works and Government Services of Canada; 1999 insomnia and its treatment in Canada. Can J Psychiatry. 2011 Sep 1;56(9):540–8. [cited 2016 Sep 15]. Available from: http://nccdh.ca/resources/entry/toward-a- 8. Mallampalli MP, Carter CL. Exploring sex and gender differences in sleep health: healthy-future a Society for Women's Health Research report. J Womens Health (Larchmt). 2014 3. Daley M, Morin CM, LeBlanc M, Grégoire J-P, Savard J. The economic burden Jul;23(7):553–62. of insomnia: direct and indirect costs for individuals with insomnia syndrome, 9. Rod NH, Kumari M, Lange T, Kivimäki M, Shipley M, Ferrie J. The joint effect insomnia symptoms, and good sleepers. Sleep. 2009 Jan 1;32(1):55–64. of sleep duration and disturbed sleep on cause-specific mortality: results from the

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Table 2 | Multinomial logistic regression model of the relationship between gender/sex and sleep quality (reference = no poor sleep quality)* (n = 39,700). Unadjusted Odds Ratios (95% CIs) Adjusted Odds Ratios (95% CIs) A little of Some of the Most of the All of the A little of Some of the Most of the All of the the time time time time the time time time time Gender Men 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Women 1.40 1.82 2.11 2.23 1.47 1.88 2.16 2.10 (1.19,1.64) (1.56,2.14) (1.79,2.51) (1.84,2.70) (1.24,1.73) (1.60,2.21) (1.82,2.57) (1.74,2.54) Age (years) Older (≥60) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Midlife (40–59) 1.42 1.37 1.50 1.25 1.36 1.34 1.47 1.47 (1.16,1.73) (1.13,1.67) (1.22,1.83) (1.00,1.56) (1.08,1.72) (1.07,1.69) (1.16,1.86) (1.13,1.91) Young (18–39) 1.98 1.87 2.16 1.53 2.12 1.92 2.11 2.09 (1.60,2.45) (1.51,2.31) (1.73,2.70) (1.19,1.96) (1.61,2.79) (1.47,2.51) (1.56,2.79) (1.51,2.90) Educational Attainment

Whitehall II cohort study. PloS One. 2014;9(4):e91965. more_doc/cchs-escc2012_2011-2012gid-eng.pdf 10. Hall MH, Okun ML, Sowers M, Matthews KA, Kravitz HM, Hardin K, et al. Sleep 13. The University of British Columbia Board of Governors. Research Involving is associated with the metabolic syndrome in a multi-ethnic cohort of midlife Human Participants [Internet]. 2012 [cited 2016 Sep 15]. Available from: http:// women: the SWAN sleep study. Sleep. 2012 Jun;35(6):783–90. universitycounsel.ubc.ca/files/2012/06/policy89.pdf 11. Patel SR, Malhotra A, White DP, Gottlieb DJ, Hu FB. Association between reduced 14. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep sleep and weight gain in women. Am J Epidemiol. 2006 Nov 15;164(10):947–54. quality index: A new instrument for psychiatric practice and research. Psychiatry Res. 12. Statistics Canada. Canadian Community Health Survey (CCHS) annual component 1989 May;28(2):193–213. user guide 2012 and 2011–12 microdata files. Ottawa: Statistics Canada; 2013 June. 15. van Anders SM. Beyond sexual orientation: integrating gender/sex and diverse 100 p. Available from: http://sda.chass.utoronto.ca/sdaweb/dli2/cchs/cchs2011/ sexualities via sexual configurations theory. Arch Sex Behav. 2015 Jul;44(5):1177–213.

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16. Mehta N, Shafi F, Bhat A. Unique aspects of sleep in women. Mo Med. 2015 Nov;112(6):430–4. 17. Patel NP, Grandner MA, Xie D, Branas CC, Gooneratne N. “Sleep disparity” in the population: poor sleep quality is strongly associated with poverty and ethnicity. BMC Public Health. 2010 Aug 11;10(1):1659. 18. Grandner MA, Jackson NJ, Izci-Balserak B, Gallagher RA, Murray-Bachmann R, Williams NJ, et al. Social and behavioral determinants of perceived insufficient sleep. Front Neurol. 2015 Jun 5;6:112. 19. Burgard SA, Ailshire JA. Gender and time for sleep among U.S. adults. Am Sociol Rev. 2013 Feb 1;78(1):51–69. 20. Sarafin C, Simard M, Thomas S. A review of the weighting strategy for the Canadian Community Health Survey. Proceedings of the Survey Methods Section; Statistical Society of Canada Annual Meeting; June 2007, St. John's. Available from: https:// ssc.ca/sites/default/files/survey/documents/SSC2007_C_Sarafin.pdf 21. Maldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol. 1993 Dec 1;138(11):923–36. 22. Vitkova M, Rosenberger J, Gdovinova Z, Szilasiova J, Mikula P, Groothoff JW, et al. Poor sleep quality in patients with multiple sclerosis: gender differences. Brain Behav. 2016 Nov;6(11):e00553. 23. Vitiello MV, Larsen LH, Moe KE. Age-related sleep change. J Psychosom Res. 2004 May;56(5):503–10. 24. Chang AK, Choi J. Predictors of sleep quality among young adults in Korea: gender differences. Issues Ment Health Nurs. 2016 Dec 1;37(12):918–28. 25. Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006 Jan 31;117(2):e247–56. 26. Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult—a mini-review. Gerontology. 2010 Mar;56(2):181–9. 27. Hale B, Hale L. Is justice good for your sleep? (And therefore, good for your health?). Soc Theory Health. 2009 Nov;7(4):354–70. 28. Hale L. Inadequate sleep duration as a public health and social justice problem: can we truly trade off our daily activities for more sleep? Sleep. 2014 Dec 1;37(12):1879– 80. 29. Bauer GR, Braimoh J, Scheim AI, Dharma C. Transgender-inclusive measures of sex/gender for population surveys: mixed-methods evaluation and recommendations. PloS One. 2017 May 25;12(5):e0178043.

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Climate change and human health Zev Dayan1*, Raiya Suleman1*, Videsh Kapoor2 Citation: UBCMJ. 2020: 11.2 (17-19)

Introduction Food Chains and Water Security limate change poses a serious threat to human health, with recent Food security is achieved when “all people, at all times, have physical Csimulations predicting an increase in mean global temperature by and economic access to sufficient, safe, and nutritious food to meet 1.5-5.8°C, as well as a 5-15% increase in mean global precipitation their dietary needs.”13 Almost all qualitative assessments predict that by the end of the century.1 These environmental changes impact climate change is going to have a negative impact on food security, several social determinants of health by affecting air quality, food particularly in developing countries.2 chains, forced migration, and the incidence of various infectious While climate change is predicted to lead to detrimental effects diseases.2-4 Within the global community, specific populations will on crop yields, agriculture also accounts for 25% of greenhouse gas be more vulnerable to these consequences than others.2,5-7 It is the emissions.14 The impacts of climate change on agriculture are expected role of healthcare professionals, through education, leadership, and to be seen after 2020, especially with the demand for agricultural advocacy, to recognize and account for these changes and adapt products increasing by about 50% by 2030.15-17 Temperature current practices. Healthcare professionals must not only be able to increases and changes in precipitation are expected to impact crop provide appropriate care to populations that are most vulnerable to yields, specifically for crops grown at the extremes of temperature.18 climate change, but also minimize the environmental burden of the The changes in crop yields will not only exacerbate existing hunger healthcare system. This will help mitigate the negative health effects through direct means, but also through decreasing the net income 19 of climate change, which are expected to surge in the coming years. of farmers. Increased CO2 is actually predicted to positively impact

Infectious Diseases crop yields, leading to a mixed picture when accounting for CO2 Many infectious agents can be impacted by climate changes.8 The changes that are expected with climate change.15,17,20 However, foods explanations as to how these affect vector-borne disease communication grown at increased CO2 environments have also been shown to have 5,21 are varied. Considerations include lengthy transmission periods due decreased iron, zinc, and protein content. Rising CO2 emissions are to changing seasonality, increasing temperatures leading to increased expected to make 150–200 million people zinc deficient, and a similar reproduction rates, and climate-induced migration of vectors and number deficient in protein.5 The decrease of insect pollinators due to human hosts.9 With varying climates globally, it is understood that the pollution and climate changes may lead to reduced intake of vitamin A distribution of infectious diseases will be impacted, leading to some and folate, as well as fruits, vegetables, seeds, and nuts.5 It is expected regions being unsuitable for certain diseases, while others becoming that the negative impacts on agriculture will be most pronounced in vulnerable. The lack of acquired immunity in these newly infected developing countries and coastal regions, with developed countries regions is concerning.10 actually benefiting from climate changes.2,13,17,22 Malaria and dengue fever are two vector-borne diseases that have The availability of freshwater has been threatened due to decreasing been influenced by temperature changes.11 An increase in temperatures glaciers, ultimately leading to deprivation, displacement, and conflict.5,14 since the 1970s in Africa has been correlated with increased malaria Additionally, various regions are turning to methods to extract water distribution at higher altitudes in the southern and eastern regions of which require increased energy, ultimately resulting in increased 11 13 the continent. Increasing temperatures are believed to shorten the CO2 emissions. Ocean warming, acidification, deoxygenation, and time it takes for mosquitoes to become infected with dengue fever, overfishing have led to a decline in seafood availability, particularly thus increasing transmission.8 Additionally, water-borne diseases are in low-income countries.14 Approximately one billion people obtain expected to be influenced as well. Specifically, the rate of cholera over 20% of their daily intake from fish, making them particularly infection in developing countries is anticipated to increase with vulnerable to the decline in wild fish harvests.5,23 Furthermore, 22 of rising temperatures.12 Challenges in food and water security will also the 33 countries that are most vulnerable to climate change impacts on force individuals to rely on unsafe food sources, therefore increasing fisheries are classified as “Least Developed Countries.”7 It is, therefore, susceptibility to food- and water-borne illness.2 Of particular concern individuals from many of the world’s lowest-income countries that are is the vicious cycle that involves food-borne illness compounding most vulnerable to these changes, as they are over twice as reliant on existing hunger, which increases an individual’s vulnerability to fish than those from less vulnerable countries.7 acquiring other infectious diseases.2 Migration Climate change also threatens human security through forced migration, which can lead to political conflict, physical and emotional 24-26 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, trauma, and death. Forced displacement is known to have severe BC, Canada 2 impacts on human health, and is associated with higher rates of Department of Family Practice, Faculty of Medicine, University of British 5,27 Columbia malnutrition, infectious disease, and mental illness. It is often those *Both authors contributed equally to this work living in low-resource settings that are subjected to forced migration, 5,6,26,28 Correspondence to therefore compounding pre-existing vulnerability. It is estimated Zev Dayan ([email protected]) that up to 700 million individuals may become displaced due to climate Raiya Suleman ([email protected]) 3 Videsh Kapoor ([email protected]) change by 2050. The causes of climate-based displacement are often

17 UBCMJ Volume 11 Issue 2 | Spring 2020 REVIEW categorized into two groups: sudden-onset and slow-onset events.24 region, government-level support is critical. For example, an enhanced Sudden-onset events, such as hurricanes, floods, and wildfires, can infectious disease program could help relieve some of the sequelae of occur rapidly.24 Slow-onset events happen over time, such as land increased disease distribution and transmission. This would include degradation and decreasing crop yields.24,29,30 public education, increased vaccination, and food and water safety Climate change also exacerbates sociopolitical conflict. For measures.41 example, millions were displaced due to the civil war in Syria, which Further populations at particular risk include the elderly, as was the result of political conflict and exacerbated by the region’s they have a higher vulnerability in heat waves as well as in cold- worst known three-year drought.5,28 Additionally, changes in land related events.42 In regions with wildfires, individuals suffering fertility have caused increased conflict over land possession.3 The from respiratory diseases, such as chronic obstructive pulmonary unreliability of harvests, in combination with the increasing incidence disease and asthma, have experienced additional exacerbations.39 of natural disasters, has led to displacement.3 Migration often Within Canada, Indigenous communities would be expected to have occurs disproportionately from rural to urban settings, which can increased sensitivity to climate-related health outcomes, as well as pose a serious problem, as many urban cities lack the capacity and a decreased adaptive capacity to climate changes, due to the lasting infrastructure to host large waves of migrants.3,25,29 intergenerational trauma, lack of healthcare access, and poverty that It is also important to recognize that it in precarious situations, it has been disproportionality experienced.43 When considering the is often the young male of the family that is forced to relocate to find many consequences of climate change on health, it is inevitable that work, increasing the vulnerability of family members left behind.24,31 climate change will impact mental health. This could be through more Children are also often sent to live with extended family to relieve severe adverse weather events, displacement, and added stress related resource demand within families.24 Studies indicate that individuals to resource deficiencies, which can lead to anxiety-related responses that migrate due to climate-based reasons prefer to stay in their place and trauma, as well as the implications on physical health that are so of origin; therefore, it is crucial that the mental health implications of closely related to an individual’s mental well-being.44 these forced displacements are also explored and treated.24 To mitigate some of the challenges of climate change, it is Air Quality essential that action is taken by the physician community. Recently, the Climate and weather have significant influences on air quality, thus global non-profit World Organization of Family Doctors (WONCA) resulting in its sensitivity to climate changes. Air pollution results from issued a declaration calling on physicians to advocate and take action a combination of emissions and untimely weather patterns.32 While to prevent climate change.45 WONCA recognized the influence that there are various air pollutants, the two key players that influence physicians could have on making immediate and constructive change health are particulate matter and surface ozone.32 Both of these in local communities. The healthcare sector is a significant contributor pollutants have been associated with higher temperatures, however, to carbon emissions. In 2016, Eckelman et al. reported that the the exact relationship between temperature and particulate matter is United States healthcare sector reached nearly 10% of the national not clear in the literature.33,34 Ozone causes respiratory inflammation output of emissions in the United States in 2013.46 The same study when inhaled, and studies have shown an increase in asthma-related showed yearly increases over a recent ten-year period, with a total hospital visits in regions with higher levels of these air pollutants.35 increase of healthcare emissions of over 28% during that timeframe. Climate change is also influencing health through its impact Unfortunately, this is a trend in the wrong direction. The WONCA on aeroallergens such as outdoor pollens. Several studies in Europe statement suggested that physicians can promote a sustainable have shown that the pollen seasonal onset is advancing in alignment workplace by reducing medical waste, encouraging active transit and with warming trends.35 Further research has suggested that increases plant-based diets, and educating themselves and their patients on climate and health. Evidently, this theme is important for medical in CO2 concentrations alone lead to greater pollen levels, through increased production and efficacy as an allergen.36 students and physicians. One possible way to build understanding Additional consequences of air quality on health include the around this issue is by creating workshops for future physicians on effects of wildfires, with elevated temperatures along with extended the topic of climate change. To this end, the University of British droughts potentially leading to an increase in fires.37 The consequent Columbia’s Global Health Initiative, a student-led initiative, has smoke in surrounding communities has been shown to lead to an recently introduced an annual climate health workshop. The session increase in hospital visits due to respiratory complaints.38 This was encourages thoughtful discussion on how climate can influence the evident in a study looking at three weeks of wildfires in Kelowna, health outcomes of varying communities. This also spurred ideas on where physician billings for respiratory illnesses were largely increased how medical students felt action could be taken in their future careers. from the same three-week period over each of the ten years prior.39 Furthermore, the UBC Faculty of Medicine plans to lead a teaching Discussion session on climate health as part of their new “Emerging Topics” The connection between climate change and health is well established initiative. The formal introduction of this issue to the curricula, as well in the literature. Although many are susceptible to these effects, it is as continued advocacy and efforts toward promoting sustainability clear that certain populations are more vulnerable to the impacts on within healthcare, is likely to create progress towards positive change. food chains, migration, infection transmission, and air quality. On a Conclusion large scale, the infrastructure and robust healthcare systems of many Climate change is expected to have detrimental effects on several industrialized countries can be expected to support their populations aspects of human health, specifically by affecting food chains, through these challenges. Unfortunately, this may not be feasible migration patterns, infectious disease distribution, and air quality. for many other regions globally, for example in coastal areas where With recognition of the complex interplay of climate and health, it infrastructure to combat rising sea levels is not affordable.40 For any is imperative that the medical community takes action to mitigate the

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negative effects that climate change has on the health of patients. discussion of summer 2003. Atmos Chem Phys. 2005 May 25;5(5):1187–203. 34. Hogrefe C, Werth D, Avissar R, Lynn B, Rosenzweig C, Goldberg R, et al. Analyzing Conflict of interest the impacts of climate change on ozone and particulate matter with tracer species, The authors have declared no conflict of interest. process analysis, and multiple regional climate scenarios. Dev Environm Sci. 2007 Jan 1;6:648–60. References 35. Kinney PL. Climate change, air quality, and human health. Am J Prev Med. 2008 1. Rosenzweig C, Iglesias A, Yang XB, Epstein PR, Chivian E. Climate change and Nov 1;35(5):459–67. extreme weather events; implications for food production, plant diseases, and pests. 36. Ziska LH, Caulfield FA. Rising carbon dioxide and pollen production of common Global Change & Human Health. 2001 Dec 1;2(2):90–104. ragweed, a known allergy-inducing species: Implications for public health. Aust J 2. Schmidhuber J, Tubiello FN. Global food security under climate change. Proc Natl Plant Physiol. 2000;27:893–8. Acad Sci USA. 2007 Dec 11;104(50):19703–8. 37. Westerling AL, Hidalgo HG, Cayan DR, Swetnam TW. Warming and earlier spring 3. Warner K, Ehrhart C, Sherbinin AD, Adamo S, Chai-Onn T. In search of shelter: increase western US forest wildfire activity. Science. 2006 Aug 18;313(5789):940–3. Mapping the effects of climate change on human migration and displacement 38. Hoyt KS, Gerhart AE. The San Diego County wildfires: perspectives of healthcare. [Internet]. UK: Climate Change CARE International; 2009 [cited 2019 Sept 20]. Disaster Management & Response. 2004 Apr 1;2(2):46–52. Available from: https://www.care-international.org/files/files/publications/ 39. Moore D, Copes R, Fisk R, Joy R, Chan K, Brauer M. Population health effects of Climate-Change-In-Search-of-Shelter-2009.pdf air quality changes due to forest fires in British Columbia in 2003. Can J Public Health. 4. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present 2006 Mar 1;97(2):105–8. and future risks. Lancet. 2006 Mar 11;367(9513):859–69. 40. Myers SS. Planetary health: protecting human health on a rapidly changing planet. 5. Myers SS. Planetary health: protecting human health on a rapidly changing planet. Lancet. 2017 Dec 23;390(10114):2860–8. Lancet. 2017 Dec 23;390(10114):2860–8. 41. McMichael T, Blashki G, Karoly DJ. Climate change and primary health care. Aus 6. Reuveny R. Climate change-induced migration and violent conflict. Polit Geogr. 2007 Fam Physician. 2007 Dec;36(12):986. Aug 1;26(6):656–73. 42. Hajat S, Kovats RS, Lachowycz K. Heat-related and cold-related deaths in England 7. Allison EH, Perry AL, Badjeck MC, Neil Adger W, Brown K, Conway D, et al. and Wales: who is at risk? Occup Environ Med. 2007 Feb 1;64(2):93–100. Vulnerability of national economies to the impacts of climate change on fisheries. 43. Adelson N. The embodiment of inequity: health disparities in Aboriginal Canada. Fish Fish. 2009 Jun;10(2):173–96. Can J Public Health. 2005 Mar 1;96(2):S45–61. 8. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present 44. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal and future risks. Lancet. 2006 Mar 11;367(9513):859–69. pathways framework. Int J Public Health. 2010 Apr 1;55(2):123–2. 9. Lafferty, KD. The ecology of climate change and infectious diseases. Ecology. 45. The World Organization of Family Doctors (WONCA). Declaration Calling for 2009;90(4):888–900. Family Doctors of the World to Act on Planetary Health [Internet]. WONCA; 2019 10. Haines A, Kovats RS, Campbell-Lendrum D, Corvalán C. Climate change and [cited 2019 Oct 9]. Available from: www.wonca.net/site/DefaultSite/filesystem/ human health: impacts, vulnerability and public health. Public Health. 2006 Jul documents/Groups/Environment/2019%20Planetary%20health.pdf 1;120(7):585–96. 46. Eckelman MJ, Sherman J. Environmental impacts of the US health care system and 11. Pascual M, Ahumada JA, Chaves LF, Rodo X, Bouma M. Malaria resurgence in the effects on public health. PloS One. 2016 Jun 9;11(6):e0157014. East African highlands: temperature trends revisited. Proc Natl Acad Sci USA. 2006 Apr 11;103(15):5829–34. 12. Rodó X, Pascual M, Fuchs G, Faruque AS. ENSO and cholera: a nonstationary link related to climate change? Proc Natl Acad Sci USA. 2002 Oct 1;99(20):12901–6. 13. Gregory PJ, Ingram JS, Brklacich M. Climate change and food security. Philos Trans R Soc Lond B Biol Sci. 2005 Oct 24;360(1463):2139–48. 14. McMichael AJ. Globalization, climate change, and human health. New Engl J Med. 2013 Apr 4;368(14):1335–43. 15. Parry ML, Rosenzweig C, Iglesias A, Livermore M, Fischer G. Effects of climate change on global food production under SRES emissions and socio-economic scenarios. Global Environ Chang. 2004 Apr 1;14(1):53–67. 16. Bruinsma J. World Agriculture: Towards 2015/2030: an FAO Perspective. London: Earthscan Publications Ltd; 2013. 444 p. 17. Wheeler T, Von Braun J. Climate change impacts on global food security. Science. 2013 Aug 2;341(6145):508–13. 18. Rosenzweig C, Iglesias A, Yang XB, Epstein PR, Chivian E. Climate change and extreme weather events; implications for food production, plant diseases, and pests. Global Change & Human Health. 2001 Dec 1;2(2):90–104. 19. Tito R, Vasconcelos HL, Feeley KJ. Global climate change increases risk of crop yield losses and food insecurity in the tropical Andes. Glob Change Biol. 2018 Feb;24(2):e592–602. 20. Watson RT, Zinyowera MC, Moss RH, Dokken DJ. The regional impacts of climate change. Cambridge: Cambridge University Press; 1998. 318 p. 21. 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CO2 threatens human nutrition. Nature. 2014 Jun;510(7503):139. 22. Lobell DB, Burke MB, Tebaldi C, Mastrandrea MD, Falcon WP, Naylor RL. Prioritizing climate change adaptation needs for food security in 2030. Science. 2008 Feb 1;319(5863):607–10. 23. Golden CD, Allison EH, Cheung WWL, Dey MM, Halpern BS, McCauley DJ, et al. Fall in fish catch threatens human health. Nature. 2016 Jun 16; 534(7607):317–20. 24. McLeman RA, Hunter LM. Migration in the context of vulnerability and adaptation to climate change: insights from analogues. Wires Clim Change. 2010 May;1(3):450– 61. 25. Barnett J, Adger WN. Climate change, human security and violent conflict. Polit Geogr. 2007 Aug 1;26(6):639–55. 26. Watson RT, Coughlan M, Obasi GOP. Report of the nineteenth session of the intergovernmental panel on climate change. IPCC. 2002 April. 27. Toole MJ. Forced Migrants: Refugees and Internally Displaced Persons. In: Levy BS, Sidel VW. Social injustice and public health. Oxford: Oxford University Press Inc, 2006. p. 190–206. 28. Kelley CP, Mohtadi S, Cane MA, Seager R, Kushnir Y. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proc Natl Acad Sci USA. 2015 Mar 17;112(11):3241–6. 29. Tacoli C. Crisis or adaptation? Migration and climate change in a context of high mobility. Environ urban. 2009 Oct;21(2):513–25. 30. Meze-Hausken E. Migration caused by climate change: how vulnerable are people inn dryland areas? Mitig Adapt Strat Gl. 2000 Dec 1;5(4):379–406. 31. Terry G. No climate justice without gender justice: an overview of the issues. Gender & Development. 2009 Mar 1;17(1):5–18. 32. Jacob DJ, Winner DA. Effect of climate change on air quality. Atmos Environ. 2009 Jan 1;43(1):51–63. 33. Ordonez C, Mathis H, Furger M, Henne S, Hüglin C, Staehelin J, et al. Changes of daily surface ozone maxima in Switzerland in all seasons from 1992 to 2002 and

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All fun and games? Exploring the positive effects educational video games can have on medical learners Ryan Chow1, Matthew Cheung1 Citation: UBCMJ. 2020: 11.2 (20-22)

Abstract Video games have transcended from being a simple pastime to a cultural phenomenon. With recent advances in computer processing and storage technology, this type of interactive media can provide a fun experience to children and adults alike. In the last decade, video games have found their way into medical education. Due to their intrinsic immersiveness, sensorimotor stimulation, and lifelike simulation capacities, medical-based games have become a popular medium for educational developers to create products that help elevate traditional pedagogical methods (i.e., didactic lecture-style learning). This commentary will discuss the positive aspects of medical video games and provide specific examples of how they have benefited medical education for both novice and expert learners.

Introduction games, where a player assumes the role of a fictional character and n November 29th, 1972, the American home computer company must make decisions that ultimately affect the progress of a narrative OAtari released the first commercially successful video game, story. Similar to the rise of video games has been the popularization Pong. Pong’s concept was simple: two players would each control a of case-based learning (CBL) in medical school curricula, which is single white line to rebound a small pixelated ball back and forth on based off the seminal problem-based learning method developed a two-dimensional plane, somewhat similar to the eponymous real- at McMaster University.6 CBL, analogous to role-playing video life sport of “ping-pong.” Since Pong’s international success, video games, involves the immersion of medical students into the role of games have transcended from once a frivolous pastime to now a a practicing physician who must employ effective clinical decision- cultural phenomenon. Much of the success of video games can be making to treat a patient and understand their underlying disease. attributed to advancements in the portability of computer technology, Because of this immersion, CBL has proven to be an effective means which allowed the transition from stagnant arcade machines to more of educating medical students and preparing them for the wards in convenient devices such as Nintendo’s Gameboy or more recent their senior years.7 Several game developers have used the intrinsic Switch products. Furthermore, with the pervasiveness of cell phone similarities between CBL and role-playing games to create educational use in North America, the ability to access these games has never products that similarly immerse medical learners. Medical Joyworks, an been easier. e-learning company founded in 2010, has been particularly successful It is the consensus in developed countries that electronic at creating a CBL-style mobile video game called Clinical Sense. With device usage and access among healthcare professionals are high. It over one million downloads on the Google Play Store, Clinical Sense is estimated that at least 80% of American physicians use portable places the player in the perspective of a physician who must correctly electronic devices, such as smartphones and laptop computers, choose the proper interaction with a virtual patient to progress the while usage among Canadian medical students is estimated to be story. Other developers have created immersive narrative video games approximately 98%.1,2 While the topic of smartphone usage in actual to teach learners how to utilize appropriate heuristics (cognitive pattern medical practice is currently under debate, the potential utility that recognition processes). In collaboration with a company called Schell these portable devices carry as educational tools has been generally well Games, researchers of a 2017 study found that a narrative video game approved.3-5 Educational video games are often stigmatized, especially called Night Shift (Figure 1) on Apple iPads proved to be a superior by students, as being unappealing because of their inherent emphasis method of training emergency medicine physicians to rapidly identify on education rather than being traditionally “fun.” However, as a moderate to severe patients requiring triage compared to traditional result of technological and pedagogical innovation, some medically didactic lecturing.8 Following a gaming session lasting at least one relevant video games have been shown to be appealing and clinically hour, the video game-trained physicians were significantly less likely relevant to students and practicing physicians alike. This commentary to under-triage, both immediately following and at six months after will discuss the benefits of medical video game-based education tools playing the game. and provide specific examples of successfully implemented medical Sensorimotor development video games. Popular video games like League of Legends are fast-paced team Case-based immersion games that require effective communication and a strong selective A major reason why video games have become such a popular form of attention span. In fact, such games have been shown to train mental interactive media among creative developers is because of their ability acuity and increase a player’s visual selective attention, reading to provide player immersion. This is especially true in role-playing accuracy, and cognitive flexibility.9-11 In addition to these cognitive benefits, video games have been shown to increase fine motor skills. Perhaps consequential to using rigorous handheld controls, 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada which train hand-eye coordination and physical dexterity, video games confer an increase in sensorimotor learning, which enhances Correspondence to 12 Ryan Chow ([email protected]) the ability to learn the dynamics of unfamiliar sensorimotor tasks.

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Figure 1 |Adapted from Moham et al. (2017), illustrating a conversation between an attending and the department chair regarding an incorrect triage. During this conversation, the chair provides criticism on their performance, and the player must choose how to respond to this criticism. The player can either choose to accept responsibility for their error or provide rationale for the decision made. Studies have shown that video games aid in the development of dexterous skills that are translatable to surgical operating rooms. In 2007, a study by Rosser et al. evaluated a group of surgical residents for their laparoscopic skills and suturing capabilities. The study found that participants who reported previous video game play exceeding 3 hours per week achieved a 27% faster completion time and did so with 37% fewer errors than their non-video game playing colleagues. They also found that those who were better at video games performed better in their laparoscopic and suturing demonstrations, concluding that there was a positive correlation between skillful video game play and increased manual dexterity.13 Further studies have confirmed this positive association and have attributed it to an increase in psychomotor skills, even going as far as to evaluate which video game consoles have the most skill translation.14-16 Practically, video game use has clinical significance as well. In 2018, an article published by the British Broadcasting Corporation interviewed a group of 33 surgeons and reported that video games have improved their quality of training and practice, strengthening factors such as concentration, reaction time, and hand-eye coordination, all of which would be important when focusing on a screen during laparoscopic surgeries.17 High-quality simulation Early video game home entertainment systems, such as the popular Super Nintendo Entertainment System in the early 1990s, had relatively low micro processing power resulting in graphically limited games that required around 0.23 megabytes to 4 megabytes of storage.18 Today, the average smartphone game on the Apple iOS store is 67.7 Figure 2 |A screenshot illustrating gameplay of Cardio Ex, made by developers Level Ex. The objective of this level (Level 1-4 “Lesion Legend”), is to guide a megabytes, and more graphically intensive games, like God of War drug-eluting stent to the site of the lesion and repair the stenotic coronary arteries. on the PlayStation 4, require around 45 gigabytes. Because of these processing and storage achievements, medical educational video game video games and later the DirectX team for Microsoft. Glassenberg developers have been able to create products that are so graphically first noticed the potential of using video games as an educational powerful that they border on realistic medical simulation. One tool when he created a mobile video game for his grandfather, an particular developer who has demonstrated great success in medical anesthesiologist, who needed to teach residents how to perform video game simulation is Sam Glassenberg, founder and CEO of Level a bronchoscopy. Since the success of its first game, Level Ex has Ex.19 Level Ex is a software development company that creates mobile produced multiple graphically intensive mobile video games that teach games specifically targeted towards physicians. Coming from a family learners how to perform challenging real-life medical procedures. In of physicians, Glassenberg was considered the “black sheep” of the March 2019, Level Ex released a game called Cardio Ex that teaches family because he was part of the LucasArts team creating Star Wars players how to perform difficult interventional cardiology procedures

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(Figure 2). Players have the ability to manipulate a fluoroscopy-based laparoscopic skills? Int J Surg. 2013 Jun 1;11(5):365–9. 16. Glassman D, Yiasemidou M, Ishii H, Somani BK, Ahmed K, Biyani CS. Effect three-dimensional representation of the heart and are equipped with of playing video games on laparoscopic skills performance: a systematic review. J a host of tools like non-compliant/semi-compliant balloons, drug- Endourol. 2016 Feb 1;30(2):146–52. 17. Video games made me a better surgeon [Internet]. BBC News; 2018 Oct 31 [cited eluting stents, polytetrafluoroethylene stents, aspiration catheters, and 2019 Oct 10]. Available from: https://www.bbc.com/news/uk-46036095 atherectomy drills. In the United States, the simulation and educational 18. Techbytes. A brief and abbreviated history of gaming storage [Internet]. UMassAmherst; 2014 Feb 10 [cited 2019 Oct 10]. Available from: https://blogs. aspects of Cardio Ex are considered so powerful by the Accreditation umass.edu/Techbytes/2014/02/10/history-of-gaming-storage/ Council for Continuing Medical Education that cardiologists who play 19. Barras C. Can you outdo a doctor at these video games? [Internet] Nature Medicine; 2019 Jun 28 [cited 2019 Oct 10]. Available from: https://www.nature.com/articles/ the game are awarded Continuing Medical Education (CME) credits d41591-019-00015-8 for reaching specific milestones.20 Currently, Level Ex has four games 20. Lougheed T. Video games bring new aspects to medical education and training. Can targeted towards cardiologists, pulmonologists, gastroenterologists, Med Assoc J. 2019 Sep;191(37):E1034–5. and anesthesiologists that can award CME credits, with more games currently in development. Conclusion As medical students who have played video games for nearly their whole lives, it is the authors’ belief that educational medical video games present a unique opportunity for learners. In addition to being fun and engaging, the underlying aspects of video games like interactive storytelling, graphical realism, and sensorimotor stimulation, warrant increased consideration from curriculum developers. These benefits are not exclusive to medical students, as evidenced by the provision of CME credits and increase in surgical performance when playing these games. Furthermore, as computer technology becomes more powerful and portable, the educational potential of video games will undoubtedly continue to improve. Whether you are a first-year medical student looking to develop your clinical decision-making skills or a seasoned cardiologist looking to expand your surgical horizons, there is likely a video game waiting for you to try.

Conflict of interest The authors have declared no conflict of interest. References 1. Moyer JE. Managing mobile devices in hospitals: a literature review of BYOD policies and usage. J Hosp Librariansh. 2013;13(3):197–208. 2. Tran K, Morra D, Lo V, Quan SD, Abrams H, Wu RC. Medical students and personal smartphones in the clinical environment: the impact on confidentiality of personal health information and professionalism. J Med Internet Res. 2014;16(5):1–8. 3. Shenouda JEA, Davies BS. The role of the smartphone in the transition from medical student to foundation trainee: a qualitative interview and focus group study. BMC Med Educ. 2018;1–10. 4. Ponce LB, Mendez JAJ, Penalvo FJG. A systematic review of using mobile devices in medical education. 2014 Int Symp Comput Educ SIIE 2014. 2014;205–10. 5. Dimond R, Bullock A, Lovatt J, Stacey M. Mobile learning devices in the workplace: “as much a part of the junior doctors” kit as a stethoscope? BMC Med Educ. 2016;1– 9. 6. Barrows HS. Problem-based learning in medicine and beyond: a brief overview. New Dir Teach Learn. 1996;1996(68):3–12. 7. Carder L, Willingham P, Bibb D. Case-based, problem-based learning information literacy for the real world. Res Strateg. 2001;18(3):181–90. 8. Mohan D, Farris C, Fischhoff B, Rosengart MR, Angus DC, Yealy DM, et al. Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial. BMJ. 2017;359:1–12. 9. Qiu N, Ma W, Fan X, Zhang Y, Li Y, Yan Y, et al. Rapid improvement in visual selective attention related to action video gaming experience. Front Hum Neurosci. 2018 Feb 13;12. 10. Glass BD, Maddox WT, Love BC. Real-time strategy game training: emergence of a cognitive flexibility trait. PLoS One. 2013 Aug 7;8(8). 11. Antzaka A, Lallier M, Meyer S, Diard J, Carreiras M, Valdois S. Enhancing reading performance through action video games: the role of visual attention span. Sci Rep. 2017 Dec 1;7(1). 12. Gozli DG, Bavelier D, Pratt J. The effect of action video game playing on sensorimotor learning: evidence from a movement tracking task. Hum Mov Sci. 2014 Dec 1;38:152–62. 13. Rosser JC, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The impact of video games on training surgeons in the 21st century. Arch Surg. 2007 Feb;142(2):181–6. 14. Kulkarni S, Kulkarni Y, Bates-Powell J, Kulkarni MS, Sule M. Evaluation of the console in acquiring laparoscopic skills through video gaming. J Minim Invasive Gynecol. 2019 Aug;pii:S1553-4650(19)30332-2. 15. Ou Y, McGlone ER, Camm CF, Khan OA. Does playing video games improve

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A review of wilderness patient transport: a British Columbian perspective Andrew Stanley1, Holly Buhler2 Citation: UBCMJ. 2020: 11.2 (23-26)

Abstract British Columbia is a mountainous province known for wilderness adventure. In British Columbia, transport of patients injured in the wilderness is conducted by a network of agencies including British Columbia Emergency Health Services (BCEHS), the Canadian Armed Forces, and 83 volunteer Search and Rescue teams. This narrative review examines select topics in order to provide allied health professionals with an understanding of resources in British Columbia and how they compare to jurisdictions elsewhere to identify areas for improvement. The mode of transport is based on the patient’s condition and factors at the scene, making it important for both air and ground resources to work together smoothly to provide the greatest benefit to the patient. Often both ground and air resources are involved on a single rescue. Transport time is heavily dependent upon the distance from the site of dispatch to the patient, the environment, and the patient’s condition. Methods of helicopter rescue in British Columbia include landing, winch rescue (raising the patient to a hovering helicopter), and Helicopter External Transport Systems. The combination of these three methods in British Columbia is similar to the combination in the United Kingdom. Qualification of transport personnel varies between resources, with some ground rescuers only required to hold first aid, while EHS helicopters in British Columbia are staffed by critical care paramedics who perform just as well as physicians on helicopters in other jurisdictions. Overall, British Columbia’s system of wilderness transport is similar to that seen in other jurisdictions, but the field would benefit from a more robust body of research.

Introduction The rate of helicopter use seen in 1088 rescues recorded by the ritish Columbia is a mountainous province that markets itself Alpine Club of Canada was 37.4%, whereas ground transport was Bas a destination for wilderness adventure.1 In British Columbia, involved in 87.1% and was the exclusive method in 49.7%.8 Notable patients injured in the wilderness are transported by a network of here is that even when the initial response is by helicopter, ground agencies working together. British Columbia Emergency Health crews may still be required to assist in the rescue and the patient Services (BCEHS) is formally responsible for prehospital care and may still be transported by ground, reinforcing the importance of transport throughout the province.2 However, BCEHS may collaborate British Columbia’s volunteer SAR teams and their ground rescue with other organizations that, for wilderness transport, include the capabilities.9,10 Canadian Armed Forces (CAF) 442 Transport and Rescue Squadron,3 While studies have demonstrated a survival benefit to and the 83 volunteer Search and Rescue (SAR) teams throughout transporting non-wilderness trauma patients by helicopter rather the province.4 Each organization in this network contributes unique than ground ambulance, few studies have examined the benefit abilities to the wilderness transport capacity in British Columbia. during wilderness transport, where the distances are often long This narrative review examines select topics relevant to wilderness and resources limited.11 A retrospective analysis of 1018 skiers and transport and relates them to current practice in British Columbia. snowboarders who suffered a traumatic brain injury compared the We hope to provide allied health professionals with an understanding effect of helicopter versus ground transport on survival: transport via of the available resources and how they compare to jurisdictions helicopter conferred a survival benefit that the authors attributed to elsewhere, and to identify areas for improvement. the ability to quickly travel the large distances from remote ski areas 12 Mode of Transport to receiving facilities. Here in British Columbia, where neurosurgical The International Commission for Alpine Rescue (ICAR) guidelines resources are concentrated in the southern one-sixth of the province specify three general indications for choosing helicopter over ground geographically, this speed-over-distance benefit has the potential to 13 transport: the patient’s medical condition, conditions at the scene be particularly valuable. However, this must be balanced against (terrain, weather, etc.), and moving bulk equipment.5 Accordingly, a the risks inherent to helicopters. For instance, helicopter accidents study of 309 helicopter transports from Swiss Alpine Club huts found that occur during wilderness transport have twice the fatality rate of 14 that medical severity accounted for about one-third of missions, and accidents during general civilian flight. remote location was responsible for the rest.6 In a review of rescues Transport Time from Banff National Parks, helicopters were used in 64% of transfers ICAR guidelines and others highlight the impact that delays in due to the remote wilderness locations and the technical nature of transport from wilderness locations can have on patients.5,15 With the terrain.7 long distances and a sparsely distributed population, the most relevant benchmark for helicopter response times in British Columbia may 1Department of Family Practice Postgraduate Program, Faculty of Medicine, come from a Norwegian study that recorded average dispatch-to- University of British Columbia 2 take-off (activation) times of nine minutes and total response times Regional Practice Lead, Research and Knowledge Translation, Interior Health 16,17 Authority averaging 47 minutes. In Central and Western Europe, total response time was found to be more closely correlated with flight Correspondence to Andrew Stanley ([email protected]) time than with activation time, suggesting the location of resources is

23 UBCMJ Volume 11 Issue 2 | Spring 2020 REVIEW the more important factor.18 with winches, allowing one service to carry out the full spectrum The complexity of a patient’s injuries, together with terrain and of helicopter wilderness transport.27 As this approach offers the environment, can also increase the time to hospital, as illustrated in advantage of pairing the greatest rescue capabilities with the greatest a study from Austria showing that 18% of major trauma patients medical skillset in a single rescue resource, it may be beneficial to took more than two hours to reach a hospital from wilderness explore the inclusion of winch rescue capabilities on EHS helicopters environments.10 A Swiss study further supported patient severity as in British Columbia. a cause of delay, with crews averaging 54 minutes on the scene with Qualification of Transport Personnel severely injured patients compared to 37 minutes with moderately The skill of wilderness transport personnel has been identified as injured patients.19 a critical factor in patient outcomes.28 For ground transport, B.C. While no published information about wilderness response times government guidelines mandate all SAR personnel remain current in British Columbia was identified during this review, most dedicated in a seven-hour first aid course and suggest each field rescue group Emergency Health Service (EHS) helicopters are based in the south have one member with a 16-hour first aid course.29 When transport of the province, suggesting increased response times should be times exceed 20 minutes, at least one member must have 70 hours expected in the vast northern wilderness.20 Increased data in this area of first aid training or more. The make-up of SAR teams in British would be helpful for drawing comparisons to other jurisdictions and Columbia is heterogeneous, and many teams have paramedic identifying areas for improvement, as suggested by ICAR.21 or physician members.21 These requirements and general team Methods of Helicopter Rescue makeup are consistent with observations in a survey of SAR teams There are three primary helicopter rescue techniques: landing, winch in the intermountain west region of the United States, where 66% rescue, and Helicopter External Transport Systems (HETS). were trained to a first aid/CPR level, 17% as Emergency Medical Landing the helicopter to embark a patient is the simplest Responders (EMR), and 17% above EMR.30 In the extreme wilderness approach, requiring the least specialized equipment, least training, and environment of Denali National Park in Alaska, however, physicians, least risk; however, its disadvantage is requiring a landing site, which mid-level providers, paramedics, emergency medical technicians, and may be some distance from the patient.22,23 The time taken to transport nurses care for 90% of all patients seen by the National Parks Service, the patient by ground to the landing site will therefore detract from whereas only 10% are cared for exclusively by a lower level provider.31 the helicopter’s benefit. No published sources were identified that described a similar targeting Winch rescue involves the helicopter hovering above the of high-level resources to extreme environments in British Columbia, patient, using a winch to lower a rescuer, and then raising both the and this may represent an opportunity to improve care for those at the patient and the rescuer to the helicopter cabin for transport.9 The greatest risk of injury. capacity for winch rescue is encouraged by ICAR to facilitate rapid In North America, rescue helicopters are typically staffed by rescue from challenging environments; however, it comes with the paramedics, whereas elsewhere, it is common to include a physician.32 greatest cost, training demand, risk of malfunction, and helicopter In Australia, the Greater Sydney Area Helicopter Emergency Medical weight requirement.19,21 Additionally, because winching is technically Services (GSAHEMS) utilizes a physician-paramedic team. A study challenging, even winch-equipped helicopters land when possible, of 120 missions by GSAHEMS found physician-only interventions with two Swiss studies showing that winch rescue was required in were carried out on 40% of patients, an outcome they felt justified just 8.4–9.3% of responses.19,24 In the United States, a review of 214 the provision of physicians on helicopters.33 However, the only winch rescues identified perceived danger associated with ground observed physician-only interventions outside the scope of practice rescue as its primary indication, though time, distance, and the need of Critical Care Paramedics (CCPs) in British Columbia were a fascia for technical rescue are identified elsewhere.9,23 iliaca block and a tube thoracostomy, with B.C. CCPs limited to needle HETS involves landing away from the patient, securing a rescuer thoracostomies.34 Two other studies from Austria and Switzerland beneath the helicopter via a fixed line, flying to the patient with the have also examined the procedures carried out by physicians on rescuer suspended below, securing the patient together with the helicopters. Similarly, tube thoracostomy and peripheral nerve blocks rescuer, and then returning them to the landing site for embarking were the only interventions performed in these studies, which were onto ground transport or the helicopter cabin.23 HETS has the same outside the scope of practice of B.C. CCPs.10,24,34 In Victoria, Australia, ability as winching to extract patients from challenging environments Intensive Care Flight Paramedics have a scope of practice similar to using smaller, more economical helicopters and less complex B.C. CCPs. In a study of 125 helicopter winch rescues carried out equipment. The drawback is that HETS requires additional landings, by Intensive Care Flight Paramedics, the most common procedures which takes extra time. Still, HETS has been shown to save at least 30 were analgesia, vascular access, and antiemetic administration. The minutes versus ground transport in the most time-critical patients, and only advanced procedures required were two thoracostomies. These ICAR considers HETS to be an acceptable alternative to winch rescue findings suggest that the scope of practice for CCPs is sufficient.27 where resources are limited.17,21 When the performance of physicians and paramedics were directly In British Columbia, BCEHS requires landing zones to embark compared, no difference in survival was found between patients patients onto its helicopters, winch rescue is conducted by the CAF, attended to by a physician and those attended to by a paramedic during and HETS is provided by helicopters contracted through volunteer rural Australian helicopter transport.35 Thus, the current practice of SAR teams.20,25,26 This arrangement is similar to that in the United staffing EHS helicopters in British Columbia with paramedics rather Kingdom, where only SAR helicopters have winch and HETS abilities than physicians seems to be supported by the literature. while EHS helicopters must land to embark patients.23 In Victoria, Australia, however, the state’s five EHS helicopters are all equipped

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Conclusion Conflict of interest Transporting patients injured in the wilderness is an essential part The authors have declared no conflict of interest. of pre-hospital care in British Columbia, a province known for its References abundant outdoor activities. For those likely to care for patients 1. Destination BC Corporation. Mountains - find a new perspective [Internet]. Victoria, BC: Destination BC Corporation; 2019 [updated 2019; cited 2019 Mar transported from wilderness locations, this review draws attention to 28]. Available from: https://www.hellobc.com/travel-ideas/mountains the variation in transport times depending on the resources involved 2. Bellringer C. Access to emergency health services - An independent audit report [Internet]. Victoria, BC: Office of the Auditor General of British Columbia; 2019 and the location of the event, which should be considered when February [cited 2019 Mar 24]. 41 p. Available from: http://www.bcauditor.com/ planning resuscitation. It also highlights the diversity of qualifications sites/default/files/publications/reports/OAGBC_EHS_RPT.pdf 3. The Government of Canada. Search and rescue (SAR) in Western Canada amongst wilderness rescue personnel in British Columbia and [Internet]. Ottawa, ON: The Government of Canada; 2018 [updated 2018 May illustrates that the use of paramedics rather than physicians on EHS 15; cited 2019 Mar 22]. Available from: https://www.canada.ca/en/department- national-defence/services/operations/military-operations/search-rescue/western- helicopters does not suggest inferior care. This review has illustrated canada.html that the components making up British Columbia’s wilderness 4. BCSARA. The BC search and rescue program - professional and volunteer driven [Internet]. Sydney, BC: BCSARA; 2017 [updated 2017; cited 2019 Mar 22]. Available transport network function similarly to those in other jurisdictions, from: https://www.bcsara.com/about/sar-in-bc/ but that there are also opportunities for improvement. In particular, 5. Tomazin I, Kovacs T. Medical considerations in the use of helicopters in mountain rescue. High Alt Med Biol. 2003;4(4):479–83. the expansion of winch rescue capabilities in this province would 6. Zen Ruffinen G, Marxer L, Selz F, Pasquier M, Hugli O, Frochaux V, et al. decrease the time to care for patients injured in the wilderness, and Indications and outcomes of helicopter rescue missions in alpine mountain huts: a retrospective study. High Alt Med Biol. 2017;18(4):355–62. further study and publication of response and transport times would 7. Wild FJ. Epidemiology of mountain search and rescue operations in Banff, Yoho, allow more meaningful comparison to other jurisdictions. and Kootenay national parks, 2003-06. Wilderness Environ Med. 2008;19(4):245–51. 8. Curran-sills GM, Karahalios A. Epidemiological trends in search and rescue Table 1 |Public wilderness transport resources based in British Columbia. BCEHS, incidents documented by the Alpine Club of Canada from 1970 to 2005. Wilderness B.C. Emergency Health Services. CAF, Canadian Armed Forces. SAR, Search And Environ Med. 2015;26(4):536–43. Rescue. HETS, Helicopter External Transport Systems. 9. Carpenter J, Thomas F. A 10-year analysis of 214 HEMS backcountry hoist rescues. Air Med J. 2013;32(2):98–101. 10. Fop E, Palma M, Voelckel W, Strapazzon G, Stroehle M, Turner R, et al. Physician Agency Resources Qualifications staffed helicopter emergency medical systems can provide advanced trauma life support in mountainous and remote areas. Injury. 2016;48(1):20–5. BCEHS Two wheel drive Licenced as one of: 11. Andruszkow H, Hildebrand F, Lefering R, Pape H, Hoffmann R, Schweigkofler ambulances: 482 Emergency Medical U. Ten years of helicopter emergency medical services in Germany: do we still need the helicopter rescue in multiple traumatised patients? Injury. 2014;45 Suppl Four wheel drive Responder 3:S53–8. ambulances: 9 Primary Care Paramedic 12. Sun H, Samra NS, Kalakoti P, Sharma K, Patra DP, Dossani RH, et al. Impact of prehospital transportation on survival in skiers and snowboarders with traumatic Sikorsky S76 helicopters: 3 Advanced Care Paramedic brain injury. World Neurosurg. 2017;104:909–918.e8. Bell 412 helicopter 13. Provincial Health Services Authority. Trauma services BC [Internet]. Vancouver, Critical Care Paramedic BC: Provincial Health Services Authority; 2019 [updated 2019; cited 2019 Mar Private helicopters hired as 28]. Available from: http://www.phsa.ca/our-services/programs-services/trauma- services-bc needed 14. Worley GH. Civilian helicopter search and rescue accidents in the United States: CAF CH-149 helicopters SAR Tech, encompassing: 1980 through 2013. Wilderness Environ Med. 2015;26(4):544–8. 15. Strapazzon G, Reisten O, Argenone F, Zafren K, Zen-Ruffinen G, Larsen GL, Equipped with winch Primary Care Paramedic et al. International Commission for Mountain Emergency Medicine consensus guidelines for on-site management and transport of patients in canyoning incidents. Arctic rescue Wilderness Environ Med. 2018;29(2):252–65. Parachuting 16. Statistics Canada. Focus on geography series, 2011 census - province of British Columbia [Internet]. Ottawa, ON: Statistics Canada; 2012 Diving [updated 2015 Nov 12; cited 2019 Mar 25]. Available from: http://www12. Mountaineering statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-pr-eng. cfm?Lang=Eng&GK=PR&GC=59 SAR Diverse land vehicles Required training: 17. Samdal M, Haugland HH, Fjeldet C, Rehn M, Sandberg M. Static rope evacuation by helicopter emergency medical services in rescue operations in southeast Norway. Four wheel drive vehicles Ground SAR course Wilderness Environ Med. 2018;29(3):315–24. All terrain vehicles First aid (7 hours) 18. Reisten O, Tomazin I, Sumann G, Kersnik J, Vegnuti M, Ellerton J. Factors impacting on the activation and approach times of helicopter emergency medical Snowmobiles Additional training: services in four Alpine countries. Scand J Trauma Resusc Emerg Med. 2012;20(1):56. 19. Corniche J, Pasquier M, Yersin B, Kern C, Schoettker P. Helicopter rescue involving Diverse water craft Rope rescue the winching of a physician. Air Med J. 2012;31(2):87–91. Boats Swift water rescue 20. BC Emergency Health Services. BC Emergency Health Services air ambulance helicopter landing zone safety procedures [Internet]. Victoria, BC: BC Emergency Jet skis First aid (16 hours) Health Services; 2016 [updated 2016; cited 2019 Mar 24]. p. 1–46. Available from: http://www.bcehs.ca/about-site/Documents/2016-08-29 BCEHS Landing Zone Hovercraft First aid (70 hours) Safety Procedures - FINAL.pdf Private helicopters hired Members may have 21. Soteras I, Ellerton J, Avbelj M, Tomazin I, Reisten O. Medical standards for mountain rescue operations using helicopters: official consensus recommendations as needed further medical and of the International Commission for Mountain Emergency Medicine (ICAR Equipped with HETS rescue training MEDCOM). High Alt Med Biol. 2011;12(4):335–41. 22. BC Emergency Health Services. Critical care program [Internet]. Victoria, BC: BC Emergency Health Services; 2019 [updated 2019; cited 2019 Mar 24]. Available from: http://www.bcehs.ca/our-services/programs-services/critical-care-program 23. Ellerton J, Gilbert H. Should helicopters have a hoist or “long-line” capability to perform mountain rescue in the UK? Emerg Med J. 2012;29(1):56–9. 24. Pasquier M, Geiser V, Riedmatten M De, Carron PN. Helicopter rescue operations involving winching of an emergency physician. Injury. 2012;43:1377–80. 25. The Government of Canada. Royal Canadian Air Force - CH-149 Cormorant [Internet]. Ottawa, ON: The Government of Canada; 2017 [updated 2017 Jun 22; cited 2019 Mar 24]. Available from: http://www.rcaf-arc.forces.gc.ca/en/aircraft- current/ch-149.page 26. BCSARA. Search and rescue techniques - Specialized for the mountains of BC [Internet]. Sydney, BC: BCSARA; 2017 [updated 2017; cited 2019 Mar 24]. Available

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from: http://www.bcsara.com/sar-groups/rescue-techniques/ 27. Meadley B, Heschl S, Andrew E, Wit A De, Stephen A, Smith K, et al. A paramedic- staffed helicopter emergency medical service’s response to winch missions in Victoria, Australia. Prehospital Emerg Care. 2016;20(1):106–10. 28. Strapazzon G, Procter E, Brugger H. The quest for evidence-based medicine in mountain areas. High Alt Med Biol. 2011;12(4):399–400. 29. The Office of Public Safety and Solicitor General. Provincial search and rescue operating guidelines [Internet]. Victoria, BC: The Office of Public Safety and Solicitor General; 2018 Nov [updated 2019 Nov; cited 2019 Mar 26]. Available from: https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/ emergency-preparedness-response-recovery/embc/volunteers/sar_safety_ program_operating_guidelines.pdf 30. Russell KW, Weber DC, Scheele BM, Ernst RP, Kanaan NC, Smith WR, et al. Search and rescue in the intermountain west states. Wilderness Environ Med. 2013;24(4):429– 33. 31. McIntosh SE, Campbell A, Weber D, Dow J, Joy E, Grissom CK. Mountaineering medical events and trauma on Denali, 1992–2011. High Alt Med Biol. 2012;13(4):275– 80. 32. Sumann G, Elsensohn F, Falk M, Brugger H, Syme D. A survey of emergency medical services in mountain areas of Europe and North America. High Alt Med Biol. 2005;6(3):226–37. 33. Sherren PB, Hayes-Bradley C, Reid C, Burns B, Habig K. Are physicians required during winch rescue missions in an Australian helicopter emergency medical service? Emerg Med J. 2014;31(3):229–32. 34. Queen’s Printer. Emergency health services act - emergency medical assistants regulation [Internet]. Victoria, BC: Government of BC; 2017 [updated 2018; cited 2019 Mar 24]. Available from: http://www.bclaws.ca/EPLibraries/bclaws_new/ document/ID/freeside/210_2010 35. Shepherd MV, Trethewy CE, Kennedy J, Davis L. Helicopter use in rural trauma. Emerg Med Australas. 2008;20(6):494–9.

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Backcountry triggered avalanches: a summary of risk factors, causes of death, and wilderness medical management Adam Stich1*, Jacob Blanco2* Citation: UBCMJ. 2020: 11.2 (27-29)

Abstract Deaths due to avalanches have a significant mortality burden in Western Canada. The aim of this review is to summarize risk factors, causes of death, and important mitigation and management strategies in treating avalanche victims. Multiple risk factors for avalanches have been identified, which relate to both physical characteristics of the avalanche environment as well as human factors. Winter backcountry recreationists should be mindful of their motivations for exposing themselves to avalanche dangers and remain objective to the physical characteristics conferring avalanche accident risk. Asphyxia is responsible for the vast majority of deaths due to avalanche, while trauma remains an important cause in certain geographic areas. Avalanche training courses educate learners on avalanche rescue sequences, which utilize avalanche transceivers, probes, and strategic shoveling techniques. The primary goal of rescue is to reduce the median time of burial, thereby decreasing the incidence of asphyxia and ultimately, death. Following the extrication of an individual from an avalanche, rescuers may have to begin resuscitation efforts. Future developments in avalanche safety should focus on public education of avalanche risk factors, incorporation of basic life support into avalanche training courses, and further development of technologies that may increase survivability.

Introduction Table 1 |Risk factors related to physical conditions. ackcountry winter recreation has spiked in popularity over the Study Outcome past few decades.1 In Canada, an average of 12 avalanche deaths (study Risk Factor Identified B Studied occurred annually between 2008–2018, with the majority occurring location) in British Columbia (82.9%) and Alberta (13%). Snowmobilers Grimsdottir Snowpack stability rated poor or very poor and contributed 48.8% of these fatalities, while backcountry skiing and Risk of Alpine environment 2 McClung out-of-bounds skiing cumulatively accounted for 25.2%. While 5 triggering (2006) avalanche Early and mid-winter the avalanche mortality burden is relatively low compared to other (British causes of death, the disproportionate impact seen in British Columbia Columbia) North, Northeast, and East facing slopes combined with the rising popularity of recreation in avalanche terrain Avalanche forecast danger level (positive highlights the necessity for greater avalanche awareness. This is Techel et al. Risk of correlation with increasing danger rating) 6 particularly pertinent given avalanche awareness and safety training (2015) avalanche (Switzerland) accident Unfavourable snowpack (i.e., persistent programs have been found to be effective in preventing avalanche weak layer) 3 accidents, as well as mitigating consequences in avalanche victims. Slab depth; fatality increased with The goal of this review is to summarize risk factors for avalanche McClung et slab depth, however risk of triggering 4 accidents, causes of death, and important mitigation and treatment al. (2014) Risk of decreased. Risk of accident was highest (Switzerland avalanche between 0.6–1.0 m strategies helpful in maximizing survivability. This review is not and British accident intended to be used as a field guide, nor should it replace formal Columbia) Slope angle 33–45°. Highest risk of wilderness medical training. triggering was between 38–40° Avalanche Risk Factors exposure to avalanche terrain, and behavioural factors influencing the It is estimated that 90% of deaths from slab avalanches in Europe decision to expose oneself to avalanche hazard (Table 2). and North America are the result of human triggering.4 McCammon Several studies have identified physical risk factors for triggering found that avalanche awareness and safety programs have been avalanches, all of which can be factored into decision-making associated with a decrease in avalanche mortality, suggesting that there regarding exposing oneself to avalanche hazard.4–6 Unsurprisingly, are mitigation strategies that can be employed to prevent avalanche- information publicly available through avalanche forecasting, including related burial, critical injury, or death.3 snowpack instability and high avalanche danger ratings, were found to We reviewed the literature to identify risk factors implicated be associated with an increase in avalanche triggering and accident in avalanche triggering or accidents and have separated these into risk.5,6 McClung et al. identified slab depths between 0.6–1.0 m and physical features relating to weather, season, or terrain characteristics slope angles between 33–45° to be associated with the highest risk (Table 1), and human factors relating to avalanche triggering risk, of triggering an avalanche of sufficient size to cause critical injury or death.4 Additionally, Grimsdottir and McClung found that the risk of triggering avalanches was greater in the alpine environment (2200 m 1Department of Family Medicine, University of British Columbia 2Department of Family Medicine, University of Calgary above sea level), in early and mid-winter, and on north, northeast, and *Both authors contributed equally to this work east facing slopes.5 Correspondence to A number of studies have identified human factors associated Adam Stich ([email protected]) with avalanche triggering risk, accident risk, and exposing oneself to Jake Blanco ([email protected]) avalanche terrain (Table 2).3,6–9 Individuals aged 25–29 were found to

27 UBCMJ Volume 11 Issue 2 | Spring 2020 REVIEW be most risk tolerant and at higher risk for avalanche accident.8,9 Males and the United States and may reflect differences in terrain or type were found to be at higher risk for avalanche accident compared to of backcountry activity. Collision with trees is often implicated in females.9 Interestingly, Gehring and Latosuo found no association traumatic avalanche accidents, which may account for this difference between avalanche terrain usage and danger rating, and found usage as there is more accessible forested terrain in parts of Western Canada, was highest on weekends regardless of avalanche danger.8 Similarly, including British Columbia and Alberta.11,14 Techel et al. found no association between avalanche terrain exposure Table 2 |Human factors associated with avalanche risk. and snowpack instability.6 These results suggest that the decision Study to enter avalanche terrain may be influenced more by recreationist Outcome (study Risk Factor Identified availability than avalanche triggering risk. A lack of formal avalanche Studied location) safety training was associated with higher risk tolerance as well as avalanche accident risk.3,8 With regards to decision-making in avalanche Forecast suggesting minimal hazard terrain, Furman et al. found that recreationists were more likely to Untracked slope expose themselves to avalanche terrain if the forecast suggested Furman et al. Exposure Familiar terrain minimal hazard, a slope was untracked or was familiar to the user, (2009)7 to avalanche Group had a leader (USA) terrain the group had an identified leader, other parties were present in the Other parties present 7 terrain, or if a skier was committed to a particular line. Furthermore, Skier committed to skiing a particular Sole and Emery found individuals who desired intense experiences line or were motivated by “fun-seeking” had a higher risk of avalanche Factors Risk tolerance decreased with 9 accident. associated with increasing levels of avalanche training Our analysis of avalanche risk factors suggests that while higher risk Gehring Age 25–29 snowpack instability and avalanche danger ratings are accounted for in and Latosuo tolerance avalanche forecasts due to their association with increased avalanche (2014)8 Weekends more common, regardless risk, these do not necessarily correlate with lower avalanche terrain (Alaska) Exposure of avalanche danger to avalanche usage by recreationists. Users should be mindful of their motivations terrain No correlation between avalanche for exposing themselves to avalanche dangers and remain objective terrain usage and avalanche danger to the physical characteristics conferring avalanche accident risk. This Techel et al. Exposure No correlation between avalanche is particularly important for high risk groups—namely, males aged (2015)6 to avalanche terrain usage and unfavourable 25–29. The findings of our review also suggest that avalanche safety (Switzerland) terrain snowpack (i.e., persistent weak layers) training remains an effective strategy for decreasing avalanche accident Avalanche Male sex incidence, both by preventing high-risk exposure and by training users mortality Age 25–29 to mitigate consequences of avalanches if they occur. Avalanche Sole and Canada reports that avalanche safety training course enrollment has Emery Desire for intense experiences been increasing with the boom in popularity of winter backcountry (2008)9 Exposure time (Western Avalanche recreation; however, the proportion of enrollment for motorized accident risk Male-dominant groups users has been low compared to self-propelled users.1 Thus, efforts to Canada) Behaviour motivated by “fun improve snowmobilers’ participation in avalanche safety training may seeking” as opposed to “memory help to reduce their disproportionately high avalanche mortality risk.10 creating” Causes of death Lack of formal avalanche safety McCammon Avalanche 3 training (due to more risks taken and Among several studies analyzing cause of death in avalanche victims, (2000) accident risk asphyxia was unanimously found to be the most common cause of (USA) decreased risk mitigation by victims) mortality.11–13 Boyd et al. analyzed the causes of avalanche fatality in British Columbia and Alberta between 1984–2005 based on Approach to Management in the Field and Safety postmortem autopsy or full external examination, and found that the Equipment majority of deaths were caused by asphyxiation (75%) and trauma Rescue Sequence (24%).11 Similarly, Hohlreider et al. reviewed autopsy reports of The Wilderness Medicine Society has published guidelines on avalanche victims presenting to the University Hospital of Innsbruck the Prevention and Management of Avalanche and Snow Burial in Austria between 1996–2005, and found that 91.7% of deaths Accidents.2 When an individual is buried in an avalanche, they first were attributable to asphyxia, while only 5.5% were due to trauma.12 recommend establishing and ensuring scene safety prior to carrying McIntosh et al. examined medical records of avalanche fatalities out the rescue. A visual surface search can then be carried out to from 1989–2006 from the Utah Avalanche Centre and the Medical identify an incomplete burial. If the visual search is not successful, Examiner's records in Utah, and found the leading cause of death rescuers are then recommended to perform transceiver search, to be asphyxia (91.7%), with only 5.4% of deaths being caused by followed by a pinpoint/probe search and strategic shoveling to trauma alone.13 uncover the avalanche victim.15 Contacting local emergency services Although these retrospective reviews consistently identified should not delay the rescue response and can happen at any point asphyxia as the most significant cause of death, geographical during the rescue. differences exist. In Western Canada, trauma is a significant cause of When avalanche rescue is initiated by companions at the scene, avalanche mortality.11 This differs from studies conducted in Europe as opposed to professional rescue teams, the time to extrication is

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shorter (16 versus 150 minutes) and the probability of survival is avalanche education programs have been shown to reduce avalanche higher (75% versus 30%).16 The use of avalanche transceivers is also mortality and we recommend that all users undertake this training associated with a shorter median burial time (20 versus 102 minutes and ensure they are proficient in avalanche rescue sequences prior to without transceivers) and reduction in mortality (53.8% versus 68%).17 entering the backcountry. Future areas for improvement in avalanche Furthermore, the probability of survival significantly decreases after safety include incorporation of first aid and basic life support into 35 minutes of burial.18 Given that asphyxia is the most common cause avalanche training courses, and further development of technologies of death, reducing burial time is paramount and backcountry users that may increase survivability. should be prepared and able to perform companion rescue efficiently. Resuscitation Conflict of interest Following the extrication of an individual from an avalanche, a rescuer The authors have declared no conflict of interest. may have to begin resuscitation efforts if clinically indicated. With References limited resources or assistance, this can be a daunting task in the 1. Avalanche Canada. 2017-2018 annual report [Internet]. 2018. Available from: https:// issuu.com/avalancheca/docs/ac_2018_annual_reportissuu avalanche terrain. In a rescue sequence, the Wilderness Medicine Society 2. Van Tilburg C, Grissom CK, Zafren K, McIntosh S, Radwin MI, Paal P, et al. Wilderness advises using the European Resuscitation Council (ERC) Guidelines.20 Medical Society practice guidelines for prevention and management of avalanche and nonavalanche snow burial accidents. Wilderness Environ Med. 2017 Mar 1;28(1):23–42. Section 4 of the ERC guidelines comments on resuscitation in special 3. McCammon I. The role of training in recreational avalanche accidents in the United environments including avalanches, recommending “high-quality States. In: International Snow Science Workshop. 2000. p. 2–6. 4. McClung DM. Risk analyses for dry snow slab avalanches released by skier triggering. cardiopulmonary resuscitation (CPR) with minimal interruption of Nat Hazards. 2014 Jun 8;72(2):1139–58. chest compressions and treatment of reversible causes.”21 Trauma 5. Grímsdóttir H, Mcclung D. Avalanche risk during backcountry skiing – an analysis of risk factors. Nat Hazards. 2006 Sep 21;39(1):127–53. can exacerbate hypothermia and asphyxia, and is an important cause 6. Techel F, Zweifel B, Winkler K. Analysis of avalanche risk factors in backcountry terrain of avalanche death in Western Canada.11 The Wilderness Medicine based on usage frequency and accident data in Switzerland. Nat Hazards Earth Syst Sci. 2015 Sep 9;15(9):1985–97. Guidelines recommend trauma care as an integral part of resuscitation, 7. Furman N, Shooter W, Schumann S. The roles of heuristics, avalanche forecast, and risk including appropriately managing suspected spine injuries using propensity in the decision making of backcountry skiers. Leis Sci. 2010 Sep 30;32(5):453– 2 69. validated guidelines such as the Canadian C-Spine Rules or Nexus. 8. Gehring B, Latosou E. Avalanche risk: assessment, preparedness, and awareness of Furthermore, avalanche resuscitation should include management of backcountry users in Turnagain Pass, Alaska. In: International Snow Science Workshop. 2014. 20 p. 932–8. hypothermia using a combination of insulation and vapor barriers. 9. Sole A, Emery C. Human risk factors in avalanche incidents. In: International Snow Science An in-depth discussion of resuscitation and management in the Workshop. 2008. p. 498–505. 10. Spencer JM, Ashley WS. Avalanche fatalities in the western United States: a comparison field is beyond the scope of this article. It is, however, important to of three databases. Nat Hazards. 2011 Jul 23;58(1):31–44. note that Basic Life Support (BLS) or CPR training is not currently 11. Boyd J, Haegeli P, Abu-Laban RB, Shuster M, Butt JC. Patterns of death among avalanche fatalities: a 21-year review. CMAJ. 2009 Mar 3;180(5):507–12. incorporated into avalanche safety courses such as Avalanche Safety 12. Hohlrieder M, Brugger H, Schubert HM, Pavlic M, Ellerton J, Mair P. Pattern and Training One or Avalanche Safety Training Two, and therefore may severity of injury in avalanche victims. High Alt Med Biol. 2007 Mar 29;8(1):56–61. 13. McIntosh SE, Grissom CK, Olivares CR, Kim HS, Tremper B. Cause of death in represent an area for future improvement in avalanche safety training. avalanche fatalities. Wilderness Environ Med. 2007 Dec 1;18(4):293–7. 14. Haegeli P, Falk M, Brugger H, Etter H-J, Boyd J. Comparison of avalanche survival Developments in Safety Equipment patterns in Canada and Switzerland. Can Med Assoc J. 2011 Apr 19;183(7):789–95. With increased backcountry usage, there has also been development 15. Edgerly B, Atkins D AR. Strategic shoveling: The next frontier in companion rescue. In: 22,23 Proceedings of the 2006 International Snow Science Workshop. 2006. p. 1–6. in technologies that may reduce mortality related to avalanches. 16. Slotta-bachmayr L. How burial time of avalanche victims is influenced by rescue method: The avalanche rescue airbag is a piece of equipment that allows the an analysis of search reports from the Alps. Nat Hazards. 2005 Mar;34(3):341–52. 17. Hohlrieder M, Mair P, Wuertl W, Brugger H. The impact of avalanche transceivers on user to inflate to emergency balloons that are integrated into a special mortality from avalanche accidents. High Alt Med Biol. 2005 Mar 16;6(1):72–7. backpack. An avalanche rescue airbag can decrease the depth of 18. Brugger H, Durrer B, Adler-Kastner L, Falk M, Tschirky F. Field management of avalanche victims. Resuscitation. 2001 Oct 1;51(1):7–15. burial during avalanche through decreasing effective density of the 19. Kornhall DK, Martens-Nielsen J. The prehospital management of avalanche victims. J user. Although the avalanche rescue bag started as a niche product R Army Med Corps. 2016 Dec 1;162(6):406–12. 20. Zafren K, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, et al. in the 1970s, it has undergone recent development and is now more Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and widely accepted amongst backcountry users.23 A retrospective review treatment of accidental hypothermia. Wilderness Environ Med. 2014 Dec 1;25(4):425–45. 21. Truhlář A, Deakin C, Soar J, Khalifa G, Alfonzo A, Bierens J, et al. European of global avalanche data found a significant reduction in mortality resuscitation council guidelines for resuscitation 2015: section 4. Cardiac arrest in special associated with usage of the airbag equipment (22% to 11%).24 As circumstances. Resuscitation. 2015 Oct;95:148–201. 22. Brugger H, Etter HJ, Zweifel B, Mair P, Hohlrieder M, Ellerton J, et al. The impact of market competition in avalanche airbag technology accelerates, avalanche rescue devices on survival. Resuscitation. 2007 Dec 1;75(3):476–83. the unit price of airbags will decrease. As the technology becomes 23. Brugger H, Falk M. Analysis of avalanche safety equipment for backcountry skiers. Avalanche News. 2004;34–8. more economical and affordable, it is expected that utilization by the 24. Haegeli P, Falk M, Procter E, Zweifel B, Jarry F, Logan S, et al. The effectiveness of backcountry community to continue to increase, having a significant avalanche airbags. Resuscitation. 2014 Sep 1;85(9):1197–203. 25. Grissom CK, Radwin MI, Harmston CH, Hirshberg EL, Crowley TJ. Respiration impact on the future of avalanche safety. during snow burial using an artificial air pocket. JAMA. 2000 May 3;283(17):2266–71. Another piece of safety equipment to consider are Artificial 26. Brugger H, Sumann G, Meister R, Adler-Kastner L, Mair P, Gunga HC, et al. Hypoxia and hypercapnia during respiration into an artificial air pocket in snow: implications for Air Pocket Devices. These mouthpieces allow avalanche victims to avalanche survival. Resuscitation. 2003 Jul 1;58(1):81–8. divert CO2 away from their airway, thereby delaying asphyxiation.25,26 The device appears promising, but there is currently a lack of data demonstrating its effectiveness in real-world use.23 Conclusion Backcountry enthusiasts who are entering avalanche terrain should take appropriate steps to educate themselves on the risk factors associated with avalanche accidents and strategies to mitigate those risks. Formal

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Medicine and the media: a synergistic combination? Paige H. Dean1*, Vito Z. Zou1* Citation: UBCMJ. 2020: 11.2 (30-31)

Abstract As second year medical students, we took part in an interdisciplinary journalism project that examined the links between fishmeal and fish farming industries in various parts of the world. Through this experience, we came to acknowledge a synergistic pairing between the fields of journalism and medicine by examining the similarities and differences in terms of information gathering and knowledge translation. Many journalism principles can aid immensely in the translation of medical knowledge to the general population, including the ability to construct a relevant narrative, gather information with open-ended and closed-ended questions, and ultimately produce a story that is influential and applicable to the audience.

n December 2018, we traveled to the coastline of Peru as fellows to permeate the entire city. A local biologist stated that this smell Iwith the Global Reporting Program, an investigative journalism stemmed from a five to ten-meter layer of sludge at the bottom of initiative based at the University of British Columbia (UBC), which the Bay of Chimbote, and illustrated this by digging up a bucketful aims to bring under-reported issues around the world into focus. We while we were out on a boat. This sludge is a consequence of decades accompanied a skilled team of UBC Masters of Journalism students of unregulated dumping of unprocessed sewage and effluent from who were conducting a reporting project on the global impact of the fishmeal factories into the bay. The journalism lens placed great fishmeal production and its supply chain. emphasis on the powerful image of the sludge itself, since it would As a team, the journalism students worked to deliver a story that provoke questions and concerns in the audience. Conversely, the highlighted the global impact of fishmeal and fish farming industries medical approach to this environmental issue would undoubtedly be in Peru, China, and Western Africa. As two medical students among to focus on investigating the health consequences, such as respiratory this group, we often felt out of place and repeatedly asked ourselves and dermatological complications that would result from exposure to what we could offer. We reasoned that we were able to contribute this unprocessed sewage. That day with the biologist provided us with to the integrity of the project by offering a perspective on health- an undeniable link between industrial activity, environmental damage, related topics in the story. Furthermore, through our experiences, we and human health consequences evidenced in the people of Chimbote. found ourselves drawing multiple comparisons between gathering In addition to participation in field work, the journalism team information for medicine and for media. It has been suggested that provided us an opportunity to act as the “team leader,” where we were the media may not accurately convey medical information,1,2 but responsible for coordinating and conducting interviews. We worked after participating in this project, we concluded that techniques used with a local nutritionist and visited a small fishing community, where in medicine and journalism could be complementary in the realm of we investigated the common nutritional deficits and health problems knowledge translation. in the area. In preparation for that day, we discussed interviewing We learned from the journalism students about acquiring strategies with a journalism colleague. She highlighted the importance information and concluded that their approach was quite different of starting with open-ended questions and subsequently moving to from what is taught in medicine. In medicine, evidence is gathered closed-ended questions. We immediately drew the parallel to medicine from a variety of sources in the literature upon which conclusions are where we are instructed to start patient interviews with open-ended based on. In journalism, it is more important to first identify a strong questions and later integrate closed-ended questions to obtain specific story, then search for powerful “characters” who can reinforce that information. We were struck by how similar principles can apply in point. This is a more direct way to illustrate a particular issue, but it professions that one would assume to be vastly different. Though can lead to scenarios in the media where contradicting viewpoints may these techniques may be similar, the focus of the interview differs. The be excluded from the story in order to strengthen its central theme. In medical interview is focused on obtaining the most accurate health best journalism practice, this exclusion is done strategically and in an information from a patient, whereas a journalism interview works to informed manner. evoke emotion by gathering quotes from the character that will most A noteworthy part of our field work was spent in Chimbote, a resonate with their storyline and target audience. fishing-centric coastal city approximately 400 kilometers north of the Together, journalistic and medical interview approaches can work capital, Lima. This city was once a pristine beach destination, but over in tandem to elicit a response in the audience that may subsequently the last few decades has become increasingly polluted as fishmeal inspire change or action. The utility of influential reporting is and fish oil production, canning, and frozen fish industries have particularly prominent in healthcare, where the information gathered implemented factories and plants. Our first impression of Chimbote by health professionals must be disseminated and applied in a variety was the overwhelmingly nauseating stench of rotten fish that seemed of settings. Medicine tends to focus on objective findings, with a subjective story lending support and additional details. In contrast, the priority in journalism is a subjective story, with objective findings 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, providing support. Complex medical topics can be made more tangible BC, Canada *Both authors contributed equally to this work to the general public when combining subjective stories with objective findings; appealing narratives are likely to influence health-related Correspondence to Vito Z. Zou ([email protected]) changes. In our medical education thus far, we have had opportunities for interprofessional education and collaboration, but exclusively with

UBCMJ Volume 11 Issue 2 | Spring 2020 30 COMMENTARY other health professions. Participating in this project exposed us to methods of knowledge translation that may not be traditionally utilized in healthcare, and allowed us to work with a multidisciplinary team to highlight the healthcare implications of an important global issue. The topics addressed in this project—health, environmental change, and economics—are of huge importance to the public. The challenge lies in presenting these issues in a way that inspires action. Combining the reporting techniques commonly used in news media with those used in medicine can be a method to motivate the public to make these changes. Although they seem different in principle, this global interdisciplinary experience demonstrated that these techniques are quite complementary and combining them will lead to a more powerful story, a stronger response, and ultimately, a more successful knowledge translation. To illustrate an example of these synergistic benefits, we would like to direct the reader’s attention to the final product of this project, titled “The fish you don’t know you eat,” which includes a webpage3 and short films4,5 that aired on NBC Nightly News. Acknowledgements We would like to thank Peter Klein and the entire UBC Global Reporting Program team for graciously inviting us to participate in this project, as well as Dr. Videsh Kapoor for her ongoing support and mentorship throughout this project.

Conflict of interest The authors have declared no conflict of interest. References 1. Moynihan R. Making medical journalism healthier. Lancet. 2003 Jun 21;361(9375):2097–8. 2. Larsson A, Oxman AD, Carling C, Herrin J. Medical messages in the media— barriers and solutions to improving medical journalism. Health Expect. 2003 Dec;6(4):323–31. 3. Global Reporting Program. The fish you don’t know you eat [Internet]. Vancouver, Canada: Global Reporting Program; 2019 Sept 27 [cited 2019 Sept 27]. Available from: https://globalreportingprogram.org/fishmeal 4. Nightly Films. The fish you don’t know you eat (Part 1) [web streaming video]. New York: NBC Universal; 2019 Sept 27 [cited 2019 Sept 27]. Available from: https://www.nbcnews.com/nightly-news/video/the-fish-you-don-t-know-you- eat-part-1-70090821824 5. Nightly Films. The fish you don’t know you eat (Part 2) [web streaming video]. New York: NBC Universal; 2019 Sept 27 [cited 2019 Sept 27]. Available from: https://www.nbcnews.com/nightly-news/video/the-fish-you-don-t-know-you- eat-part-2-70090821898

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Caution and guidance for the social media savvy physician Wajid I. Khan1 Citation: UBCMJ. 2020: 11.2 (32-33)

Abstract The advent of social media has brought forth the freedom to communicate information instantly to a large audience and its application in medicine has been beneficial for both patients and practitioners. Healthcare institutions and practitioners are utilizing the power of social media to inform and educate their peers and patients as well as the public. Patients are engaging in social discourse online, enabling them to become more involved in and informed about healthcare. It is in this climate that the matters of professionalism and patient privacy become a concern. Without a formal system of peer-review and the perception of anonymity, posting content on social media websites by healthcare providers is susceptible to crossing professional and ethical boundaries. Medical students and residents should be especially careful when posting online, as unprofessional content is common in their groups. Physicians should also be wary of self-promotion through entertainment, or “medutainment,” which can put patient privacy in harm’s way. When doctors review their intentions and follow guidelines (such as the Canadian Medical Protection Association tips) prior to posting on social media, a beneficial outcome can be achieved.

ver the last decade, the accessibility and popularity of social Patient confidentiality is another concern when doctors use Omedia have empowered both patients and physicians to share social media. The tendency for online content to stray into medical their opinions and stories online. Patients are using Twitter to express education entertainment, or “medutainment,” can place privacy their dissatisfaction with healthcare,1 and joining Facebook groups at risk. Medutainment is commonly observed in medicine when or websites such as www.PatientsLikeMe.com to connect with other the purpose is to entertain or sensationalize in order to promote sufferers for support.2 For physicians, social media can serve as a oneself.11 One such case involving a breast reduction surgery led to platform to educate peers, patients, and the general public. Experts an undesirable confrontation between the surgeon and his patient.12 agree that physicians should legitimize their roles as public figures After obtaining patient consent, the surgeon shared a video of the by taking an active part in social media to help combat the growing procedure on Snapchat in which he held the patient’s breast tissue problem of health misinformation.3 While social media can evidently and told his audience, “Look at how much extra breast tissue you benefit medicine, it can also have a negative impact upon doctors and might be carrying around.” Later during a follow-up visit, the patient patients when content crosses professional and ethical boundaries. appeared visibly upset and asked the surgeon, “You hold up my breast Social media makes it easier for individuals to behave in ways tissue for the world to see and call that education?” and then stated, that they would not behave in person. This “online disinhibition “I assumed you’d treat my experience with respect.” Although the effect” is influenced by the lack of a formal review process, absence surgeon had obtained consent before posting the video, the patient of social cues, and the perception of anonymity.4 Consider the case nevertheless felt her privacy was exploited. Such situations can be of a group of high-school students who had their acceptance to avoided by placing the interest of the patient above the need for self- Harvard University rescinded as a result of posting offensive “meme” promoting medutainment. More importantly, a fully informed consent content on a Harvard Facebook group.5 Or, the discovery of past process that includes educating patients about the risks of having their offensive tweets made by Hollywood celebrities in recent years, which information disseminated online should be implemented.12 Patients has led to significant backlash from the public. When healthcare should be reminded that public content may be viewed by anyone, professionals use poor judgement, they may find themselves in a including audience members who may be immature or underage. similar predicament. Indeed, posts containing unprofessional content Furthermore, complete removal may be impossible because the are common among medical students and residents.4,6 In certain content can be downloaded or shared. Patients can also be invited to instances, individuals harbouring prejudice may circulate racist or view and approve their content prior to posting. discriminating comments. Such was the case with a Cleveland Clinic When utilized appropriately, the benefits of social media in medical resident who was terminated for commenting on Twitter medicine can outweigh the harms. It offers physicians the convenience that she intended to mismanage patients of Jewish ethnicity, among of communicating medical knowledge instantaneously to a wide other anti-Semitic remarks.7 Unfortunately, individuals or groups audience. Moreover, it enriches medical education by fostering publicizing hateful and offensive content through social media are a collaboration, resource sharing, moral support, and feedback from growing problem, and resources to combat the issue are inadequate.8 peers and faculty.13 Indeed, research shows that integration of social Policing hate speech is a controversial topic, and some proponents of media into one’s practice can promote excellence in abilities described free expression suggest hate speech is best remedied with counter- in the CanMEDS framework, such as communication, interpersonal speech or speech that denounces offensive posts.9 Amidst the debate, skills, professionalism, knowledge translation, and scholarly a simple yet helpful tip for physicians and students to remember is: if approach.13 Pathologists in the United States, for example, have made you would not say it in person, refrain from saying it online.10 great educational strides by posting de-identified case images on social media.14 Medical Wikis, such as Radiopedia and WikiSurgery, are 1Saba University School of Medicine crowdsourced encyclopaedias maintained by volunteers and utilized by students as well as professionals.15 Furthermore, microblogging Correspondence to Wajid I. Khan ([email protected]) on Twitter is becoming a popular choice for medical journals and online journal clubs to share news of the latest medical literature.

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Interestingly, a positive correlation between a journal’s impact factor reach.” Present information using professional language with and the size of its Twitter following has been described.16 The Journal credible sources. of Cardiovascular Electrophysiology has taken advantage of this trend 6. “Generate interest and participation.” Invite and respect by integrating the peer-review process into Twitter. Cardiologists can differing viewpoints and opinions. post electrophysiology cases with images, and by including the hashtag 7. “Be aware that libel, slander, and defamation apply.” Avoid #JCEtweet2press, the cases can be peer-reviewed by professional untrue or damaging statements. editors and published in the journal. 8. “Develop a social media policy.” Inform staff and patients Social media is also tremendously useful for engaging patients in of your policy. healthcare and notifying the public. Hospitals use microblogging to 9. “Manage privacy and minimize breaches.” Become familiar broadcast notifications for organ donations, health fairs, bioterrorism with security settings and policies. alerts, fundraising, and results of satisfaction surveys.17 Alternatively, 10. “Follow College guidelines.” the Centers for Disease Control and Prevention uses social media to connect followers with information on health and safety topics.18 Conflict of interest Medical blogs are also an excellent way for patients and physicians The author has declared no conflict of interest. to exchange dialogue about important topics and make informed References decisions about healthcare. For example, the New York Times’ health 1. Vogel L. Medicine slow to recognize social media as window into the patient experience. CMAJ. 2019 Jan 21;191(3):E87–8. blog Well posts on topics ranging from medical research to patient 2. Kabbur G. Can social media help increase the organ supply while avoiding well-being.19 Readers can share their comments and stories, and the exploitation and trafficking? AMA J Ethics. 2016 Feb 1;18(2):115–21. 3. Motluk A. Do physicians have a duty to share their views on social media? CMAJ. most popular pieces are placed in the “Reader Picks” section. Another 2018 Mar 12;190(10):E302–3. highlight is their sub-column Ask Well, which brings physicians and 4. Collier R. Professionalism: Social media mishaps. CMAJ. 2012 Sep 4;184(12):E627– 8. experts together to answer health questions such as “When is the Best 5. The Harvard Crimson. Harvard Rescinds Acceptances for At Least Ten Students Time to Get Your Flu Shot?” and “How Do You Treat Positional for Obscene Memes [Internet]. Cambridge, MA: The Harvard Crimson; 2017 [cited 2019 Oct 10]. Available from: http://www.thecrimson.com/ Vertigo?” Podcasts are another social medium popular for their article/2017/6/5/2021-offers-rescinded-memes/ episodic format. Healthcare podcasts such as Dr. Brian Goldman’s 6. Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media. J Gen Intern Med. 2010 Nov;25(11):1227–9. White Coat Black Art provide listeners with an in-depth perspective 7. MDA National. Doctor Sacked for Inappropriate Tweets [Internet]. Australia: MDA on healthcare issues relevant to Canadians while also encouraging National; 2019 [cited 2019 Oct 11]. Available from: https://www.mdanational.com. 20 au/advice-and-support/library/blogs/2019/01/doctor-sacked-for-inappropriate- discussion on such topics. From microblogging on Twitter to blogs, tweets podcasts, and YouTube videos, a variety of social media platform 8. Council on Foreign Relations. Hate Speech on Social Media: Global Comparisons [Internet]. New York, NY: Council on Foreign Relations; 2019 [cited 2019 Dec options are available to healthcare practitioners and institutions. 4]. Available from: https://www.cfr.org/backgrounder/hate-speech-social-media- Social media has now become an integral component of society. global-comparisons 9. Journal ABA. Free speech or censorship? Social media litigation is a hot legal It is important to realize that while technology allows sharing of battleground [Internet]. ABA Journal: Chicago, IL; 2019 [cited 2019 Dec 4]. information instantly across the globe, healthcare professionals must Available from: http://www.abajournal.com/magazine/article/social-clashes- digital-free-speech uphold high moral and ethical standards while doing so. Patients entrust 10. Vartabedian BS. Anonymous physician blogging, commentary 1. AMA J Ethics. physicians with their care, and physicians have a responsibility to take 2011 Jul 1;13(7):440–3. 11. Mercer C. “Medutainment” — are doctors using patients to gain social media the necessary precautions to protect patient confidentiality and dignity celebrity? CMAJ. 2018 May 28;190(21):E662–3. as well as perpetuate a positive public perception of their profession. 12. Bennett KG, Vercler CJ. When is posting about patients on social media unethical “Medutainment”? AMA J Ethics. 2018 Apr 1;20(4):328–35. To aid in this process, the Canadian Medical Protection Association 13. Davis WM, Ho K, Last J. Advancing social media in medical education. CMAJ. (CMPA) has published articles on social media etiquette for Canadian 2015 May 19;187(8):549–50. 21,22 14. Crane GM, Gardner JM. Pathology image-sharing on social media: medical students and physicians. The CMPA recognizes that social recommendations for protecting privacy while motivating education. AMA J Ethics. media is a powerful tool for exchanging information, provided that 2016 Aug 1;18(8):817–25. 15. Wikipedia. List of medical wikis [Internet]. United States: Wikipedia, 2019 [cited users are mindful of the pitfalls. Their tips (summarized below) can 2019 Dec 3]. Available from: https://en.wikipedia.org/w/index.php?title=List_of_ serve as a helpful guideline for healthcare professionals to navigate medical_wikis&oldid=927313568 16. Cosco TD. Medical journals, impact and social media: an ecological study of the social media professionally and mitigate mistakes made online. Twittersphere. CMAJ. 2015 Dec 8;187(18):1353–7. CMPA’s top ten tips for using social media in professional 17. Glassy EF. The rise of the social pathologist: the importance of social media to 22 pathology. Arch Pathol Lab Med. 2010 Oct;134 (10): 1421-3. practice: 18. Center for Disease Control. CDC Social Media Tools, Guidelines & Best Practices 1. “Have an objective and select the right platform.” Facebook [Internet]. United States: CDC; 2012. [updated 2019 July 24; cited 2019 Dec 1]. Available from: https://www.cdc.gov/socialmedia/tools/guidelines/index.html and Twitter are great for engagement, updates, and networking. 19. Well. Ask Well Homepage [Internet]. New York, NY: The New York Times; 2019 Blogging and podcasts are best for informing the public, while [cited 2019 Dec 2]. Available from: https://www.nytimes.com/column/ask-well 20. CBC Radio. White Coat, Black Art with Dr. Brian Goldman [Internet]. Ottawa, YouTube is appropriate for educational videos. ON: CBC; 2019. [cited 2019 Dec 1]. Available from: https://www.cbc.ca/radio/ 2. “Avoid social media for one-on-one discussions.” Online whitecoat 21. CMPA. Social media: The opportunities, the realities [Internet]. Ottawa, ON: chats place patient confidentiality at risk. CPMA; 2014 [cited 2019 Oct 10]. Available from: https://www.cmpa-acpm.ca/ 3. “Establish clear boundaries.” Separate your personal and en/advice-publications/browse-articles/2014/social-media-the-opportunities-the- realities professional accounts. 22. CMPA. Top 10 tips for using social media in professional practice [Internet]. 4. “Recognize that the reach is wide and the audience is Ottawa, ON: CMPA; 2014 [cited 2019 Oct 10]. Available from: https://www. cmpa-acpm.ca/en/advice-publications/browse-articles/2014/top-10-tips-for- unknown.” Keep information general as it may be difficult to using-social-media-in-professional-practice tailor advice to a specific audience. 5. “Consider the impact of your communication style and

33 UBCMJ Volume 11 Issue 2 | Spring 2020 COMMENTARY COMMENTARY

The role of the public on physician remuneration in Canada: the cases of British Columbia and Ontario Brendan McNeely1 Citation: UBCMJ. 2020: 11.2 (34-35)

Abstract In Canada, publicly funded universal healthcare incorporates many stakeholders including provincial governments, healthcare professionals, and the general public. A recent move to openly disclose the dollar value billed each year by each healthcare provider in Ontario has received divided feedback. While this disclosure holds healthcare professionals accountable for their billing, it provides an exaggerated surrogate measure for their take-home salary. It is important to determine how well the public understands this limited information as public perception, through political pressure, may have important consequences for future determinations of healthcare policy, physician remuneration, and the quality of public healthcare as a whole.

urrently only British Columbia, Manitoba, Ontario, and B.C. physicians is in place until 2022.6 Listing B.C. physicians alphabetically, CNew Brunswick publicly disclose physician names and their the “Blue Book” presents each physician’s total yearly billing for the respective billing amounts.1 This holds important implications for healthcare services they provided but does not list the remuneration the determination of future financial contracts between provincial of salaried physicians. Physician remuneration in British Columbia has governments and their respective medical associations. For example, as received substantially less media attention than recent changes in Ontario, the Ontario government aims to reassess remuneration for healthcare although B.C. physicians continue to make less than the national average.7 billing following a new financial contract between legislators and the Based on their current financial agreement, the discrepancy in financial Ontario Medical Association (OMA), it is essential that any changes compensation between B.C. physicians and their provincial counterparts to the contract between physicians and policy makers are evidenced- may be further exacerbated in the coming years. The current Physicians’ based and in the best interest of both the public seeking medical care Master Agreement in British Columbia only allocates a 0.5% annual and the healthcare providers. increase in billing rates per year,6 whereas across the other provinces The current four-year healthcare compensation contract in excluding Quebec, yearly billing increases range from 1% to the respective Ontario outlines an average health service billing increase of 1% per province’s annual increase in cost of living (~2.5–3%).8–12 Despite a year. However, this increase does not account for the overhead costs one-time payment of $7500 to physicians who earned over $75,000 in of running a medical practice, such as staff salary, office space rental, 2018, the financial agreement is not conducive to recruiting physicians supplies, and equipment, all of which continue to increase with inflation from other provinces to practice in British Columbia.6 In addition, the (~3% per year).2,3 To mitigate the discrepancy between government exaggerated discrepancy will likely set B.C. healthcare professionals billing and the associated overhead costs of a medical practice, physicians behind their colleagues and could ultimately result in B.C. physicians will be required to see more patients to maintain the same take-home seeking job opportunities elsewhere. However, this is speculative and the salary. With a growing and aging population in Canada, there is already an relocation of practicing Canadian physicians between provinces is a topic increased demand for healthcare services; as such any subsequent increase which requires further investigation. With a reduced number of working in patient volume will likely come at the expense of physician work-life physicians, there could be additional strain on the B.C. healthcare system balance and/or decreased quality of patient care, including decreased including longer waiting times and increased physician burnout. Public duration of appointments. Moreover, the Supreme Court of Canada has support for potential B.C. physician advocacy groups during financial declined an appeal by the OMA to prevent the public disclosure of the contract discussion could serve as an avenue for the public to reduce highest billing Ontario physicians by name.4 While the public disclosure the discrepancy between British Columbia and the rest of Canada and of such information will maintain transparency and accountability already potentially reduce wait times and improve patient care in British Columbia present for many physicians, the true context of how the billing relates through physician recruitment and retention. to healthcare practitioner income may be lost, particularly within specific Importantly, a potential next step as provinces look to further openly specialties or towards specific physicians. For example, medical specialties disclose their physicians’ billing amounts is for future research to be like Ophthalmology and Orthopaedics incur greater operational costs, aimed at determining the public’s understanding of healthcare provider therefore it is important to also determine whether public perception may remuneration. Evidence-based policy making serves as a contemporary be skewed for specific specialties.5 effort to match government expectations to relevant on-the-ground Meanwhile in British Columbia, the Medical Services Commission conditions.13 As such, determining public opinions on physician has released their annual report (colloquially known as the “Blue Book”) remuneration can serve to direct future changes at the legislative level since 1986 while the current financial agreement between legislators and and ensure that healthcare professionals are accurately compensated.14,15 Moreover, in an effort to maximize physician health and the care of their patients, it is essential to assess how public perception affects remuneration 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada for healthcare billing across all specialties and their respective patient visits/procedures.1 Providing a base of verified information from which Correspondence to Brendan McNeely ([email protected]) the public can make informed decisions can help direct the governing bodies concerning physician compensation.

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Ultimately, provincial governments across the country should continue to work with their respective healthcare providers to determine fair compensation. In addition, there exists a role for the public to support healthcare providers by advocating for fair healthcare compensation to their local governments. First, it is essential that the public is fully informed as to the manner and degree in which healthcare providers are compensated in order to form well-informed opinions. In particular, when publicly disclosing information pertaining to remuneration of its employees, governments should openly include all pertinent information including the operating costs of a practice and whether the physician is salaried or compensated on a billing/fee-for-service platform. Providing contextual information in combination with the specific billing values would thereby provide the public with the full picture of physician remuneration. Altogether, open transparency on the part of physicians and governments can inform decisions that result in improving patient care countrywide.

Conflict of interest The author has declared no conflict of interest. References 1. Mercer C. The downside of transparent physician payments: public distrust of the entire profession. CMAJ. 2019;191(21):E589–90. 2. Kaplan arbitration board releases decision on compensation for Ontario physicians: Report. [Internet]. Ontario Med Assoc News Reports; 2019 [updated 2019 Feb 19; cited Dec 28 2019]. Available from: https://content.oma.org/sections/news- events/news-room/all-news-releases/kaplan-arbitration-board-releases-decision- on-compensation-for-ontario-physicians/. 3. Scales of Grading and Remuneration. Ontario Med Assoc. Toronto; 2019. 4. Release of Physician Billings Data Confirms High Patient Demand and Commitment of Ontario’s Doctors. [Internet]. Ontario Med Assoc News Reports. 2019 [updated 2019 Apr 11; cited Dec 28 2019]. Available from: https://content.oma.org/ sections/news-events/news-room/all-news-releases/release-of-physician-billings- data-confirms-high-patient-demand-and-commitment-of-ontarios-doctors/ 5. Wranik DW, Durier-Copp M. Physician Remuneration Methods for Family Physicians in Canada: Expected Outcomes and Lessons Learned. Heal Care Anal. 2010;18(1):35–59. 6. Physicians Master Agreement. Br Columbia Gov News Release. Vancouver; 2019 7. Physicians in Canada, 2016: Summary Report. Ottawa; Can Inst Heal Inf. 2016. Report No. N/A 8. Alberta Medical Association Agreement 2018 (Edmonton). 9. Agreement between the workers’ compensation board and the Saskatchewan Medical Association 2015 (Regina). 10. Government Employed Doctors Collective Agreement 2019 (Winnipeg). 11. New Brunswick Medical Society Master Agreement 2017 (Fredericton). 12. Doctors Nova Scotia Health Services and Insurance Act 2019 (Nova Scotia). 13. Howlett W. Policy analytical capacity and evidence-based policy-making: Lessons from Canada. Can Public Adm. 2009;52(2):153–75. 14. Tuohy CH. The costs of constraint and prospects for health care reform in Canada. Health Aff. 2002;21(3):32–46. 15. Maxwell J, Rosell S, Forest PG. Giving citizens a voice in healthcare policy in Canada. Br Med J. 2003;326(7397):1031–3.

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An analysis of current trends in multimedia platform usage and surgery Farhad Rushad Udwadia1, Haaris Mahmood Khan1 Citation: UBCMJ. 2020: 11.2 (36-37)

Abstract The past few years have seen a significant increase in social media use amongst surgeons/surgical trainees across various subspecialties. In this paper, we argue that social media can positively impact the field as it serves as a platform for furthering education and important social movements. That being said, physicians and educators must be aware of the shortcomings it poses as well. These include threats to professionalism, privacy, and quality of information.

Background their board examination percentile scores by 13.7% on average. One s of 2019, there are 3.48 billion social media users globally, with hundred percent of these users also reported that daily microblogging Aa yearly increase of 9%.1 Social media can be defined as “an prompted them to engage in academic reading.13 online-mediated technology that facilitates the creation and sharing While traditionally, surgical education was only available to of information, ideas and other forms of expression via virtual those financially and geographically privileged, social media has communities and networks.”2 A broader definition of social media the potential to increase access to education for those working in can be taken to include modalities such as podcasts, tablet apps, and resource poor settings globally. This is a major leap forward from blogs. traditional publication methods, which involve considerable financial While a majority of people use social media for networking commitment and minimal scope for interaction. It is important to amongst friends, sharing media, and staying on top of current trends,3 note that social media does not only provide access to educational a substantial amount of people have started to use social media for resources to surgeons, but to patients as well. These are often professional purposes. This is especially true amongst certain surgical accessible and in real time, such as Facebook Live Q&A discussions.14 subspecialties. In a 2012 national survey, the number of U.S. plastic In addition, there is now considerable advancement in interactive surgeons using social media for professional purposes almost doubled multimedia social media platforms, which play a prominent role in from 28.2% in 2010 to 50.4% in 2012.4,5 A similar increase was seen surgical training. Platforms like YouTube contain a plethora of videos in U.K. colorectal surgeons during the years 2013–2016,6 and even with surgeons narrating various surgical procedures. Virtual reality amongst neurosurgeons with 70% of neurosurgeons across the U.S. platforms, such as Medical Realities, are often integrated with social reporting social media use for professional purposes in 2017.7 media platforms to promote access.15 A growing body of literature The rise in social media use amongst surgical trainees and suggests that virtual reality has enormous potential to enhance surgeons can be seen to positively impact the field in the sense that technical surgical skills outside of the operating room in a safe, low- it can help with knowledge dissemination, patient engagement, and risk manner.16 the erosion of harmful stereotypes. That being said, surgeons should Social media can also serve as a catalyst for other progressive, be aware of the potential for harm as well, which includes threats social-based initiatives in surgery. Recently, it has been used as a to professionalism and the potential to adversely impact public platform to tackle age-old and harmful stereotypes by highlighting perception. the increasing diversity of the surgical profession. The hashtag Trends in education and social justice #ILookLikeASurgeon, in reference to women in surgery being Social media can greatly assist in the dissemination of knowledge misidentified, went viral on Twitter with more than 128 million 17 to surgeons, surgical trainees, and the general public given the impressions and roughly 40,000 tweets. Addressing harmful widespread reach that the internet has.8–10 The presence of platforms, stereotypes is an important step towards breaking down barriers such as Research Gate and Twitter, have made information readily to diversity in surgical practice. Studies have shown that up to accessible to users. Surgical journals that have social media accounts 91% of practicing women in surgery have experienced some form 18 have significantly higher outreach and engagement rates than journals of gender-based discrimination. Female surgeons report being that do not.11 Information is even distributed in more informal ways frequently mistaken for other types of hospital employees. The such as “Tweetorials,” which take the form of short explanations lack of representation for women and minorities amongst surgical of tricky medical/surgical concepts.12 It seems that surgical trainees specialties continues to intimidate and distance qualified applicants have been quick to pick up on this, with a 2016 study finding that from pursuing these careers. Additionally, showcasing this diversity general surgery residents who were Twitter participants increased to patients would make diverse patient populations more comfortable when accepting care. Threats to professionalism, confidentiality, and quality 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, of information BC, Canada Professionalism in surgery is essential for surgical practice, patient Correspondence to care, and maintaining public trust. A rise in online social media use Farhad Rushad Udwadia ([email protected]) Haaris Mahmood Khan ([email protected]) has resulted in breaches in professionalism and patient confidentiality

UBCMJ Volume 11 Issue 2 | Spring 2020 36 COMMENTARY in medical communities. A national survey of American medical use of social media among surgeons: results of a multi-institutional study. J Surg Educ. 2017;75(3):804–10. schools documented instances of unprofessional content posted 11. Wang J, Alotaibi NM, Ibrahim GM, Kulkarni AV, Lozano AM. The spectrum of online by medical students and residents, often in legal violation.19 altmetrics in neurosurgery: the top 100 “trending” articles in neurosurgical journals. World Neurosurg. 2017;103:883–95. They found that 13% of the cases involved a direct breach in patient 12. Topf JM, Sparks MA, Phelan PJ, Shah N, Lerma EV, Graham-Brown MPM, confidentiality and that schools may not have adequate policies to et al. The evolution of the journal club: from Osler to Twitter. Am J Kidney Dis. 2017;69(6):827–36. address such online postings. 13. Lamb LC, DiFiori MM, Jayaraman V, Shames BD, Feeney JM. Gamified twitter These lapses of judgement may be especially prone to happen microblogging to support resident preparation for the american board of surgery in-service training examination. J Surg Educ. 2017;74(6):986–91. in surgical subspecialties such as cosmetic surgery, where the sharing 14. Medical News Today. Is bariatric surgery right for me? Lose weight, gain life of outcomes may involve identifiable visual information. Given the [Internet]. Brighton, UK: Healthline Media UK Ltd; 2018 April 7 [cited 2019 Oct 6]. Available from: http://blogs.jefferson.edu/atjeff/2018/04/07/is-bariatric- nature of various social media platforms, such as Facebook, patients surgery-right-for-me-lose-weight-gain-life/ now have access to the personal information of their physicians as 15. Hughes K. What role could social media play in surgery? Surg. 2018;36(11):671–3. 16. Palter VN, Grantcharov TP. Virtual reality in surgical skills training. Surg Clin North well, resulting in professional lines being blurred. Again, instances Am. 2010;90(3):605–17. range from a “friend request” putting a physician in an awkward 17. Katharyn H. #Ilooklikeasurgeon goes viral: how it happened. Bull Am Coll Surg. 2015;100(1):10–6. situation, or a physician being stalked and even assaulted through 18. Bruce AN, Battista A, Plankey MW, Johnson LB, Marshall MB. Perceptions of information gained from social media.20 gender-based discrimination during surgical training and practice. Med Educ Online. 2015;20:25923. With an increased use of social media for the purpose of 19. Chretien KC. Online posting of unprofessional content by medical students. medical education, there is also an increased risk for the spread of JAMA-J Am Med Assoc. 2009;302(12):1309–15. 20. Azoury S, Lindsay B, Warm W, Liepert A. Surgeons and social media: threat to misinformation. Given the unregulated nature of many social media professionalism or an essential part of contemporary surgical practice? Bull Am Coll sites, there is a greater potential for the circulation of poor-quality Surg. 2015;100(8):45–51. information. This can pose harm to patients who engage with social media for health purposes. Additionally, social media tends to highlight individual experiences that may be anecdotal, which might not be representative of collective, evidence-based knowledge. Conclusion With billions of users worldwide, social media has revolutionized the way people communicate and consume information. Given the pervasiveness and considerable benefits of social media, it is imperative that medicine and surgery adapt accordingly. Moving forward, surgical programs should consider providing social media and interactive multimedia training sessions for residents and staff to increase proficiency in these platforms. Rather than avoiding social media due to fear of unprofessional behaviour or threats to privacy, medical students, residents, and physicians should be educated about confidentiality, social media regulations, and boundaries. With technology advancing at an exponential rate, the medical community needs to embrace social media and utilize the enormous potential that it has.

Conflict of interest The authors have declared no conflict of interest. References 1. Smart Insights. Global social media research summary [Internet]. Leeds, UK: Smart Insights; 2019 Feb 12 [cited 2019 Oct 6]. Available from: https://www. smartinsights.com/social-media-marketing/social-media-strategy/new-global- social-media-research/ 2. Ovaere S, Zimmerman DDE, Brady RR. Social media in surgical training: opportunities and risks. J Surg Educ. 2018;75(6):1423–9. 3. We Are Social Media Inc. The 10 top reasons why we use social networks [Internet]. New York City, NY: We Are Social Media Inc; 2018 [cited 2019 Oct 6]. Available from: https://wersm.com/the-10-top-reasons-why-we-use-social-networks/ 4. Vardanian AJ, Kusnezov N, Im DD, Lee JC, Jarrahy R. Social media use and impact on plastic surgery practice. Plast Reconstr Surg. 2013;131(5):1184–93. 5. Wheeler CK, Said H, Prucz R, Rodrich RJ, Mathes DW. Social media in plastic surgery practices: emerging trends in North America. Aesthetic Surg J. 2011;31(4):435–41. 6. Kilkenny J, McDonald JJ, Brady RR. Increased engagement with social media in colorectal surgery. Color Dis. 2017;19(6):592–4. 7. Udawatta M, Ng E, Westley Phillips H, Chen J-S, Wilson B, Prashant GN, et al. Age-related differences in social media use in the neurosurgical community: a multi- institutional study. Clin Neurol Neurosurg. 2019;180:97–100. 8. Alamri A, Rogers P, Kearns C, Doke T, Al-Habib A, Servadei F, et al. Social media for dissemination and public engagement in neurosurgery-the example of Brainbook. Acta neurochir. 2019;161(1):5–9. 9. Scanfeld D, Scanfeld V, Larson EL. Dissemination of health information through social networks: Twitter and antibiotics. Am J Infect Control. 2010;38(3):182–8. 10. Wagner JP, Cochran AL, Jones C, Gusani NJ, Varghese TK, Attai DJ. Professional

37 UBCMJ Volume 11 Issue 2 | Spring 2020 COMMENTARY COMMENTARY

Young physicians on YouTube: helping patients connect with health care Lauren Rietchel1 Citation: UBCMJ. 2020: 11.2 (38-39)

Abstract Medical channels, created by young physicians on YouTube, are popular sources of medical information. They may help demystify the vast world of clinical knowledge and empower patients to seek help from their professional healthcare providers. By understanding clinical decision-making and the complexities of healthcare systems from an online physician’s perspective, patients may be more understanding of their own physician’s clinical rationale. This may lead to better communication with their doctor and an improved therapeutic alliance. Despite the conveniences in overcoming patient barriers through this format, medical advice should continue to maintain professional standards of clinical practice and strive to reach only the intended audience.

here is a growing community of young physicians on YouTube, or not.15 He fosters a trustworthy community that arguably allows Toften under or around 30 years of age, who run successful people to feel confident seeking out advice from their own doctor. medical channels targeting the general population.1 Although not Patients may be hesitant to trust the opinion of just one doctor,16 standardized,2 common themes include general medical entertainment so if a patient completes prior research or understands decision- for a public audience, synopses of daily life for various medical making processes better through these other physician videos, then specialties, and medical information or advice.1 Some physicians they may feel more comfortable with their in-person physician even describe thought processes behind clinical decision-making, a offering similar opinions. One study assessing the patient-physician component patients have expressed greater demand for since the rise relationship found that the knowledge level of a patient was highly of collaborative decision-making and patient autonomy.3 For those correlated to their trust in their physician.17 A high level of trust was seeking a medical opinion, the internet is one of the first resources found to be related to higher adherence, higher satisfaction with care, accessed for guidance and research prior to consulting in-person and better health outcomes overall.17 By increasing the transparency medical advice.4–7 However, a lack of health literacy (the knowledge of medical decision-making and medical recommendations through to make good health decisions) among patients has been identified these types of YouTube channels, patients may feel a greater sense as a major global healthcare challenge.8 While a study that evaluated of trust in the healthcare system and in their own providers, possibly highly formal medical channels on YouTube (with educational videos strengthening their own patient-physician relationship. It can also be on different diseases) found a large benefit to patients in this regard,9 expected that there may be a greater sense of accountability within the following commentary proposes that more casual individual the medical community for healthcare professionals to stay up-to-date physician YouTube channels can show a similar benefit to patients and continue to deliver high-quality care if patients are able to access through demystification of the medical profession, which may this type of information online. ultimately benefit patients by 1) increasing their trust in physicians; Another frequent theme of the young physician YouTube 2) improving their satisfaction with health care; and 3) providing an community is the explanation and portrayal of residency training. A updated, refreshing approach to accessing a younger generation of popular YouTube resident physician, Violin MD,18 shows the daily life patients. This commentary will also address some of the ideas that of an internal medicine resident, including a first-person perspective may be explored in future research on these types of channels. of the grueling and frequent 26-hour call schedule,19 encounters with Doctor Mike, a family physician on YouTube based out of New difficult decision-making, and complex multidisciplinary patient care. York City,10 is an example of how transparency in medicine can be built When the general population watches this exhilarating yet exhausting with an online community of people. With 4.26 million followers,10 he lifestyle through an accessible platform like YouTube, patients may is able to answer inquiries directly from subscribers, explain medical develop greater understanding and empathy towards their own busy advice in a clear and explicit way, and promote healthy living to an physician. They may be more appreciative of the uncertainties and audience equivalent to a population almost twice as large as that in the delays in medicine when a physician runs late or needs to order an Greater Vancouver area.11,12 His videos include himself explaining why additional test, and recognize their doctor’s imperfections (e.g., in vaccines are important and why certain symptoms should prompt a the context of mistakes and the breakdown in patient care). Greater person to seek medical advice.13,14 He educates patients with evidence- connection with and understanding of a physician leads to higher based research and shares medical stories that explain the daily clinical patient satisfaction with healthcare,17 which is supported by the decision-making processes within a physician’s mind, such as the observation that the primary reason for physician complaints is a approach in deciding whether to prescribe an antibiotic to a patient breakdown of communication with a physician, not that physician’s medical knowledge.20 With an increased appreciation of the medical profession through these kinds of YouTube videos, patient satisfaction 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada with care might increase, and the incidence of filed complaints against physicians may decrease. A topic of further research could aim to Correspondence to Lauren Rietchel ([email protected]) describe the relationship between use of physician video media platforms and the frequency and/or type of malpractice complaints.

UBCMJ Volume 11 Issue 2 | Spring 2020 38 COMMENTARY

Since physicians posting on these online platforms are often about 11. Doctor Mike. Playlists [Internet]. USA: Doctor Mike; 2016 [cited 2019 Oct 3]. Available young, this refreshed approach to medicine may make it more from: https://www.youtube.com/channel/UC0QHWhjbe5fGJEPz3sVb6nw/ accessible to groups often missed in the healthcare system. Young playlists 21 12. Statistics Canada. Population and Dwelling Count Highlight Tables. Canada: adults aged 18–25 are the least accessible group in medicine, Statistics Canada; 2017 Feb 8, 1. frequenting physicians only in extreme circumstances,21 and perhaps 13. Doctor Mike. The Thing About Vaccines... | Vaccine Controversies | Doctor Mike [web streaming video]. USA: Doctor Mike; 2017 Aug 6 [cited 2019 Oct 3]. Available could be accessed with the assistance of this type of video platform. from: https://www.youtube.com/watch?v=y2WtUMvNjzQ When the importance of visiting the doctor or the complexities of the 14. Doctor Mike. What Your Body is Telling Me | Doctor Mike [web streaming video]. USA: Doctor Mike; 2017 Aug 13 [cited 2019 Oct 3]. Available from: https://www. medical system are explained, barriers to care for this demographic youtube.com/watch?v=21DMW8hDcso may decrease, which might even increase the rate of physician visits. 15. Doctor Mike. She Asked For Antibiotics & I said NO | Wednesday Checkup [web streaming video]. USA: Doctor Mike; 2019 Apr 3 [cited 2019 Oct 3]. Available While further research is required to address this topic, young people from: https://www.youtube.com/watch?v=whcLEyG81SQ may not feel fully comfortable with their primary care doctor until 16. Moumjid N, Gafni A, Bremond A, Carrere MO. Seeking a second opinion: do patients need a second opinion when practice guidelines exist? Health Policy. 2007 after they find information on a streaming platform where a younger Jan 1;80(1):43–50. doctor is able to empower them to seek out medical care. 17. Pearson SD, Raeke LH. Patients' trust in physicians: many theories, few measures, and little data. J Gen Intern Med. 2000 Jul;15(7):509–13. The young medical community on YouTube may also present 18. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient challenges, including adherence to patient confidentiality and the relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994 Jun 27;154(12):1365–70. maintenance of professional behavior. This is an important aspect to 19. Violin MD. About [Internet]. Canada: Violin MD; 2017 [cited 2019 Oct 3]. Available consider, as one major concern of the internet is the dissemination from: https://www.youtube.com/channel/UCiamy6DLsjIeCgfz8TLXg9Q/about 20. Violin MD. 26 HOUR CALL SHIFT: Day in the Life of a Doctor, INTENSIVE of unprofessional topics and behaviours reaching an unintended CARE UNIT [web streaming video]. Canada: Violin MD; 2019 Sept 7 [cited 2019 audience.22 The content depicted, if deemed unprofessional, can exert Oct 3]. Available from: https://www.youtube.com/watch?v=mIWDF_eTrr0 21. Bonnie RJ, Stroud CE, Breiner HE. Table 7-1: Past-year health care utilization rates a large influence on the opinions of patients worldwide and should by age group: 2009 medical expenditure panel survey. In: Investing in the health and be carefully monitored.22 As well, if a patient mistakenly thinks their well-being of young adults. National Academies Press; 2014. 22. Farnan JM, Paro JA, Higa J, Edelson J, Arora VM. The YouTube generation: medical issue is resolved by watching a video and does not attend a implications for medical professionalism. Perspect Biol Med. 2008;51(4):517–24. medical appointment as a result, then these channels could even be viewed as harmful if they cause a delay for necessary medical care. If patients are able to understand that the purpose of the YouTube physician community is to educate the general public and promote healthcare, and that visiting an in-person healthcare professional is an important step in health management, then improved patient- physician and patient-healthcare system relationships are anticipated. Formal research should be conducted on the benefits and harms of informal medical channels on YouTube, as well as their ultimate impact on patient care and the therapeutic alliance, given that this platform reaches such a large audience. A formalized evaluation and rating system of individual physician YouTube channels would help bring credibility to this platform as a resource for medical knowledge.

Conflict of interest The author has declared no conflict of interest. References 1. Travelingrockstars.com [Internet]. Unknown: Traveling Rockstars; 2019. Top 15 Doctor Youtubers to Follow in 2019; 2019 Jul 4 [cited 2019 Oct 3]. Available from: https://travelingrockstars.com/top-15-doctor-youtubers-to-follow-in-2019/ 2. Gabarron E, Fernandez-Luque L, Armayones M, Lau AY. Identifying measures used for assessing quality of YouTube videos with patient health information: a review of current literature. Interact J Med Res. 2013;2(1):e6. 3. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect. 2007 Sep;10(3):248–58. 4. Lim Fat MJ, Doja A, Barrowman N, Sell E. YouTube videos as a teaching tool and patient resource for infantile spasms. J Child Neurol. 2011 Jul;26(7):804–9. 5. Stellefson M, Chaney B, Ochipa K, Chaney D, Haider Z, Hanik B, Chavarria E, Bernhardt JM. YouTube as a source of chronic obstructive pulmonary disease patient education: a social media content analysis. Chron Respir Dis. 2014 May;11(2):61–71. 6. Atkinson N, Saperstein S, Pleis J. Using the internet for health-related activities: findings from a national probability sample. J Med Internet Res. 2009;11(1):e5. 7. Rutten LJ, Squiers L, Hesse B. Cancer-related information seeking: hints from the 2003 Health Information National Trends Survey (HINTS). J Health Commun. 2006 Feb 1;11(s1):147–56. 8. Nutbeam D, Kickbusch I. Advancing health literacy: a global challenge for the 21st century. Health Promot Int. 2000 Sep 1;15(3):183–4. 9. Desai T, Shariff A, Dhingra V, Minhas D, Eure M, Kats M. Is content really king? An objective analysis of the public's response to medical videos on YouTube. PLoS One. 2013 Dec 18;8(12):e82469. 10. Doctor Mike. About [Internet]. USA: Doctor Mike; 2016 [cited 2019 Oct 3]. Available from: https://www.youtube.com/channel/UC0QHWhjbe5fGJEPz3sVb6nw/

39 UBCMJ Volume 11 Issue 2 | Spring 2020 COMMENTARY COMMENTARY

Launching resident-led simulations to augment the undergraduate medical school curriculum Paul A. Moroz1, Sarah LM. Douglas2, Dib D. Gill2 Citation: UBCMJ. 2020: 11.2 (40-42)

Abstract There is good evidence for the benefits of simulation-based learning in medicine. However, difficulties with financing physician teachers and accessing simulation infrastructure are commonly cited barriers to simulation training. We developed a low-cost simulation program meant to augment early didactic teaching in the undergraduate medical curriculum with the help of residents as simulation teachers. Residents were provided with specially designed cases highlighting clinical aspects of recent curricular material. Residents were well suited for undergraduate teaching given the near-peer phenomenon. We described how our program could be replicated with minimal financial investment using a standard mannequin, a computer, and a supportive residency program.

Introduction in undergraduate medical curricula? n the journey to become physicians, pre-clinical medical students Although data are limited, the main barriers to simulation in pre- Oaround the world are taught foundational concepts primarily clinical training included limited faculty availability for teaching, limited through didactic lectures and textbook readings. This learning financial resources, and student availability.10 In 2018, our group of environment offers limited opportunity to make clinical decisions or undergraduate medical students from the Island Medical Program at observe their impacts which, despite focused preparatory courses, the University of British Columbia (UBC), in partnership with the can result in a jarring transition into clinical education.1 Case-based University of Victoria, sought out to better prepare students for learning (CBL) attempts to address this gap by presenting students clinical medical education by launching an extracurricular simulation with a text-based clinical scenario and a series of questions meant program. In the context of an undifferentiated patient presenting to to build knowledge relevant to a real-world problem.2 Unfortunately, the emergency department, we developed cases allowing students to a pre-written case offers no opportunity to interact with a patient, use their history taking and physical examination skills to make clinical integrate physical examination skills, or make decisions which alter decisions. The simulated emergency room setting was felt to be most the course of the case. CBL is an excellent tool for helping students conducive for bridging the gap between pre-clinical and clinical grasp new concepts, but it calls for a counterpart that allows students training as students were able to investigate a complaint, establish a to bend, twist, and stretch their knowledge to make the decisions differential diagnosis, institute a treatment plan, and practice lifesaving that will arise in clinical training. This counterpart is simulation-based procedures. The successes, challenges, and methodology of our learning. program are discussed below, with the hope that it can be adopted in Simulation-based learning strives to accurately imitate real world other undergraduate medical programs. scenarios through deliberately planned problems which participants Residents as Teachers must solve in real time. Simulation training has been used in the Lacking the funds to hire faculty physician teachers, we opted to aviation industry for years as a means of safely teaching trainees to connect with residents and fourth-year medical students to host deal with dangerous or uncommon situations. Within medical training, the simulations. We felt that this relationship could offer significant simulation plays the same role.3 This teaching technique allows benefits to both the teachers and learners. Proficiency in teaching is medical students to make clinical decisions and receive immediate a core objective in many residency programs.11 Running simulations feedback, while posing no risk to patients. Simulation has been shown creates an opportunity to practice the art of teaching without the to improve the utilization of treatment algorithms among medical pressure of a waiting room full of patients. These opportunities may students and residents.4–6 Knowledge retention also increases from be particularly helpful for residents pursuing academic positions or 20% in lectures alone, to 50% when knowledge is discussed (e.g., in fellowship training. Residents are valuable teachers because they bring CBL), and up to 75% when knowledge is put into practice, as done in the benefits of a “near peer” to the classroom. In addition to being simulations.7 In 2015, a systematic review and meta-analysis showed more familiar with the knowledge base and comfort levels of medical an improvement in patient safety when simulations were incorporated students, having recently been in their position, residents are also into medical training.8 Even universal skills like leadership, teamwork, perceived as more approachable.12 We recognize that staff physicians and communication have been shown to improve following simulation would be more adept with the intricacies and advanced management training.9 So why is this valuable teaching technique not more prevalent of simulated topics. However, the goal of our simulations was to highlight core decision-making in the diagnosis and treatment of relatively common conditions. 1Postgraduate Medical Education, University of Toronto, Toronto, ON 2MD Program, Faculty of Medicine, University of British Columbia, Vancouver, We recruited teachers by emailing residents in the UBC Family BC, Canada Medicine, Internal Medicine, and Emergency Medicine residency Correspondence to programs in Victoria, BC. All residents participated voluntarily and Paul A. Moroz ([email protected]) simulations were scheduled around resident availability, typically Sarah LM. Douglas ([email protected]) Dib D. Gill ([email protected]) after business hours. In cases where residents were unavailable, we

UBCMJ Volume 11 Issue 2 | Spring 2020 40 COMMENTARY

Table 1 |Summary of simulation topics, content, and attendance Simulation Core simulation concepts University of British Columbia curriculum Attendance Theme week pertaining to simulation Trauma, motor Overview of primary survey, approach to shortness of breath, Week 6 and 7 Pneumonia, cough, and COPD 6 Students vehicle accident diagnosis and management of pneumothorax Week 10 Abdominal pain 2 Teachers

Endocarditis Chest pain differential, cardiac features, risk factors, cardiac Week 66 Hypotension, Shock 4 Students workup Week 56 Chest pain 1 Teacher Stroke Neurological exam in unresponsive patient, assessing causes of Week 22 Stroke 6 Students stroke, altered level of consciousness differential 1 Teacher Arrhythmia Chest pain differential, workup for abnormal ECG, treatment Week 43 Arrhythmia 8 Students for common arrhythmias Week 56 Chest pain 2 Teachers Syncope Types of syncope, differential and workup for syncope Week 8 Heart murmur 7 Students Week 43 Arrhythmia 2 Teachers Head Injury Initial management, disability assessment, sequelae of head Week 20 Spinal cord injury 4 Students trauma, imaging modalities to consider, interventions to reduce Week 29 Head injury 1 Teacher rising intracranial pressure Appendicitis, Differential and workup for abdominal pain, physical exam Week 10 Abdominal pain 5 Students Abdominal Pain findings in appendicitis, appropriate workup and management Week 12 Gastrointestinal bleeding 1 Teacher of abdominal pain Week 16 Pregnancy recruited fourth-year medical students to run simulations. All teachers themes (Table 1). Each session had eight to ten student participants were given a curated list of simulation topics and asked to instruct and contained two to four related cases. At the start of each session, only on the material that they were comfortable with. the teacher reviewed core principles relevant to the simulation with Many of our teachers have hosted multiple simulations and the student group, such as how to conduct a primary survey in trauma, expressed a desire to continue teaching undergraduate students. During the differential diagnosis for syncope, and imaging modalities in our feedback sessions, teachers conveyed that running simulations abdominal pain. The students were then split into four to six person was helpful for reinforcing their own knowledge base and building teams and assigned roles—typically one physician leader, several confidence with teaching. We recognize that residents are often busy nurses, and a recorder. Regardless of their role, all team members with clinical duties and that relying solely on resident volunteers may were encouraged to voice their ideas regarding the case. The teacher not be sustainable. In the future, partnering with a residency program would present a clinical vignette with the patient’s chief complaint that has allocated time for residents to teach undergraduate students and the team would proceed to take a history and physically examine may foster a mutually beneficial relationship that provides medical the mannequin. The role of the teacher during the simulation was to programs with reliable access to near-peer teachers. help the case progress by answering history questions, adjusting the Materials and Methods mannequin’s behaviour, announcing positive or negative physical exam All simulations were held in the Royal Jubilee Hospital simulation lab findings, and providing the results of investigations or interventions. in Victoria, BC. The simulation lab included specialty equipment such The teacher was instructed to step in to redirect the group if they were as high-fidelity mannequins, vital sign monitors, airway equipment, unable to proceed or if they focused on a topic that was not central mock medications, and other equipment typically found in an to the simulation. With the completion of each case, the teacher emergency room resuscitation bay. The mannequin could produce provided a resolution to the patient’s hospitalization, debriefed with physical exam findings such as peripheral pulses, respirations, pupil students, and addressed any remaining questions. Informal feedback reactivity, abnormal chest sounds, and cyanosis. More advanced was collected from the students and teachers for improving future simulation equipment such as a defibrillator and an anesthesiology sessions. workstation were also available. Looking Back Each simulation was taught by a resident or fourth-year medical In reflecting on the feedback and experiences of the students and student who received a choice of case topics accompanied with teachers involved, perhaps the most challenging component seemed learning goals, a case outline, and information about the knowledge to be molding simulations to simultaneously fit different knowledge level of their students. This ensured that students were not faced with levels. Our sessions were open to all medical students, meaning that clinical scenarios which they lacked the ability to solve. In the case some cases had first, second, and third-year students present. At times, of a chest pain simulation, students may have identified the need for senior students would dominate the case and bypass high yield learning an electrocardiogram, but lacked the training to interpret the results. points that would have been useful for junior students to reason Acknowledging this expected limitation, teachers volunteered the through. Other times, senior students would become disengaged result of the test and offered a brief explanation of the diagnostic while the teacher reviewed core concepts. These issues can be avoided tool without delving into its intricacies. by limiting each simulation session to a particular year of training. If Starting in October 2018, we hosted a simulation every four to this is not possible, groups of mixed training levels may fare better if six weeks over a ten-month period, covering seven different clinical teachers encouraged the use of “time outs” or intermittently stepped

41 UBCMJ Volume 11 Issue 2 | Spring 2020 COMMENTARY in to discuss the rationale around significant decision points. with interpreting simulated findings that were not central to the case. We identified two common themes among the simulations To mitigate this in future sessions, we may transition to completely which drew the most participants. The first was hosting simulations verbalized physical exam findings. focusing on topics which students had recently covered in classes. A standard low-fidelity mannequin, a laptop computer, and a The opportunity to apply newly acquired concepts and collect clinical resident are the only resources required to bring simulation training pearls gave students the ability to prepare for both curricular exams to pre-clinical medical students. With the strategies outlined above, and clinical practice. The second was advertising that procedural skills we believe that a comparable simulation experience can be created at teaching would be incorporated into the simulation, for example, most medical training programs with minimal financial expenditure. airway interventions, basic ultrasound, or cervical collar application. Conclusion We believe that many students are aware of the utility of these skills We developed an extracurricular simulation training program aiming and were eager to gain competence ahead of their clinical rotations. to supplement undergraduate curricular learning and prepare medical We received strongly positive feedback from the students students for clinical training. This learning environment provided involved in our simulations. With student permission, we included a safe opportunity for students to integrate concepts and practice some of the comments we received: clinical decision-making. Although residents made for effective I found it interesting having the opportunity to apply what I learned in class teachers given the near-peer phenomenon, we recognize that relying to a clinical situation. It was also good to see some of the anesthesiology procedures on resident volunteers may not be sustainable at a larger scale. This being simulated before going on the wards. – Third-year student issue may be mitigated by partnering with a residency program that offers dedicated time for teaching endeavors. Simulation organizers You can get lost in the textbooks. The ER sim lab was a great change of may also find improved student engagement if simulations cover pace. It was an exciting and fun way to learn. – Second-year student recent curricular material, incorporate procedural skills, and limit participants to the same training level. The active nature of the sim lab was inspiring, refocusing, and fun; There is good evidence for the benefits of simulation training integrating and applying our learning while on the go consolidated it far better than in medical education.1-5,7,9,12 We suggested low cost alternatives to simply hearing about it. – Second-year student commonly cited barriers to simulation training in the form of standard mannequins, free digital resources, and resident simulation instructors. I felt like I was integrating and applying classroom learning in an engaging We hope that the experiences and methodology outlined in our paper way that was preparing me for clerkship. – First-year student can be used to bring simulation training to pre-clinical curriculums Looking Forward around the country. Our group is keen to continue providing medical students with simulation opportunities to augment their learning. The reason we Conflict of interest have organized these simulations, and subsequently prepared this The authors have declared no conflict of interest. article, is because we believe that simulation-based learning should References be regularly incorporated into every medical school’s pre-clinical 1. O'Brien B, Poncelet A. Transition to clerkship courses: preparing students to enter the workplace. Acad Med. 2010;85(12):1862–9. curriculum. Goolsby et al. showed that a single focused simulation 2. Williams B. The implementation of problem-based learning & case-based learning: training session was enough to impart medical students with confidence shaping the pedagogy in ambulance education. JEPHC. 2004;2(3–4):9. 13 3. Al-Elq A. Simulation-based medical teaching and learning. J Fam Med Community and knowledge that lasted throughout their emergency rotation. A Health. 2010;17(1):35. study surveying medical students after a similar simulation initiative 4. Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009 Aug found that participants valued the learning experience and benefited 1;76(4):330–43. from the opportunity to apply knowledge and develop an approach 5. Wayne DB, Siddall VJ, Butter J, Fudala MJ, Wade LD, Feinglass J, et al. A longitudinal 14 study of internal medicine residents retention of advanced cardiac life support to clinical problems. Undergraduate medical programs lacking the skills. Acad Med. 2006;81(Suppl):S9–12. resources to secure training equipment and teachers may overcome 6. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team these barriers with improvisation. As described above, residents responses at an academic teaching hospital. Chest. 2008 Jan;133(1):56–61. made for strong accessible teachers and likely derived benefit from 7. Lalley JP, Miller RH. The learning pyramid: does it point teachers in the right direction? Education. 2007;128(1):64–79. hosting simulations. With the completion of an academic year’s worth 8. Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA. Linking simulation-based of simulation sessions, we will be connecting with the residency educational assessments and patient-related outcomes: a systematic review and meta-analysis. Acad Med. 2015 Feb;90(2):246–56. programs in Victoria in hopes of securing dedicated time for residents 9. Banerjee A, Slagle JM, Mercaldo ND, Booker R, Miller A, France DJ, et al. A interested in simulation teaching. simulation-based curriculum to introduce key teamwork principles to entering medical students. BMC Med Educ. 2016 Nov 16;16(1):295. Although we were fortunate to have an advanced simulation 10. Heitz C, Eyck R Ten, Smith M, Fitch M. Simulation in medical student education: lab available to us at no cost, we seldom utilized the high-fidelity survey of clerkship directors in emergency medicine. West J Emerg Med. 2011 Nov; 12(4):455–60. features or specialized training devices. Our most utilized simulation 11. Busari J, Prince K, Scherpbier A, Vleuten C, Essed G. How residents perceive their device, the adjustable vital sign monitor, can be replicated through a teaching role in the clinical setting: a qualitative study. Med Teach. 2002;24(1):57–61. 15 12. Nguyen S, Divino C. Surgical residents as medical student mentors. Am J Surg, 2007 free program on a standard computer. The physical exam findings Jan;193(1):90–3. produced by high-fidelity mannequins can be verbalized by teachers 13. Goolsby CA, Goodwin TL, Vest RM. Hybrid simulation improves medical student procedural confidence during EM clerkship. Mil Med. 2014 Nov 1;179(11):1223–7. when students gesture toward a physical exam maneuver. We believe 14. Weller JM. Simulation in undergraduate medical education: bridging the gap that the purpose of simulation in early medical training is to explore between theory and practice. Med Educ. 2004 Jan;38(1):32–8. 15. Schwander F. Vital Sign Simulator: Free Patient Monitor [Internet]. HealthySim; clinical reasoning rather than to perfect physical exam skills. We found 2017 [cited 2019 Sep 18]. Available from: https://www.healthysimulation. that junior students would often become preoccupied by difficulties com/3032/downloadable-vital-sign-simulator-patient-monitor/.

UBCMJ Volume 11 Issue 2 | Spring 2020 42 LETTER LETTER

Mixed reviews: critiques and compliments of physician rating websites Braedon Ronald Paul1 Citation: UBCMJ. 2020: 11.2 (43-44)

n an era dominated by social media, physician rating websites are were ultimately revealed to be written by an individual who had Irapidly growing in popularity. Among these sites, RateMDs.com has never set foot in his office.10 In light of this and other similar cases, gained the most popularity among Canadians. Launched in 2004, the Canadian Medical Protective Association (CMPA), a prominent RateMDs.com features over 1.7 million active physician profiles across medical malpractice insurer, has started to offer physicians advice on Canada and the United States and over 2.6 million posted reviews.1 As how to manage their online presence and, if needed, how to draft of 2018, over 57,000 of these profiles were of Canadian physicians, letters to offending websites requesting the removal of defamatory representing well over 50% of actively practicing physicians in comments.14 Concerns regarding rating validity are not exclusive to Canada.2 Part of its appeal undoubtedly lies in its simplicity; any negative reviews, however. In fact, a 2010 study of physician-rating visitor may rate their doctor using a one to five-star rating system websites revealed several positive narrative reviews that appeared to based on punctuality, staff, helpfulness, and knowledge, as well as be written by the physicians themselves.15 Consequently, ratings on narrative comments.1 The entire process can be completed in a matter unverified physician-rating platforms should be viewed with a dose of of minutes and, most notably, can be done anonymously. healthy skepticism by patient and physician alike. While non physicians tend to view rating websites favourably, Despite several shortcomings of physician-rating websites, their rising popularity has been viewed less approvingly among some they also play an important role in patient-centred care, in that physicians, who argue that such sites do more harm than good.3–5 they empower patients to freely and openly share their healthcare Among other reasons, these sites have been heavily criticized for the experiences, both good and bad. If used appropriately, these online lack of accountability held by anonymous reviewers.6 Despite these platforms also serve to benefit physicians by offering valuable insight criticisms, both Canadian and U.S. studies have found that posted into their medical practice from the perspective of patients. Such an ratings are predominantly positive.2,7 Negative ratings still occasionally opportunity is particularly helpful for reflecting on and honing the take their toll, though, with some physicians going so far as to “soft skills” of medicine that are rarely formally evaluated throughout launch defamatory lawsuits claiming damaged reputation and loss of medical training and practice. As such, one cannot dismiss these income.4,8–10 platforms as entirely ineffective. As these rating systems rely entirely on the subjective experience Regardless of how truthful online comments may be, the premise of a patient, “hidden roles” of the physician, such as after hours of anonymous reviewing raises another dilemma. While it is certainly paperwork, liaising with other providers, and lab test follow-up, are true that receiving several complaints of a similar nature is likely to rarely taken into consideration. Moreover, unnecessarily ordering uncover an area needing improvement, the ability to openly criticize a imaging and bloodwork or loosely prescribing inappropriate provider who is unable to adequately address concerns without risking medications to quell patient concerns might be rewarded with positive patient confidentiality inevitably leads to an uneven playing field.4 ratings. In a similar manner, failing to perform these same tasks might To help address this issue, online reputation management services result in a negative review—this places pressure on physicians to have started to emerge. By distributing patient experience surveys abandon guidelines and incorporate costly and potentially unsafe that reflect the content of physician-rating websites, these services practices into the care they provide.11,12 Indeed, while patient-reported work to “drown out” negative reviews by collecting and submitting outcomes are crucial to the improvement of healthcare systems, positive reviews, thus inflating a physician’s overall score.16,17 However, patient satisfaction and best patient outcome are often at odds.13 by selectively submitting positive reviews, such services themselves Perhaps even more concerning is the fact that reviews are raise concerns about the reliability of online ratings. Similarly, there unverified. Consequently, there are no barriers in place to prevent is no mechanism in place to prevent physicians from selectively an individual from posting a review that is grossly exaggerated or, in encouraging reviews from patients who they believe will rate them some instances, demonstrably false. Such reviews can understandably positively, a technique that is well documented outside of medicine.18 cause significant distress and even risk damaging the career of any However, for physicians who wish to remove particularly damaging or physician who falls victim. Early last year, for example, an infectious defamatory reviews, few options exist aside from pursuing legal action, disease specialist in Kingston, Ontario was involved in a defamation which can be costly, timely, and laborious, or flagging comments for lawsuit following a series of slanderous comments posted to removal, which requires the review to be deemed inappropriate by the RateMDs.com and OntarioDoctorDirectory.ca. These comments, which hosting website.19 As of 2018, a physician wishing to have negative falsely portrayed him as incompetent and a danger to his patients, reviews removed from RateMDs.com must purchase a package plan, which can cost anywhere from $179 to 359 USD per month.4 While physicians should feel encouraged to monitor their profiles 1MD Program, Faculty of Medicine, University of British Columbia, Vancouver, if they so desire, most will face some form of online criticism at BC, Canada some point in their career, whether it be through RateMDs.com or Correspondence to another online source. As such, ongoing efforts should be focused on Braedon Ronald Paul ([email protected]) improving the validity of these platforms in order to ensure content is

43 UBCMJ Volume 11 Issue 2 | Spring 2020 LETTER accurate and criticisms are constructive. One plausible solution would 9. Mackay B. RateMDs.com nets ire of Canadian physicians. Can Med Assoc J. 2007 Mar 13;176(6):754. be for these websites to incorporate a more scientifically rigorous 10. Duffy A. Kingston doctor wins cyber libel case against malicious web critic psychometric methodology into the design of their rating systems, [Internet]. Ottawa Citizen. 2019 May 9 [cited 2019 Oct 11]. Available from: https:// ottawacitizen.com/news/local-news/kingston-doctor-wins-cyber-libel-case- allowing a more reliable translation of subjective patient data into against-malicious-web-critic validated objective data. Although such changes would surely improve 11. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. J Am Med Assoc. 2012 Apr 4;307(13):1377–8. the current system, it is unlikely that this transformation will occur in 12. Brett AS, McCullough LB. Addressing requests by patients for nonbeneficial the near future. In the meantime, physicians should feel encouraged interventions. J Am Med Assoc. 2012 Jan 11;307(2):149–50. 13. Black N. Patient reported outcome measures could help transform healthcare. BMJ. to reach out to the CMPA with any questions or concerns regarding 2013;346:f167. their online presence. Provincial physician-support services, such as 14. Canadian Medical Protective Association. Online physician reviews: how to manage your virtual presence, and real reputation [Internet]. Ottawa, ON: Canadian Medical the Physician Health Program of BC, are also available for physicians Protective Association. 2019 Apr [cited 2019 Oct 7]. Available from: https://www. seeking guidance.20 Regardless of one’s stance on this issue, one thing cmpa-acpm.ca/en/advice-publications/browse-articles/2019/online-physician- reviews-how-to-manage-your-virtual-presence-and-real-reputation is certain: physician-rating websites will continue to thrive for years to 15. Lagu T, Hannon NS, Rothberg MB, Lindenauer PK. Patients’ evaluations of health come. Perhaps it is time they were rated themselves. care providers in the era of social networking: an analysis of physician-rating websites. J Gen Intern Med. 2010 Sep;25(9):942–6. 16. myPracticeReputation. Reputation Management For Doctors [Internet]. Conflict of interest Spartanburg, SC: Practice Builders; [cited 2019 Oct 9]. Available from: https:// www.mypracticereputation.com/ The author has declared no conflict of interest. 17. GlowingMDs. GlowingMDs.com [Internet]. GlowingMDs.com; 2017 [cited 2019 References Oct 9]. Available from: https://glowingmds.com/ 1. RateMDs Inc. RateMDs [Internet]. Westlake Village: RateMDs Inc.; [cited 2019 18. Cox T. How small businesses can manage reviews to strengthen their online Oct 11]. Available from: https://www.ratemds.com reputation [Internet]. Washington, DC: The Manifest. 2019 May 2 [cited 2019 2. Liu JJ, Justin Matelski J, Bell CM. Scope, breadth, and differences in online physician Oct 9]. Available from: https://themanifest.com/public-relations/how-small- ratings related to geography, specialty, and year: observational retrospective study. J businesses-manage-online-reviews-strengthen-online-reputation Med Internet Res. 2018 Mar 7;20(3):e76. 19. RateMDs [Internet]. Westlake Village: RateMDs Inc. Frequently Asked Questions; 3. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, [cited 2019 Oct 9]. Available from: https://www.ratemds.com/about/faq/ perception, and use of online physician rating sites. J Am Med Assoc. 2014 Feb 20. Doctors of BC [Internet]. British Columbia Medical Association; 2017. Physician 19;311(7):734–5. Health Program (PHP); [cited 2019 Nov 29]. Available from: https://www. 4. Crowe K. Who’s rating doctors on RateMDs? The invisible hand of "reputation doctorsofbc.ca/resource-centre/physicians/physician-health-program-php management" [Internet]. CBC News. 2018 Oct 27 [cited 2019 Oct 11]. Available from: https://www.cbc.ca/news/health/ratemds-privacy-reputation- management-1.4880831 5. Ma L, Kaye AD, Bean M, Vo N, Ruan X. A five-star doctor? Online rating of physicians by patients in an internet driven world. Pain Physician. 2015;18(1):E15–7. 6. Segal J. The role of the internet in doctor performance rating. Pain Physician. 2009;12(3):659–64. 7. Kadry B, Chu LF, Kadry B, Gammas D, MacArio A. Analysis of 4999 online physician ratings indicates that most patients give physicians a favorable rating. J Med Internet Res. 2011 Nov 16;13(4):e95. 8. Gossman WG, Varacallo M. Defamation. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2019 [cited 2019 Oct 7]. Available from: http://www. ncbi.nlm.nih.gov/pubmed/30285367

UBCMJ Volume 11 Issue 2 | Spring 2020 44 STAFF

2019-2020 UBCMJ Staff

EXECUTIVE SECTION EDITORS EXTERNAL

Editors in Chief Academics Finances, Advertising & Christine Wang (Sr.) Alvin Liu, BSc (Sr.) Sponsorship Seo Am Hur, MSc (Sr.) Brian Hayes, MSc (Jr.) Amanda Wong, BSc (Sr.) Emma Finlayson-Trick, MSc (Jr.) Sophia Ly, BSc (Hons) (Sr.) Olivia Tsai, BSc (Jr.) Case and Elective Reports Shailee Siddhpuria, BHSc (Jr.) Michael Minkley, MSc (Sr.) Melodie Kim, BHSc (Jr.) Managing Editors Katherine Gray, BSc (Jr.) Mark Trinder, MSc (Sr.) IT Managers Aishwi Roshan (Sr.) Reviews Ryan Sandarage, BSc (Sr.) Daniel Kwon, MSc (Jr.) Rohit Singla, MASc (Sr.) Rachel Zhao (Jr.) Valerie Doyon, BSc (Jr.) Publications Managers Mark Cahalan, BHSc (Sr.) Commentaries Maryam Vaseghi-Shanjani, MSc (Jr.) Allyssa Hooper, MSc (Sr.) PUBLICATIONS Jessica Li, MPH (Sr.) Communications Katie Baillie, BSc (Hons) (Jr.) Layout & Graphics Editors Alvin Qiu, BSc (Sr.) Olivia Yau, MSc (Jr.) Talise Lindenbach, BSc (Sr.) Drake Comber, MSc (Jr.) Rachel Zhao, BSc (Jr.) News and Letters Vivienne Beard, BSc (Sr.) Dhiraj Mannar, BSc (Hons) (Jr.)

STAFF WRITERS COPYEDITING COMMUNICATIONS

Braedon Paul Chief Copyeditors Distributed Site Representatives Andrew Golin, BSc Andy An, BSc (Sr.) IMP Rep Erik Haensel, BA Alex Cheng, MSc (Jr.) Rohit Singla, MASc (Sr.) Farhad Udwadia, MBE Valerie Doyon, BSc (Jr.) Saman Fouladirad, BSc Copyeditors Brendan McNeely, MSc Cassia Tremblay, BSc (Sr.) NMP Rep Amardeep Sekhon Derek van Pel, PhD (Sr.) Erik Haensel, BA (Sr.) Wajid Khan, MD Katrina Besler, BSc (Sr.) Katherine Gray, BSc (Jr.) Nathan Ko (Sr.) Jonathan Choi, BSc (Sr.) SMP Rep Sophie Zhang-Jiang (Sr.) Carlee Clyde (Sr.) Lianne Cho, BSc (Sr.) Brian Hayes, MSc (Jr.) Vincent Hou, BHSc (Jr.) Steven Mancini, MSc (Jr.) Videography Team James Taylor, BSc (Jr.) Sebastian Swic (Sr.) Priscilla Chan, MSc (Jr.) Vivian Huang (Sr.) Komal Adeel, BSc (Jr.) Melissa Kong (Jr.) Kevin Zhang (Jr.)

45 UBCMJ Volume 11 Issue 2 | Spring 2020 SUBMISSION GUIDELINES

he University of British Columbia Medical Journal (UBCMJ) is a student-driven academic journal with the goal of engaging students in Tmedical dialogue. Our scope ranges from original research and review articles in medicine to medical trends, clinical reports, elective reports, and commentaries on the principles and practice of medicine. We strive to maintain a high level of integrity and accuracy in our work, to encourage collaborative production and cross-disciplinary communication, and to stimulate critical and independent thinking.

Submission Guidelines Reviews Articles are submitted online via our online submissions system, OJS Reviews provide an overview of a body of scientific work or a (http://ojs.library.ubc.ca/index.php/ubcmj). For detailed submission medical trend. Reviews may outline a current medical issue or give instructions, please refer to the complete online version of the insight into the principles of practice of a clinical field. Authors may UBCMJ Guide to Authors, which can be found at http://ubcmj.med. choose to review the etiology, diagnosis, treatment, or epidemiology ubc.ca/submissions/ubc-medical-journal-guide-to-authors/. of a specific disease. Articles may also provide a survey of literature Author Eligibility dealing with philosophy and social science as it pertains to medicine. Authors must acknowledge and declare any sources of funding or Case and Elective Reports potential conflicting interest, such as receiving funds or fees from, Case Reports describe patient encounters in a clinical or public health or holding stocks and benefiting from, an organization that may setting. The case should provide a relevant teaching point for medical profit or lose through publication of the submitted paper. Declaring students, either by describing a unique condition OR by presenting a competing interest will not necessarily preclude publication but will new insights into the diagnosis, presentation, or management of a be conducive to the UBCMJ’s goal of transparency. Such information more common condition. A template form to be used by the authors will be held in confidence while the paper is under review and will to obtain documented consent is provided on our website. The not influence the editorial decision. If the article is accepted for patient’s consent form should be retained by the authors for a period publication, the editors will discuss with the authors the manner in of five years. Please do not provide the patient’s name or signature which such information is to be communicated to the reader. UBCMJ directly to the UBCMJ. expects that authors of accepted articles do not have any undisclosed Elective Reports provide a specific description of the scope of financial ties to or interest in the makers of products discussed in the practice of a medical specialty and/or training program, and recall the article. student’s impressions and reflections during and upon completion of In the interest of full transparency, no current members of the the elective. UBCMJ staff will be permitted to publish in the journal, except for News and Letters those officially invited in a staff writer capacity to author a news piece This section includes articles that touch on current events in the or editorial. This policy is intended to limit the potential for conflicts field of medicine, significant medical advances, or brief summaries of interest. All former members of the UBCMJ staff are exempted of research in an area. Note that submissions to this section do not from this policy, as they will not have involvement in the workings of require extensive elaboration on the methods or results of the review the journal at the time of their submission. process. Author Originality Commentaries Authors must declare that all works submitted to the UBCMJ contain Commentaries are intended to provide a platform for intellectual original, unpublished content and have been referenced according to dialogue on topics relevant to the study and practice of medicine. the appropriate academic style. Written content that displays excessive Submissions should correspond to one of the following categories: similarity to previously published works, including works written by the • Subjective pieces relevant to medical studies, life as a future submitting authors, will not be published by the UBCMJ. This policy physician, or the current social context of medicine. is consistent with the UBC policy on plagiarism. The UBCMJ editorial • Clinical perspectives on an interesting research study or area of staff reserves the right to request revisions, to deny publication, or to focus. require retraction of submitted or published work that contains clear Correspondence violations of this policy. For any questions related to your submission, please contact the Specific Submission Criteria appropriate Section Editors. Academic Research Research articles report student-driven research projects and Academic Research ([email protected]) succinctly describe findings in a manner appropriate for a general Case and Elective Reports ([email protected]) medical audience. The articles should place findings in the context Reviews ([email protected]) of current literature in their respective disciplines. UBCMJ currently News and Letters ([email protected]) accepts both full length articles and research letters. Commentaries ([email protected]) If in your manuscript you acknowledge anyone for a contribution Editorial Inquiries ([email protected]) that goes beyond administrative assistance, you must obtain written Other Inquiries ([email protected]) permission from that person to publish his or her name (a) where the Sponsorship ([email protected]) manuscript or article contains any material(s) (including text, images or other media) or other contribution(s) which belong to others, the author(s) are solely responsible for obtaining permission in writing from the owner(s) for its publication in the article.

UBCMJ Volume 11 Issue 2 | Spring 2020 46 ACKNOWLEDGMENTS

University of British Columbia MedicalJ ournal This issue of the UBCMJ could not have been possible without the support and guidance of the following individuals: Linda Herbert Dr. Janette McMillan Dr. Michelle Wong Jennifer Fong

The University of British Columbia Medical Journal uses an open access publishing policy in line with our mandate to publish in a socially responsible way. We endorse open access publishing as the preferred model for scholarly communication and encourage the adoption of open access principles by universities and research agencies.

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