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DIGITAL MEDICINE & SOCIAL MEDIA

FEATURE ARTICLES: > Key Trends in eHealth to Propel Health Transformation and Education > Extending the Reach of Medical Care for Remote First Nations Communities ALSO INSIDE: Interview with Kevin Pho, founder of Kevinmd.com

UBCMJ | MARCH 2014 5(2) | www.ubcmj.com PLEASE RECYCLE THIS PUBLICATION

EDITORIAL Medicine 2.014 – The Digital Age of Medicine 4 Alvin Ip, Terry Chu, Ryan Rawski, Lingsa Jia, Alexandra Cole FEATURE Key Trends in eHealth to Propel Health Transformation and Education 6 Kendall Ho

Extending the Reach of Medical Care for Remote First Nations Communities: 9 Beyond Technology John Pawlovich, Marie-Pierre Dallaire CASE AND ELECTIVE REPORTS Evolutionary Medicine: An Academic Elective 12 Cory Weissman COMMENTARIES Three Concrete Tips for Teaching Clerkship Medical Students 14 Neil Dinesh Dattani

A Tip to Pre-Med Students: Don’t Put All Your Eggs in the Science Beaker 16 Michael J. Horkoff

Cosmetic Psychopharmacology: The Ethics of Antidepressant Therapy 17 Fareed B. Kamar

The benefits of open source electronic medical record (EMR) systems: OSCAR McMaster as 21 a case study Matthew Toom

Smartphone Use in the Emergency Department 24 Kerry E. Walker NEWS AND LETTERS Medicine in the Fast Lane 26 Shelly Fan

Maintaining Professionalism Online: An Interview with Dr. Kevin Pho 27 Kiran Dhillon

Telehealth: Connecting with BC Physicians Online 29 Pretty Verma

On the Future of Open-Access 30 Kabir Toor

Developing Digital Educational Tools for Medical Students: An Interview with Dr. Stan 31 Bardal on the UBC Formulary App UBCMJ Staff

GLOBAL HEALTH Dispatch: Waiting at the Doorstep - Learnings from India 32 Saama Sabeti

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 3 EDITORIAL

Medicine 2.014 – The Digital Age of Medicine

Alvin Ipa, BKin; Terry Chua, BSc; Ryan Rawskia, MSc; Lingsa Jiaa; Alexandra Colea, BSc aVancouver Fraser Medical Program 2016, Faculty of Medicine, University of British Columbia

omputer technology and social media have dramatically screening and monitoring of autoimmune diseases, cancers, changed the way that people spend their time, interact and strokes5. The ability to monitor patient health using Cwith others, and acquire knowledge. In the Digital Age technology as ubiquitous as a smartphone represents a novel that we live in now, we have seen the advent of “big data” tool for health care providers, but with it comes the ethical with the newfound ability to manipulate massive amounts and logistical challenges that come with such easy access to of information. Global networks facilitate communication personal health information. between geographically distant communities. The influence This issue of the UBC Medical Journal (UBCMJ) of these technologies on clinical medicine, termed “digital highlights the increasing use of technology in the field medicine”, has been defined as “the transformation of health of medicine, and the potential impacts of utilizing social care that is coming about as computer technology is used in the media as a means of health care communication. Our feature creation and application of medical knowledge”1. articles explore the potential for electronic health strategies Digital medicine impacts three broad areas of health to optimize patient care and physician competency (Ho), and care: patient care, communication, and patient empowerment. highlight the importance of medical technology as a means of With the capabilities of medical researchers to leverage transformative change (Pawlovich). Our other articles include “big data”, the discovery of monogenic diseases gleaned an insightful interview with Dr. Kevin Pho (founder of www. from sequencing entire genomes has made it possible for kevinmd.com) that provides recommendation for physicians prenatal screening of various inherited disorders, including on maintaining an online presence (Dhillon), and the use of disorders of hemoglobin, which affect thousands of children in developing countries2. The way that doctors care for patients are also changing, as medical care is starting to be delivered digitally. Medeo.ca is a prime example of digital medicine that is emerging for residents in British Columbia; using a computer, iPhone, or iPad, patients can log in to a secure video-conferencing platform and have a provincially- insured virtual visit with a licensed physician3. Technological advances are also empowering patients to manage their own health. Fitbit® is one of many electronic devices that enables users to monitor biometrics, such as physical activity, giving them the opportunity to set self-directed health improvement goals and have a digital record of activity they can discuss with their health care provider4. Digital medicine is altering the way researchers’ further our understanding of the human body, the way clinicians deliver medical care, and how patients are able to interact with the medical system. In this evolving climate of digital medicine, it is particularly important to stay informed about existing breakthroughs, and to continue looking forward to the next advancement. One particularly notable development in digital medicine is a bloodstream nanosensor that communicates with your smartphone. The nanosensor chip is injected into the blood to constantly monitor for early markers of a heart attack, and uses wireless capabilities to send alerts to a smartphone5. The possibilities of nanosensor surveillance are endless, including

Correspondence [email protected]

4 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com EDITORIAL open-source software in medicine (Toom). In addition, Dr. We hope this issue of the UBCMJ adds to the expanding Stan Bardal sheds light on the UBC Formulary App and its wealth of knowledge in this area of medicine and offers our potential in the context of medical education and patient care readers some insight into the technological advancements (UBCMJ Staff). that aim to improve quality of patient care through changes at Health care professionals are expected to engage in the system and provider levels. lifelong learning; therefore, it is necessary to evolve and follow the trajectory of technological advancements in society. In today’s digital age of medicine, health care professionals must REFERENCES be resourceful and humble enough to accept the limitations 1. Bushko RG. Future of Health Technology. IOS Press. 2002; 200. of personal knowledge. Physicians need to be effective 2. Weatherall D, Clegg J. Inherited Haemoglobin Disorders: An team players in order to use communication technology to Increasing Global Health Problem. Bulletin of the World Health collaborate with other physicians and involve patients in more Organization. 2001;79(8):704-12. aspects of their care as they are empowered by technology to 3. Medeo [Internet]. [cited 2014 Jan 16]. Available from: https://medeo. do more for their own health. Health care workers must also ca/ 4. Fitbit® Official Site [Internet]. [cited 2014 Jan 16]. Available from: be able to adapt and embrace changing practice paradigms and http://www.fitbit.com/ technologies. However, it is important to note that in many 5. Eric Topol on How to Prevent Heart Attacks with Nanosensors cases, technology does not replace older tools, but rather [Internet]. [cited 2014 Jan 16]. Available from: http://www.qmed. augments them (eg. the function of laboratory tests and imaging com/mpmn/medtechpulse/eric-topol-how-prevent-heart-attacks- is complementary to a thorough history and physical exam). nanosensors Therefore, we must continue to use our knowledge, talents, and efforts in combination with the new tools of digital medicine to keep patient care at the forefront of medical practice.

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 5 FEATURE

Key Trends in eHealth to Propel Health Transformation and Education

Kendall Hoa, MD, FRCPC aProfessor of Emergency Medicine; Director, eHealth Strategy Office, University of British Columbia

KEYWORDS: mobile health, social media, telehealth, electronic health records, eHealth

INTRODUCTION their patients. Computers, mobile phones, and tablets can serve as decision support aids for clinicians to exercise their best judgment ccess, quality, and affordability of health care for in the management of patients. Medical websites such as Up-to- citizens—not only for patients living in urban, but Date (www.uptodate.com) and essential evidence plus (www. Aparticularly for those living in rural and remote areas— essentialevidenceplus.com), and stand-alone mobile phone–based have been increasingly brought into focus over the last decade by guidelines (www.bcguidelines.ca) developed over the past decade governments, health organizations, health professionals, and health can help physicians to rapidly search for answers to their clinical consumers themselves in all countries. Canada is no exception, as questions while interacting with patients. reflected by major health reports by leading Canadian figures such Health systems are increasingly using EHR to support 1 as the Romanow Report that speaks to the need for eHealth, and health system–based decision support, linking literature-based the tracking of progress in telehealth and electronic records by the evidence with real-life practice experiences. For example, 2 Health Council of Canada. having computerized physician order entry (CPOE) as part With the rapid evolution of information and communication of a hospital–based EHR helps prescribers to harmonize their technologies (ICT), such as mobile smart phones, tablets and mobile computers, and the reach of the mobile network and the Internet globally and in Canada, technology-enabled health applications, With the emerging or eHealth, are rapidly gaining ground in providing improved or unprecedented healthcare solutions. For example, electronic importance of entrenching health records (EHR) not only improve documentation of patients’ “ eHealth into our healthcare health history to help health professionals and individuals to delivery system, it behooves health longitudinally track their illnesses and medication usage, but also facilitate population health analyses for trends and costs for health professionals collectively to familiarize organizations and governments. Using electronic technologies themselves with the use of ICT for to connect patients and health professionals at a distance—or telehealth—significantly increases the reach of the health system health services delivery and peer to provide services to patients in rural and remote communities or communications and consultations. those with difficulties leaving their homes due to health challenges. This article explores three rapidly evolving and highly important medication selections in clinical disease entities based on literature trends in eHealth that are quintessential for health professionals to evidence, patient needs, and medication availability in the hospital watch and consider for incorporate into their health practices to pharmacies. Tracking health and disease trends, such as the improve health outcomes of their patients and the health system— evolving types of skin infections in hospitals or communities due technology–enabled knowledge translation.3,4 to methicillin–resistant Staphylococcus aureus (MRSA), can help health clinics and hospitals to choose the right antibiotic coverage Trend #1: From Electronic Health Records to Translational for their patients. The Province of British Columbia has a provincial Informatics Pharmanet system (http://www.health.gov.bc.ca/pharmacare/ With the rapid explosion of biomedical research and knowledge pharmanet/netindex.html) to monitor medication usage of B.C. generated, health professionals are finding it increasingly difficult citizens over the last two decades, helping to make decisions as to keep up with the latest evidence–based medical management of to which medications are to be supported or purchased in British Columbia. Correspondence In addition to EHR, genomic data will increasingly be used Kendall Ho, [email protected]

6 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com FEATURE as part of healthcare decision-making processes. Currently, even conditions in addition to being able to view and communicate though certain genes are well known to be associated with medication with them virtually. For example, weight, blood pressure, sensitivities—carbamazepine with Stevens-Johnson Disease5 or oxygen saturation, simple lung functions, heart rhythms and warfarin hypersensitivity6—rarely do patients currently have their electrocardiograms can now all be easily monitored, continuously genomic data checked prior to prescription of these medications. if necessary, on patients from the comfort of their own homes, However, with the decreasing costs of decoding human genomes and with the results transmitted electronically to monitoring centers of the increasing understanding of genomics, proteomics, epigenetics, clinicians’ offices. These telemonitoring approaches, together with and the rapid pace of research in these domains, it is clear that in virtual telehealth interviews, greatly extend the access and quality of care beyond the acute care hospitals into community settings.

To address the need to Trend #3: Mobile Health and Social Media integrate eHealth into medical Mobile and smart phones are rapidly opening up unprecedented education, the University of opportunities for use in health, also known as mobile health “ or mHealth. Strategies of use include virtual and continuous British Columbia Faculty of Medicine monitoring of patients as mentioned in the previous section, and is introducing eHealth into its new provide connectivity for the individuals to communicate with others in multimedia fashion through social media, videos, and medical school curriculum. voice. For example, cell phones have been successfully used as heart rate and oxygen saturation monitors, pedometers, diabetes the near future, genomic data will become a key part of clinical monitors, and pregnancy and post-partum care guides. Mobile practice. Already, 23andMe (www.23andme.com) is a web–based EHR can facilitate patients’ entering of their own data to track service that has been active in offering genomic decoding for the health progress in real time. general population at an affordable price to find out about maternal Four categories of mHealth applications are increasingly and paternal lineage, ancestry composition and DNA relatives. deployed, including: The service was previously offering health-related genetic reports 1. Biometrics monitoring: the aforementioned real-time to inform the person of the types of known inheritable diseases monitoring strategies through development of peripherals and medication reactions to which one was vulnerable. However, that can be attached to commercially available mobile this health-related service was suspended upon the urging of the phones are rapidly expanding. Close-to-commercial release United States Food and Drugs Administration, as 23andme needed of ultrasound probes or eye screening tools and clinical-grade to prove the accuracy of prediction of these diseases to FDA for microscopes are already of large-scale implementation. approval.7 There is a call for integrating genomic data into EHR 2. SMS: text messaging functionality, which is highly popular to longitudinally track disease manifestations and correlate them amongst mobile phone users, is actively being leveraged to with the person’s own genomic data to uncover new associations. assist patients in their knowledge acquisition and behavioural For example, the PREDICT project at the Vanderbilt hospital8 is a change. Strong evidence is currently accumulating in using pharmacogenomics project that tailors medication prescribing to text-messaging functions to promote smoking cessation12 or individual patients’ genetic information as a demonstration of the regular medication usage.13 For example Text4baby (http:// power of personalized medicine9, the customization of healthcare www.text4baby.org) is a highly successful service offered to the individual patient. in the United States to promote healthy pregnancy and post- partum well baby care through the sending of a series of Trend #2: Telehealth and Telemonitoring timely messages to help mothers with their own health and Traditionally, telehealth refers to the use of ICT to facilitate the wellness of their newborns. consultations between clinicians—such as primary care doctors 3. Health Apps: educational materials, such as clinical guidelines with medical specialists—or between clinicians and patients for patients to follow or information about medications, directly. This approach is most aptly applied for the diagnosis calculators for health–related numbers such as body-mass and management of patients in rural and remote communities, index, can be put into downloadable reading materials or or other locations where patients are routinely underserved. The even interactive Apps. book Telehealth in the Developing World10 and a recent World 4. Mobile social media: many social media sites, such as Health Organization report “Telemedicine: Opportunities and Facebook, Twitter, Tumblr, and microblogs, can now be Developments in Member States – Report on the Second Global accessed through mobile phones. Patients can connect Survey on eHealth”11 chronicle many exemplars of telehealth in themselves to related communities of shared health interests action. for knowledge exchange. In addition, clinicians can also In the last decade, tremendous progress has also been made in communicate with patients to support them in their optimal telemonitoring, using technologies to monitor patients’ conditions self care. In British Columbia, the interCultural Online health and health statuses in real time, whether the patients are in a clinic, Network (iCON, www.iconproject.org) endeavours to carry hospital, or home environment. These monitoring technologies out this support through Web 2.0 to the province’s Chinese extend the clinicians’ ability to understand the patients’ health citizens in addition to other cultural groups, including South

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 7 FEATURE

Asian and Aboriginal populations. 5. Communication with patients, the public, and the community: to understand and use electronic approaches Clinicians’ roles in eHealth Uptake such as social media, text messaging, emails and other Clinicians such as physicians and nurses play pivotal roles in the means to communicate with patients and the general public delivery of health services to patients in all communities. With the to improve health services and support them in healthy emerging importance of entrenching eHealth into our healthcare living delivery system, it behooves health professionals collectively to 6. Fundamental principles in eHealth: the above five familiarize themselves with the use of ICT for health services delivery eHealth competencies are underpinned by important core and peer communications and consultations. They need to understand principles that need to be understood including: Privacy and the advantages and limitations of ICT and blend this understanding confidentiality of databases, such as electronic health record with their health expertise and perspectives to maximize the efficacy or health surveillance systems; data quality, documentation, of eHealth services in order to match the expectations of their patients and analysis that determine the usefulness of electronic and the governments that represent them. In the meantime, health databases; basics in components of information systems and system leaders and health policy-makers also need to steer health approaches for selection and usage; and types of electronic reform to incorporate exemplars of eHealth as part of the fabric tools available to support eHealth, the principles behind their of improving health access, quality, and cost-effectiveness so as use and their limitations, and how they can be improved in to maximize the leverage of modern technologies into supporting clinical settings patient wellness, whenever and wherever patients live and work. National efforts in eHealth education are also taking place, Serious consideration of how to integrate these eHealth trends such as the eHealth education committee of the AFMC16, and the into our health care service delivery will help bring success in the eHealth expert working group of the CanMEDS 2015.17 future. Calls for integration of eHealth into the core part of training of the next generation of health professionals surface in major CONCLUSION reports such as the Global Independent Commission’s “Health Professionals for a New Century” report14 and the Association This is an exciting time in eHealth to accelerate health system of Faculties of Medicine of Canada’s (AFMC) “The Future of reform, improve health service delivery, and build capacity with Medical Education in Canada” (FMEC) report.15 eHealth training. These trends also increase expectations for To address the need to integrate eHealth into medical physicians to determine how they will incorporate technologies education, the University of British Columbia Faculty of Medicine into their practices. It would be ideal for health professionals and is introducing eHealth into its new medical school curriculum. trainees to not only be aware of these eHealth trends, but also Synthesis of the literature on eHealth training identifies the actively participate in shaping these trends into routine health following six core curricular domains to be essential competencies: practices over time that benefit our communities. 1. Knowledge acquisition and management: to pose appropriate clinical questions and be able to access and search electronic ACKNOWLEDGEMENTS resources to locate and compile the relevant evidence to The author would like to acknowledge the members of the UBC guide current practice; and to document these issues for Faculty of Medicine eHealth Curriculum Working Group, the knowledge dissemination and exchange AFMC eHealth Education Committee, and the Royal College of 2. Critical analysis, clinical reasoning and decision support: Physicians and Surgeons of Canada eHealth Expert Working Group to carry out critical appraisal of electronic knowledge for their contributions towards the formation of the 6 domains acquired, and to interpret through clinical reasoning to apply of eHealth curriculum. The author would also like to thank Ms. knowledge to guide patient treatment or health resource Joanna Pedersen, Acting Assistant Director of Education in the allocation; to document actions in electronic health records UBC Faculty of Medicine eHealth Strategy Office, for assisting or surveillance databases and track progress over time; and with the integration of eHealth into the UBC Faculty of Medicine to identify current evidence gaps that require future research curriculum renewal. 3. Using technologies for health service delivery: to use electronic technologies such as videoconferencing (VC), REFERENCES desktop VC, mobile devices or tablets, mobile sensors, social media, or other communication strategies to deliver health 1. Romanow RJ. Building on values: the future of health care in Canada services or monitor patients remotely; and to understand the [Internet]. Saskatoon: Commission on the Future of Health Care in Canada; Nov 2002 [cited 2013 Nov 29]. 356 p. Final Report. Available from: http:// limitations of these strategies and what improvements are bit.ly/HOKbaz necessary for continuous quality improvement 2. Health Council of Canada. Progress report 2012: health care renewal in 4. Intra- and interprofessional communication and collaboration Canada [Internet]. Toronto; Jun 2012 [cited 2013 Nov 29]. Available from: for patient–centred care: to improve communication between http://bit.ly/MtxKLZ doctors, nurses, and other health professionals in order to 3. Ho K. Technology enabled knowledge translation: using information and communication technologies to accelerate evidence based health practices. better coordinate patient care through seamless knowledge In: Kushniruk AW, Borycki EM, editors, Human, social, and organizational exchange, therapeutic decision making, and safe monitoring aspects of health information systems. Hershey (NY): Medical Information of patients’ progress Science Reference; 2008. p. 301-13. 4. Ho K, Jarvis-Selinger S, Novak Lauscher H, Cordeiro J, Scott RE, editors.

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Technology enabled knowledge translation for eHealth. New York: Springer; observatory for eHealth series, vol 2. Available from http://bit.ly/fk0wZJ. 2012. 440 p. 12. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile 5. Hung, SI, Chung WH, Jee SH, Chen WC, Chang YT, Lee WR, et al. Genetic phone-based interventions for smoking cessation. Cochrane Database Syst susceptibility to carbamazepine-induced cutaneous adverse drug reactions. Rev. 2012 Nov 14;11:CD006611. doi: 10.1002/14651858.CD006611.pub3. Pharmacogenet Genomics, 2006;16(4):297-306. 13. Steinberg DM, Levine EL, Askew S, Foley P, Bennett GG. Daily text 6. International Warfarin Pharmacogenetics Consortium. Estimation of the messaging for weight control among racial and ethnic minority women: warfarin dose with clinical and pharmacogenetic data. N Engl J Med. 2009 randomized controlled pilot study. J Med Inernet Res 2013;15(11):e244 Feb 19;360(8):753-64. 14. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health 7. Holpuch A. FDA orders genetics company 23andMe to cease marketing professionals for a new century: transforming education to strengthen of screening service. The Guardian. [Internet] 2013 [cited 2013 Nov 25]. health systems in an interdependent world. The Lancet. 2010 Dec Available from http://bit.ly/1i6qdoi. 4;376(9756):1923-58. 8. Vanderbilt University Medical Center. PREDICT fact sheet for providers. 15. Association of Faculties of Medicine of Canada. Future of medical education [Internet]. 2013 [cited 2013 Nov 29]. Available from: http://bit.ly/1blPp4U. in Canada: a project funded by Health Canada [Internet]. Association of 9. U.S. Food and Drug Administration [Internet]. Silver Spring (MD): U.S. Faculties of Medicine of Canada; 2010 [cited 2013 Nov 29]. Available from: Food and Drug Administration; 2013. Personalized medicine: a biological http://bit.ly/InbfKq approach to patient treatment. A conversation with Issam Zineh, Director 16. Canadian Healthcare Education Commons [Internet]. Association of of CDER’s Office of Clinical Pharmacology; 2012 [cited 2013 Nov 29]. Faculties of Medicine of Canada; c2013. Infoway physician in training Available from: http://1.usa.gov/1aBTnW4 e-Health curriculum and e-Learning; 2013 [cited 2013 Nov 29]. Available 10. Woottoon R, Patil NG, Scott RE, Ho K, editors. Telehealth in the developing from: http://bit.ly/Hakw8o world. Glasgow (UK): Royal Society of Medicine; 2009. 17. Royal College of Physicians and Surgeons of Canada. CanMEDS 2015: Does 11. World Health Organization. Telemedicine: opportunities and developments “eHealth” have a place in the revised framework? Dialogue [Internet]. 2013 in Member States: report on the second global survey on eHealth [Internet]. Jul 13 [cited 2013 Nov 29];13(7):6-8. Available from: http://bit.ly/17R28kT Geneva: World Health Organization; 2010 [cited 2013 Nov 29]. 93 p. Global

Extending the Reach of Medical Care for Remote First Nations Communities: Beyond Technology

John Pawlovicha, MD, FCFP; Marie-Pierre Dallaireb, MD, CM, FRCPC a REAP (Rural Education Action Plan, BC) Program Coordinator; Clinical Associate Professor, Dept. of Family Practice, UBC bGeneral Internal Medicine Fellow, University of British Columbia

KEYWORDS: rural medicine, First Nations, aboriginal population health, healthcare delivery, Telehealth

s British Columbia’s life expectancy (81.1 years) recognizing the effect of the ratio of primary care providers to continues to increase for the majority of the population, population as a main contributor to general population health is historically, it has been significantly lower (74.7 years) abundant.3,4 A 1 for First Nations, Metis and Inuit populations. Suicide, traumatic The Aboriginal population has been one of the fastest injuries, infectious diseases such as tuberculosis, complications growing in BC, increasing by 15.3% between the 2001 and 2006 of diabetes, and heart disease are general culprits.2 Despite censuses, while the non–Aboriginal population increased by obvious needs in terms of primary and specialty care, recruitment 4.9%. The total Aboriginal population in BC was 196,075 as of and retention of physicians in remote communities remain a 2006.5 systemic challenge. While the life expectancy differential cannot However, individual communities are small (50-600 be accounted for solely by the difference in healthcare providers’ people) and widely spread throughout a vast territory. Getting distribution, the physician–to–patient ratio is an internationally to the local clinic, laboratory or X–ray facility often means recognized index of general health. Moreover, the literature travelling by road, air, or water for many hours. Issues such as social isolation, substance abuse, violence, poor compliance with Correspondence medications, and medical investigations are further significant John Pawlovich, [email protected] barriers to the implementation of a reliable, consistent primary

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Figure 1. Aboriginal communities we serve in the Northern Interior Health Service Delivery Area of British Columbia.7 care service.6 Moreover, most physicians do not fully realize the audio and high–speed connections are not only useful for Skype; extent of cultural differences and collective traumatic experiences they are actively used as an adjunct to on–the–ground healthcare shared by this population and may not always offer consistent, services. Welcome to the new world of Telehealth. Using secure culturally sensitive care. Unfortunately, this has led to an erosion connections through satellite, microwave signals, or landline of trust over decades and cultivated a feeling of isolation in these fibre, remote communities today can have access to healthcare communities. provider (physician, nurse practitioner, nurse, etc.) expertise 24 In brief, challenges are plentiful, but the situation is not hopeless. Creative solutions aimed at addressing the aforementioned gaps in healthcare are evolving. Throughout the Telehealth is not medical world, innovative programs have been pioneered to provide better alchemy. Rather, it is another access to healthcare services with a reduction in total expenditures. So imagine this: You are a family physician responsible arrow in a quiver bursting for primary care of 1500 patients. Sound easy? They live 1000 “ with options. In the right hands kilometres from your home, and they are distributed over a 1000– square–kilometre area without reliable road access (Figure 1). it can transcend insurmountable And yet, as their primary care physician, you are able to geographical distances, forge care for them on a regular and semi–urgent basis, any day of the week. relationships between healthcare How? By thinking differently.This new paradigm requires providers and patients, and augment a fundamental reorganization of healthcare delivery. Physicians on–the–ground services. today rarely work in isolation. It is expected that nurses, physiotherapists, colleagues, specialists, and ancillary staff hours a day, 7 days a week. Amazingly, urgent and non–urgent all support and share clinical work to enhance a patient’s care. healthcare needs can now be supported. However, this model is expensive and not always economically This new model creates the following scenario: when a suited to sparsely populated, isolated areas. By realigning the nurse feels they require assistance in managing a patient, they traditional physician–centred model, a community that is too can call a physician or nurse practitioner to connect directly to small to sustain a full–time physician practice on its own may the remote site via Telehealth technology. The physician and be big enough to warrant 24/7 healthcare worker presence. And, nurse practitioner are knowledgeable about the limitations even if it is too small and isolated to sustain a nurse, a Community and strengths of the local health centre and can, therefore, give Health Representative can still be designated and trained. First recommendations that are contextually appropriate. Moreover, pioneered in Alaska, Community Health Representatives are patients have access to healthcare providers with whom they community members who are trained to recognize emergencies, are familiar and have developed relationships. In this model of are competent with medical jargon, and can perform basic first care, virtual and face–to–face interactions are complementary aid. to each other. Monthly visitations to these remote communities How then can a healthcare provider, such as a primary by the physician and nurse practitioner further strengthen the care physician or nurse practitioner, reach out to patients and relationships that the virtual interactions continue to nurture. healthcare staff located in a variety of remote settings separated by Given the cultural uniqueness of the population in question and such large geographical distances? This new paradigm, alluded to the difficulties First Nations communities have faced, this trust– above, harnesses the power of technology to support the building enhancing feature is an often–overlooked benefit of Telehealth. of connections and relationships. Videoconferencing, high–grade Modern Telehealth technology now allows for the

10 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com FEATURE examination of a patient that not too long ago seemed impossible, significant medium– and long–term reductions in morbidity and or at best farfetched. The direct visualization and listening through cost, in addition to increased productivity (e.g. no days lost for high definition cameras and stethoscopes in real–time, or as saved travel or spent waiting in the waiting room).8,9 So why are we not files, is now common. The saving and sending of digital images doing more of this? or sounds over a secure connection is known as “store & forward” Many will recall the story of the videoconferencing unit that in the Telehealth lexicon. This model utilizes real–time Telehealth went out to help a rural or remote community. Unfortunately, more technology over a secure connection. Collaborating on the early often than not, the videoconferencing unit suffered an ignominious management of a critically ill patient (e.g. sepsis, myocardial end and was laid to rest in a dark closet or basement. At the infarction, trauma), and helping to facilitate timely transfer to very best, it was brought back to life to facilitate administrative a larger medical centre are not uncommon uses of Telehealth meetings. It was never normalized into everyday practice, like a technology in the settings this model supports. As a value added telephone. Hence, the videoconferencing unit is often seen as a piece, real time connection over Telehealth fosters professional clunky, daunting, often unreliable piece of technology that is best support where once there was little. Helping a nurse suture a left in its dormant state. complex laceration, perform an incision, and drain an abscess Transformative change in medicine is not easy. Change for the first time are examples of professional collaboration that theory tells us that to normalize such a revolutionary way of the technology supports. Timely, responsive care has led to more delivering care, technology is the least of our concerns. We need appropriate management within the communities and a reduction to convince patients, providers, health authorities, academic in costly patient transfers. institutions, and government that it works, it is safe, it is cost– On the less urgent side of the healthcare spectrum lies effective, and it is sustainable. We need to build trust between all the world of chronic disease—a world that First Nations people these players that this technology is a positive step into the future. experience far too often. Arguably, this is where Telehealth may In other words, it’s all up to us. We have some work to do. We are prove to have its greatest benefit. Primary care providers are hopeful that this success story stirs interest and creates intrigue in often confronted with uncertain diagnoses or questions about care the hearts of the reader and medical community at large. Medicine options for their patients. Specialist help is many hours away by is in great need of transformation and technology is here to help road and appointments are difficult, not to mention risky, to get if we will let it. to. So how can technology support a new specialist experience for the patient and the primary care providers? Here is an example. REFERENCES Scenario: As a primary care provider you are challenged 1. Provincial Health Officer. The health and well-being of the Aboriginal by a patient that seems to fit into the rheumatologic spectrum population [Internet]. Victoria (CAN): Office of the Provincial Health of medical problems. However, you find yourself in need of a Officer of BC; 2012 [cited 2013 Nov 7]. 13 p. Available from: http://www. specialist colleague to help make the formal diagnosis and health.gov.bc.ca/pho/pdf/interim-update.pdf possibly recommend best treatment options. Welcome to the 2. Health Canada. A statistical profile on the health of First Nations in Canada: collaborating general internist. Every three months, she comes Vital Statistics for Atlantic and Western Canada, 2001/2002. [Internet]. Ottawa: Health Canada; 2011 [cited 2013 Nov 7]. 66 p. Cat.: H34-193/3- along with the primary care team and provides face–to–face 2008. Available from: http://www.hc-sc.gc.ca/fniah-spnia/alt_formats/pdf/ consultations for a variety of internal medicine problems. She can pubs/aborig-autoch/stats-profil-atlant/vital-statistics-eng.pdf facilitate necessary tests, liaise with subspecialty care, and reduce 3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems the number of trips needed outside the community by the patient. and health. Milbank Q. 2005;83(3):457–502. As a bonus, she is available for consultation and follow–up every 4. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37(1):111–26. working day, via Telehealth. In contemporary medical vernacular, 5. Statistics Canada. Aboriginal identity population, by province and territory “Shared Care” can occur in this remote First Nations community. (2006 Census) [Internet]. Ottawa: Government of Canada; 2009 [updated The primary care provider, consultant and patient collaborate, 2009 Sep 30; cited 2013 Nov 7]. Available from: http://www.statcan.gc.ca/ in real time, to work out solutions for the patient. This virtual tables-tableaux/sum-som/l01/cst01/demo60a-eng.htm. triangle consisting of the medical providers and the patient leads to 6. MacMillan HL, MacMillan AB, Offord DR, Dingle JL. Aboriginal health. CMAJ. 1996 Dec 1;155(11):1569–78. improved relationships, trust, compliance and hope. To date, other 7. Hesperus Arts. First Nations Communities [Image on internet]. Smithers specialties participating in virtual consults for the communities (BC): Morgan Hite; n.d. [cited 2013 Nov]. Available from: http://www. we support have included general and thoracic surgery, infectious hesperus-wild.org/GIS_carto/Figure1.html disease, nephrology, dermatology, mental health and addictions— 8. Hiratsuka V, Delafield R, Starks H, Ambrose AJ, Mala Mau M. Patient and with interest still growing. provider perspectives on using telemedicine for chronic disease management among Native Hawaiian and Alaska Native people. Int J Circumpolar Health Telehealth is not medical alchemy. Rather, it is another [Internet]. 2013 Aug [cited 2013 October 2];72: 21401 Available from: arrow in a quiver bursting with options. In the right hands it http://dx.doi.org/10.3402/ijch.v72i0.21401 can transcend insurmountable geographical distances, forge 9. Doorenbos AZ, Eaton LH, Haozous E, Towle C, Revels L, Buchwald D. relationships between healthcare providers and patients, and Satisfaction with Telehealth for cancer support groups in rural American augment on–the–ground services. Telehealth does not replace Indian and Alaska native communities. Clin J Oncol Nurs [Internet]. 2010 Dec [cited 2013 July 9];14(6):765–770. Available from: http://www.ncbi. face–to–face contact; it enhances it. It ensures continuity, closer nlm.nih.gov/pubmed/21112853 follow–up, and consistency. Studies have shown that it enhances patients’ and providers’ satisfaction, and others have found

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 11 CASE AND ELECTIVE REPORTS

Evolutionary Medicine: An Academic Elective

Cory Weissmana, BSc aVancouver Fraser Medical Program 2015, Faculty of Medicine, University of British Columbia

ABSTRACT This article includes an argument for the importance of academic electives in undergraduate medical education, along with a description of an academic elective that I took during the summer of 2012. The elective was a one-week course in evolutionary medicine, which is a growing field that is guiding exciting new medical advances. The key theme of the elective was the application of evolutionary theory to research and clinical practice in the fields of infectious disease and oncology. The elective took place in the beautiful setting of Mount Desert Island, in Maine, with a small group of learners of various ages and academic backgrounds. Leaders in the field were present to discuss the bright future of this young discipline. Through this elective I was able to develop new perspectives on my approach to medicine, which I will carry throughout my career. Academic electives of all types are an effective way for medical students to widen their knowledge base, which helps in both understanding disease and in patient communication.

KEYWORDS: evolutionary medicine, evolution, academic elective, paradigm shift, medical research, cancer, infectious disease, public health

n most medical schools, the first two years of study traditionally to treat and predict the course of disease.1 The authors gave four consist of classroom learning while the last two years involve examples of areas in medicine in which evolutionary theory can hands-on clinical work. Current changes in medical school be applied: infection (host-parasite interaction), injury and toxins, I 1 curricula allow for earlier clinical exposure in years one and two genetics, and host-environment interactions. One example they at the expense of time spent in lecture and group discussion. This explored in detail is the role of iron sequestration and fever during encroachment may be of concern, because in-depth study of the bacterial infection.1 Research has shown that treating fevers in core sciences of medicine, through lecture and group discussion, certain situations with antipyretics, as well as supplementing iron lays a foundation of knowledge for students to build upon with deficiency during infection, can actually worsen an infectious clinical experience. Doctors must be fluent in the language of course.1 Humans have evolved mechanisms to make their bodies science beyond a superficial level in order to be confident in less hospitable to pathogenic bacteria during infection, including today’s science–heavy, evidence–based clinical world. A greater increasing their body temperature and decreasing circulating understanding of the language of science not only helps students substrates available for bacterial use.1 Appreciation of these fully grasp the complex intricacies of patient management, evolutionary explanations for the adaptive roles of fever and but also aids in the acts of explanation to and communication iron sequestration in the setting of bacterial infection informs with patients, which are powerful healing tools in themselves. physicians that minimal treatment may be the best treatment Keeping up with the science is an ever-growing task for medical in this setting.1 This is just one example of many of the uses of students, as the frontiers of research and knowledge continue to evolutionary medicine in everyday clinical practice. Overall, spread rapidly. Therefore, opting to take an academic elective is the main message that proponents of evolutionary medicine are one way that medical students can expand and solidify their pre- trying to share is: we are human animals with a biological history clinical scientific knowledge base and begin their journey as life- understood best through the theory of natural selection, so why long learners. This article is an account of the experiences that I not use this truth to maximize self-knowledge, as a species, and had during a fully academic elective in evolutionary medicine. promote human health and well-being? The original article that jump-started the field of I set forth to explore the field of evolutionary medicine evolutionary, or Darwinian, medicine was written in 1991 by through a one-week course that took place during the summer psychiatrist Randolph Nesse and biologist George C. Williams.1 of 2012. The elective consisted of an engaging and dynamic They described evolutionary medicine as the application of the combination of lecture, small group discussion, and workshops. theory of natural selection to medicine as a means to enhance It was bracketed by inspiring talks from leaders of the field, our understanding of human biology and to improve our ability including Dr. Nesse, in which current advances in the application of evolutionary thought to the study of infectious disease Correspondence and cancer were presented; hence the title: Evolutionary Cory Weissman, [email protected] Foundations of Medicine and Public Health: Focus on Infection

12 UBCMJ | MARCH 2014 5(2) | www.ubcmj.com CASE AND ELECTIVE REPORTS

that was a highlight of the elective and an experience that only Learning about this exciting this type of environment could foster. It turns out that the point Michael made is a highly relevant one to today, as some research research first-hand from in prokaryotic gene biology is starting to be viewed once again these researchers was an through the lens of Lamarckian evolution.4 “ The elective took place at the Mount Desert Island experience that only an academic Research Laboratory in Bar Harbor, Maine, which is an idyllic elective could provide. place to study biology and ecology, and a refreshing change of pace from the busy hospital environment. The research center and Cancer. Two leaders in these academic niches presented has a rich history and is set up as a group of cabins and tiny their research. Dr. Carlo Maley explained how his expertise in marine laboratories sprawled across rocky beaches on the Eastern computer programming was essential for the development of coast of Mount Desert Island. Many researchers have gone there a mathematical model for clonal selection in cancers. He used to study marine life during the summer months over the past Barrett’s esophagus as the basis of his model.2 Dr. Andrew Read, century. Today, the labs are used for research in a wide range of a researcher in infectious disease, argued that the conventional topics within biology and ecology. Regenerative biology is one wisdom of treating infections with antibiotics over–aggressively example, which is the study of cellular regeneration of constituent is shortsighted; a more conservative approach with less selection parts of non-mammals with implications for understanding aging pressure on resistant strains could increase the lifespan of our in humans.5 current antibiotic arsenal. He used a model of malarial infection To help patients, doctors must be both compassionate in mice for his experiments.3 Both professors used fundamental and knowledgeable. Academic electives are a great way for tenets of evolutionary theory to guide their research designs and physicians-in-training to widen their knowledge base. They to interpret their results. Learning about this exciting research encourage medical students to confront ideas and interact with first-hand from these researchers was an experience that only an people that are not found in the traditional clinical setting. They academic elective could provide. also add richness to the study of medicine that will stick with While the majority of my time was spent learning new medical students throughout their careers. This kind of elective and interesting facts and concepts in organized lectures and opportunity is not hard to organize. I found this elective with a discussions, the time spent outside structured events rounded ten-minute online Google search. Any medical student can do my experience. There were only around 40 participants, which the same, he/she just has to hone in on what his/her academic created a very intimate environment and facilitated engaging passion is and search for the opportunity in order to bridge it and insightful conversation at meals or during hikes of the into their study. Evolutionary medicine is just one example; local Acadia National Park. Everyone was so excited about the there are many other fast–growing, exciting fields in medicine future of the field and their role in it; the energy and optimism including such disparate areas as mindfulness and meditation, was contagious. Teenage undergraduate students, middle-aged medical robotics, and nanomedicine. These experiences motivate practicing doctors, and retired professors all came together a renewed passion for learning, which will ultimately make us through this shared academic interest. It was refreshing to learn better physicians. alongside a heterogeneous and enthusiastic group of people that were present to share and create new perspectives on approaches For further reading on evolutionary medicine refer to: to medicine. Clinical electives cannot provide such a diverse http://evmedreview.com/. group of learners to interact with. During a lecture on infectious disease and antibiotic REFERENCES resistance one of the older participants, philosopher of science 1. Williams GC, Nesse RM. The dawn of Darwinian medicine. Q Rev Biol. Michael Ruse, brought up an interesting point. The lecturer 1991 Mar;66(1):1-22. was describing the historical origins of the commonly known 2. Maley CC, Greaves M. Clonal evolution in cancer. Nature. 2012 Jan;481(7381):306-13. medical truth that patients should finish their entire prescription 3. Read AF, Day T, Huijben S. The evolution of drug resistance and the curious of antibiotics, even if they feel better, during an infectious course. orthodoxy of aggressive chemotherapy. Proc Natl Acad Sci U S A. 2011 An old American advertisement from the early 20th century with Jun;108 Suppl 2(26):10871-7. 4. Koonan EV, Wolfe YI. Is evolution Darwinian or/and Lamarckian. Biol a phrase that described this point was displayed on the screen. Direct. 2009 Nov;4(42). Michael conjectured in his inquisitive British accent: based 5. Mount Desert Island Biological Laboratory [Internet]. Salisbury Cove, on the wording and considering the time of its posting, the ad Maine: MDIBL; 2009 2013 [cited 2013 December 7]. Available from: http:// seemed to be hinged on the Neo-Lamarckian view of inheritance www.mdibl.org/research.php of acquired traits, and not on the Darwinian view of natural selection. Was antibiotic treatment of bacterial infection once scientifically backed by the old abandoned science of Lamarckian evolution (i.e. the evolutionary theory of inheritance of acquired traits hypothesized in the early 1800’s4)? There was no clear-cut answer to this question, but it sparked an interesting discussion

UBCMJ | MARCH 2014 5(2) | www.ubcmj.com 13 COMMENTARIES

Three Concrete Tips for Teaching Clerkship Medical Students

Neil Dinesh Dattania, BHSc aClass of 2014, Faculty of Medicine, University of Toronto, Toronto, ON

ABSTRACT Medical education, and specifically the training of future physicians, is given a lot of importance, for good reason. Current teaching paradigms aim to teach medical students the principles of adult learning, which in this context refers to the ability to access resources and learn independently to meet self–imposed knowledge expectations. While emphasizing adult learning is effective at making students aware of the role they play in their own learning, clerkship students are not yet independent practitioners, and thus are supervised by numerous residents and staff physicians on any given rotation. There is enormous potential for learning to take place in supervisor– student relationships. However, teaching in these settings is often ineffective for a number of reasons. This paper summarizes the recent research literature in clerkship medical education, and then presents three concrete tips for residents and staff physicians to keep in mind when supervising and teaching clerkship medical students.

KEYWORDS: medical education, clinical clerkship, clinical skills, teaching strategies

LITERATURE REVIEW effective medical education at all levels; however, “effective” must be defined from the students’ point of view. Students find here is a large body of research on teaching clerkship feedback especially effective when it is related to a history medical students, especially for surgery, internal or physical examination they performed, to a case that they Tmedicine, radiology, and psychiatry. Among other things, presented, or on their written communication skills.6,7 In terms studies have looked at what forms of teaching and clinical roles of how it is given, trainees appreciate genuinely delivered, well– clerks value most during their rotations, what clerks feel are communicated feedback given in private that focuses on both qualities and practices of effective supervisors, and what types what they are doing well and what they need to improve.6,7 of feedback clerks value most. An interesting and relatively recent development in A recent study on surgical clerkship teaching highlighted clerkship medical education is the attention paid to the role a disconnect between clerks and their resident or faculty of residents. Residents have become increasingly recognized supervisors, with clerks desiring less teaching and more as integral parts of clerkship medical education, and formal practical experience during rounds than their supervisors programs training residents to be effective teachers have become thought appropriate.1 A different study found clerks desired more common.8 In fact, clerkship students commonly identify residents instruction and feedback, especially on practical surgical skills.2 as their primary teachers, especially on surgical rotations.2,9,10,11 In a third study, internal medicine clerks described receiving Review articles on the overall importance of medical high–quality feedback and orally presenting their cases, with education reform have been around for decades,12,13 and these their own assessments and plans, to be associated with a more articles are helpful in summarizing objectives for training positive learning experience.3 programs at the administrative level. However, most clinical Studies have identified several qualities and practices of educators work directly with medical students during clerkship effective clinical supervisors from the clerks’ point of view. rotations, and teaching must be done within the confines of the Admired qualities include professionalism, a collaborative school’s curriculum and other clinical responsibilities. The three mindset, being experts in their fields, and facilitating learning practical tips outlined here can easily be implemented in almost rather than asserting it.4,5 Well–received practices include any clinical teaching setting. explaining decisions, respecting students, and emphasizing the development of clinical skills as opposed to just medical TEACHING TIPS knowledge.4,5 Effective feedback is recognized as a cornerstone of I. Get Them Involved Clerks often feel caught between learning and working, which can Correspondence be confusing. Getting them involved in any meaningful capacity Neil Dinesh Dattani, [email protected]

14 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com COMMENTARIES helps them to feel they are part of the team while teaching them the training of future doctors, fundamental teaching strategies simultaneously. Even seemingly menial jobs or “nothing events” in medical schools continue to evolve. In just three or four are often new to medical students, so get them involved with such years, medical students must gain the knowledge required to tasks, especially when there are senior learners around to work be effective residents, as well as the skills to be self–directed on more complicated tasks. For example, have them perform learners for their future careers. Strategies in medical school the subcutaneous injection of heparin before an operation while should balance direct teaching with the facilitation of adult they are on surgery, or arrange the IV fluid lines while they are learning, and clerkship is an opportune setting in which to do on anesthesia. When appropriate, calling family doctors’ offices this. for further information is good practice in communicating with This paper has outlined three concrete tips for residents colleagues, as is consulting necessary services when needed. and staff physicians to keep in mind when supervising clerkship Presenting cases at team rounds or signover is good practice for medical students. The clinical setting and patient requirements summarizing cases and taking ownership of patient care. Ideally, will always dictate how much focus can be put on teaching there should always be a specific reason why you are not letting but, when possible, get medical students involved, keep high a clerk perform a task that could teach him or her something. expectations for them, and be aware of what they know coming into the rotation. This will improve the students’ learning, the Clerks often feel caught supervisory relationship you have with them, and their overall clerkship experience. between learning and working, “ which can be confusing. Getting ACKNOWLEDGEMENTS them involved in any meaningful I would like to acknowledge Dr. Cynthia Whitehead, Department capacity helps them to feel they are of Family and Community Medicine at the University of Toronto, for her invaluable support and guidance with this project. part of the team while teaching them simultaneously. REFERENCES 1. Quillin RC III, Pritts TA, Tevar AD, et al. Students’ expectations on the surgery clerkship exceed those of residents and faculty. J Surg Res II. Keep High Expectations 2013 1:6. Get students involved, as mentioned above, but then take it 2. De SK, Henke PK, Ailawadi G, et al. Attending, house officer, and medical student perceptions about teaching in the third–year medical further and challenge them to accept their new roles as members school general surgery clerkship. J Am Coll Surg 2004 199:932-942. of the patient care team. Give them responsibilities that are fair 3. Torre DM, Sebastian JL, and Simpson DE. Learning activities and high– and safe for their level of education, and expect them to follow quality teaching: perceptions of third–year IM clerkship students. Acad Med 2003 78:812-814. through with them. Let students know if they are not meeting 4. Elnicki DM, Kolarik R, and Bardella I. Third–year medical students’ the standard you expect of them, and tell them specifically what perceptions of effective teaching behaviors in a multidisciplinary needs to improve. Taking ownership of roles in the management ambulatory clerkship. Acad Med 2003 78:815-819. 5. Kassab S, Al-Shboul Q, Abu-Hijleh M, and Hamdy H. Teaching styles of of patients gives clerks confidence, and this is such an important tutors in a problem–based curriculum: students’ and tutors’ perception. stage of training that most clerks will remember the first time Med Teach 2006 28(5);460-464. they experienced it. Expect them to take such ownership as early 6. Torre DM, Simpson D, Sebastian JL, and Elnicki DM. Learning/ feedback activities and high-quality teaching: perceptions of third–year as possible. Set the bar high for students, as high expectations medical students during an inpatient rotation. Acad Med 2005 80:950- communicated in a non–threatening way stimulate learning. Just 954. be careful to keep the next suggestion in mind when doing so. 7. Ramani S and Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach 2012 34:787-791. 8. Morrison EH, Friedland JA, Boker J, et al. Residents–as–teachers III. Be Aware of What They Know Coming into the Rotation training in U.S. residency programs and offices of graduate medical When caring for patients on the wards, there is no limit to how education. Acad Med 2001 76(10):October supplement. 9. Whittaker LD, Estes NC, Ash J, and Meyer LE. The value of resident much one can know. This is daunting for clerks, who are new to teaching to improve student perceptions of surgery clerkships and having a role in the hospital environment. Compounding this is surgical career choices. Am J Surg 2006 191:320-324. the fact that pre–clerkship medical school education is mostly 10. Bing-You RG and Sproul MS. Medical students’ perceptions of themselves and residents as teachers. Med Teach 1992 14(2):133. centred on diagnosis, and generally there is less emphasis on 11. Mann KV, Sutton E, and Frank B. Twelve tips for preparing residents as all the details of management. Keep this is mind when teaching teachers. Med Teach 2007 29:301-306. medical students. A big adjustment when entering clerkship 12. Goodstein RK. Psychiatry clerkship success skills and styles. Gen Hosp Psychiatry 1980 3:213-218. is becoming responsible for proposing management plans, so 13. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education working with clerks to gain the knowledge and skills required to by the Carnegie Foundation for the Advancement of Teaching: 1910 and do this will be well received. 2010. Acad Med 2010 85(2):220-227.

CONCLUSION With so much attention being given to medical education and

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 15 COMMENTARIES

A Tip to Pre-Med Students: Don’t Put All Your Eggs in the Science Beaker

Michael J. Horkoffa, BSc aVancouver Fraser Medical Program 2015, Faculty of Medicine, University of British Columbia

ABSTRACT Every year in Canada, over 10,000 students apply to medical schools across the country.1 While each of these applicants has a unique story to tell about why they are considering medicine as a career, they are all trying to figure out the best academic pathway in to the program. Arguably, exploring a pathway that provides for a successful career in medicine should be of utmost importance. However, many students are content with their undergraduate science degree despite the majority of the curriculum being of little use to their future medical training and careers.

KEYWORDS: pre-medical education, undergraduate, science, diversity, medicine

t the University of British Columbia (UBC), the science degree develop skills in these areas. In contrast, courses overwhelming majority of applicants to the medical focusing on management and organizational behavior teach students Aprogram have completed a Bachelor of Science degree. This how to develop their interpersonal skills and present their ideas in a comes as no surprise, as nearly all prerequisite courses for medicine well–thought–out manner. An example of a specific course offered are core components of a science degree.2 Furthermore, the Medical by UBC that touches on these aspects is COMM 292, Management College Admissions Test (MCAT), which must be completed by all and Organizational Behaviour, where students focus on learning and applicants, has a substantial science component.3 Thus, pursuing a practicing presentation skills.4 Other undergraduate courses aimed Bachelor of Science degree should ensure that an applicant achieves at communication and leadership skill development can greatly the required pre–requisites for medical school while providing contribute to a student’s chance of success during the interview. These adequate preparation for the MCAT. After speaking with several skills continue to be helpful during CaRMS matching, a selection prospective medical students and recalling my own undergraduate process for residency placement that nearly every medical student in education, I’m certain that this is a recurring thought process among Canada undergoes. Matching success is not based solely on academic undergraduate students across Canada. Part of the reasoning behind performance: it is more heavily based on how well the applicant this thought process is the competitiveness and difficulty of medical will “fit in” among others in the specialty.5 Therefore, education school entry. Students worried about these aspects can forget to in interprofessional behavior is another great asset for students, as consider the utility of their undergraduate studies in the future building positive therapeutic relationships with patients and other because they are concentrating on short–term goals such as getting physicians is key to success in residency and medical practice. an interview invitation. Although a degree in science teaches students Thus, any academic advantage that students might have carried into to study diligently, a seemingly important fourth–year genetics medical school after studying only science — rather than exploring elective is unlikely to be helpful in preparation for the numerous courses in interpersonal studies, communications, or management — hurdles medical students must overcome, such as the medical school is of less long–term value. interview, the Canadian Resident Matching Service (CaRMS) The day eventually comes where all medical graduates enter process, and the daily tribulations of running a medical practice. into independent practice. Currently in Canada, 95% of family All medical students entering UBC medical school have gone physicians and the majority of specialists operate on a “fee-for- through a Multiple Mini–Interview (MMI), which is a major part service” basis, with many setting up companies under their own of the selection process for incoming medical classes. Although name to better manage the financial aspects of their practice.6 this interview is slightly different every year, scoring well on it is Unfortunately, skills for management of a medical practice are not dependent on the interviewee’s ability to present their ideas in an currently part of most medical school curriculums, including that organized and logical way. Prospective students must also have a at UBC. Therefore, MD graduates with a business background are general knowledge of medical ethics and be able make decisions arguably much better prepared to enter into an independent practice surrounding controversial scenarios. Few aspects of a conventional from a management perspective. Consideration of this issue as well as that of cost management of healthcare in Canada has led many Correspondence universities — starting with McGill in 1997 — to offer combined Michael J. Horkoff, [email protected] MD-MBA programs.7 Although UBC does not currently offer such

16 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com COMMENTARIES a program, discussions exploring the possibility have started as part current students thinking of a career in medicine, there are so many of the current curriculum renewal process.8 As a business education opportunities to diversify your university education, and many of is of value for physicians, undergraduate studies are an ideal time for them could make you a better medical student and physician. Start students to obtain a basic level of understanding of this material. your training early by diversifying your undergraduate studies.

For the current students thinking REFERENCES of a career in medicine, there are 1. Canadian Medical Education Statistics. The Association of Faculties of Medicine of Canada [Internet]. 2012 [Updated 2012; Cited 2013 Oct 15]. Available from: so many opportunities to diversify http://www.afmc.ca/pdf/Cmes2012OCRreduced.pdf “ 2. MD Undergraduate Program Admissions. University of British Columbia, Faculty your university education, and many of of Medicine, MD Undergraduate Program [Internet]. 1994 [Updated 2013; them could make you a better medical Cited 2013 Oct 15]. Available from: http://mdprogram.med.ubc.ca/admissions/ welcome-message/ student and physician. 3. About the MCAT Exam. Association of American Medical Colleges [Internet]. 1995 [Updated 2010 Oct 1; Cited 2013 Oct 15]. Available from: https://www. When considering which undergraduate degree is most suitable aamc.org/students/applying/mcat/about/ prior to medical school, students must be aware that most Canadian 4. Vancouver Academic Calendar 2013/2014. University of British Columbia universities, including UBC, do not have bias towards a particular [Internet]. 2013 [Updated 2013 Jun 28; Cited 2013 Oct 15]. Available from: http:// academic background.2 Thirty pre–requisite credits from a variety of www.calendar.ubc.ca/vancouver/ 2 5. Personal correspondence – CaRMS demystified presentation. University of science courses are necessary to apply to the program at UBC. This British Columbia. 2012. leaves students with some options to fill the remaining 90 credits 6. Fee-for-service billing. Canadian Medical Association [Internet]. 1995 to round out four years of university studies, the average amount [Updated 2013; Cited 2013 Oct 15]. Available from: http://www.cma.ca/ that students entering medical school have.2 For many pre–medical practicemanagement/fee-for-service-billing students, this might be an unrecognized opportunity to absorb and 7. Thorne S. McGill launches first combined MD-MBA program. Can Med Assoc J. 1997 Jun 01;156(11):1612. practice lifelong skills needed in their daily medical practice 8. Dean’s Task Force on MD Undergraduate Curriculum Renewal. The University Having personally now completed a focused science degree and of British Columbia [Internet]. 2010. [Updated 2010 May; Cited 2013 Oct 15]; two years of medical school, I often reflect on how my undergraduate [Page 18]. Available from: http://cr.med.ubc.ca/files/2011/01/appendixd16808.pdf degree will help me during medical practice in the future. For the

Cosmetic Psychopharmacology: The Ethics of Antidepressant Therapy

Fareed B. Kamara, BSc aVancouver Fraser Medical Program 2014, Faculty of Medicine, University of British Columbia

ABSTRACT Antidepressant medication, a commonly prescribed antidote for the depressed mood, continues to prove its value in primary and psychiatric health care. Its popularity in society requires its administrators and users to reflect on its function not only as a mood enhancer, but also as a modifier of the human self. Inspired by Peter Kramer’s Listening to Prozac, this commentary on psychological materialism discusses the ethics of antidepressant therapy in the context of the idea of cosmetic psychopharmacology, the psychotherapeutic alternative, and the antidepressant placebo effect.

KEYWORDS: antidepressants, ethics, depression, psychiatry, cosmetic psycho-pharmacology, cosmetic psychotherapy

istening to Prozac, Peter Kramer’s chronicle of clinical An anecdotal exploration of the biological, psychological, and social encounters involving antidepressant therapy, offers insight implications of antidepressants, Kramer’s collection of case studies Linto the innovation of pharmacological psychotherapeutics. questions whether these drugs medicate mood or alter an individual’s sense of self. This issue engenders a discussion about mood enhancers Correspondence Fareed B. Kamar, [email protected], 403-969-3760 as cosmetic agents and about their prescription in light of both the

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he University of British Columbia Medical Journal (UBCMJ) is a student-run academic journal with a goal to engage students in dialogue in medicine. Our scope ranges from original research and review articles in medicine to medical trends, clinical reports, Telective 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.

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UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 19 COMMENTARIES psychotherapeutic substitute and their placebo effect. pharmacotherapy for the management of depression. Although Originating from this bestseller, the term cosmetic psychotherapy requires more time, causes emotional pain, and can psychopharmacology is a reflection of Kramer’s clinical experiences create conflicts, it represents the more authentic means of recovery with antidepressants as they relate to the variability of the human self. because our culture values self–change through self–work.8,9 Cosmetic therapy can be described as an intervention in the absence The introspective discovery of the unconditioned self through of pathology, be it surgery for aesthetic enhancement, or in Kramer’s psychotherapy allows for a more easily upheld inner refinement than its pharmacologic rival. Instead of a chemical shortcut to mood enhancement,3,10 psychotherapy provides an understanding of the Are individual idiosyncrasies self by exploring feelings, behaviors, and thoughts. It is this journey or even identities not at stake unique to psychotherapy that gives meaning to the psychological when psycho-enhancers are outcome. Psychotherapy also empowers its patients through stressor “ control, while pharmacotherapy offers little motivation for lifestyle used to conform to society’s standards change. Antidepressants might, on the other hand, provide patients of acceptance? the confidence to overcome adverse situations. Because psychotherapy and pharmacotherapy are not exclusive strategies, physicians must be aware of the treatment effect of case, medication for patients without depression.2 Such patients who antidepressants. It has been suggested that while these medications are received antidepressants became disinhibited,1 an observation that beneficial, especially for severe depression,11 they have an important calls into question the role of these medications as possible cosmetic placebo effect.12-14 The placebo effect is further underestimated by the enhancers of the psyche. presence of publication bias,15 and some authors have even suggested Kramer’s support for fluoxetine (Prozac) stems from its value in that antidepressants have no effect on mild depression.16,17 Despite improving social functioning by instilling self-assurance. It could be being in a control group, patients receiving placebo in these trials that this character change through antidepressant therapy represents found symptom relief due to nonspecific care from the research the recovery of a person’s natural personality. It is for this reason that staff.18 Does the truth about their placebo effect sabotage the success he suggests “listening to Prozac”,1 for this medication exposes the of antidepressants? Uncovering this living myth could be unethical innate temperament from a shell that becomes damaged by stress. if it causes a loss of faith in pharmacotherapy.19 In spite of that, is it While antidepressants might offer inner purification, this effect begs dishonest to advocate a dummy pill? While factors such as price and further questioning regarding the implications of self-transformation. branding affect the success of all drugs in the marketplace,20,21 it seems Because successful interactions in today’s social environments particularly wrong for an industry to profit from an official placebo. rely on an attitude of assertiveness, patients may turn to their doctors If the antidepressant is indeed a placebo, then perhaps prescribing it for help in acquiring this desired trait. Achieving an emotional should not be limited to health care practitioners. This placebo effect boost through medication might, however, alter self-perception in of antidepressants is also disconcerting given their associated side individuals either “losing themselves” or “becoming themselves.”1 effects, which is important whether they are being used for medical Are individual idiosyncrasies or even identities3 at stake when or cosmetic reasons. psycho-enhancers are used to conform to society’s standards of Antidepressant pharmacotherapy exemplifies the ethical acceptance? While everyone is judged according to the social ideals considerations of drug prescription. Whether they could be at large, it seems wrong that these ideals should select emotions considered as cosmetic enhancers for the psyche or as medications for requiring chemical remedy. If sadness and anxiety are problems, then psychological illness, the effects of antidepressants on society and on is psychological homogenization the solution?4 the human self remain open for discussion. With new antidepressants Despite their established role in mental illness, the use of on the way, it will behoove both physicians and patients to contemplate antidepressants might reflect more than Kramer’s attempt to undo matters such as the value of the psychotherapeutic alternative and the distortion of self-perception. Because sadness and anxiety are their placebo effect. Not only will this reflection clarify the role feelings fundamental to the human experience,5 antidepressant use of biological treatment in the “biological-psychological-social” might represent a method of numbing pain.3 If recreational drugs approach to mental illness, it will also help answer questions like can also serve to numb pain,6 then where should antidepressants fall Peter Kramer’s query, “How is it that taking a capsule for depression on society’s moral compass? This question speaks to the standards can so alter a person’s sense of self?”1 of medication use in a society where the line between cosmetic and pathological repair is often ill-defined.7 REFERENCES Perhaps the concept of chemical dehumanization5 is the consequence of an overestimated value of antidepressants in the 1. Kramer PD. Listening to Prozac. New York: Penguin; 1993. Print. care of a depressed patient. Rather than recognizing difficult normal 2. Bjorklund P. Can there be a ‘cosmetic’ psychopharmacology? Prozac unplugged: the life experiences, antidepressants argue a biological etiology for search for an ontologically distinct cosmetic psychopharmacology. Nurs Philos. 2005 Apr;6:131-143. depression. While medications require diagnosis, psychotherapy 3. DeGrazia D. Prozac, enhancement, and self-creation. Hastings Cent Rep. 2000 Mar- does not. It then becomes a matter of refuting the notion that Apr;30:34-40. pharmacotherapy treats disorders while psychotherapy only treats 4. Mahmood F. Listening to Prozac: A review and Commentary [Internet]. 2008 [cited the self.8 2014 February 7]. Available from: http://serendip.brynmawr.edu/exchange/node/2007 Psychotherapy has only recently become competitive with 5. Sperry L, Prosen H. Contemporary ethical dilemmas in psychotherapy: cosmetic

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psychopharmacology and managed care. Am J Psychother. 1998 Winter;52:54-63. antidepressant and placebo response rates in antidepressant efficacy trials: Meta- 6. Cerullo MA. Cosmetic psychopharmacology and the President’s Council on Bioethics. analysis. Br J Psychiatry. 2007 Apr;190:287 292. Perspect Biol Med. 2006 Autumn;49:515-523. 15. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication 7. Rangel EK. Cosmetic psychopharmacology and the goals of medicine. Virtual Mentor. of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008 2007 Jun;9:428-32. Jan;358:252 260. 8. Svenaeus F. The ethics of self-change: becoming oneself by way of antidepressants or 16. Rapaport MH, Nierenberg AA, Howland R, Dording C, Schettler PJ, Mischoulon D. psychotherapy? Med Health Care and Philos. 2009 Feb;12:169 178. The treatment of minor depression with St John’s Wort or citalopram: failure to show 9. Stein DJ. Cosmetic psychopharmacology of anxiety: bioethical considerations. Curr benefit over placebo. J Psychiatr Res. 2011 Jul;45:931 941. Psychiatry Rep. 2005 Aug;7:237-238. 17. Barbui C, Cipriani A, Patel V, Ayuso-Mateos JL, van Ommeren M. Efficacy of 10. Rothman DJ. Shiny, happy people: the problem with “cosmetic psychopharmacology.” antidepressants and benzodiazepines in minor depression: systematic review and meta- New Repub. 1994 Feb;210:34-38. analysis. Br J Psychiatry. 2011 Jan;198(1):11 16. 11. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et 18. Thase ME. The small specific effects of antidepressants in clinical trials: what do they al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. mean to psychiatrists? Curr Psychiatry Rep. 2011 Dec;13(6):476 482. JAMA. 2010 Jan;303:47 53. 19. Ioannidis JPA. Effectiveness of antidepressants: an evidence myth constructed from a 12. Gibbons RD, Hur K, Brown CH, Davis JM, Mann JJ. Benefits from antidepressants: thousand randomized trials? Philos Ethics Humanit Med. 2008 May;3(14). synthesis of 6-week patient-level outcomes from double-blind placebo-controlled 20. Rao AR and Monroe KB. The effect of price, brand name, and store name on randomized trials of fluoxetine and venlafaxine. Arch Gen Psychiatry. 2012 buyers’ perceptions or product quality: an integrative review. J Marketing Res. 1989 Jun;69(6):572 579. Aug;26(3):351 357. 13. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial 21. Waber RL, Shiv B, Carmon Z, Ariely D. Commercial features of placebo and severity and antidepressant benefits: a meta-analysis of data submitted to the Food and therapeutic efficacy. JAMA. 2008 Mar;299:1016 1017. Drug Administration. PLoS Medicine. 2008 Feb;5(45). 14. Posternak MA, Zimmerman M. Therapeutic effect of follow-up assessments on

The benefits of open source electronic medical record (EMR) systems: OSCAR McMaster as a case study

Matthew Tooma, BSc (CS,MBB) aVancouver Fraser Medical Program 2016, Faculty of Medicine, University of British Columbia

KEYWORDS: EMR, electronic medical record, open-source, software, OSCAR, technology

s medicine continues to be revolutionized by computer products are built using open source languages, including technology, open source software (OSS) is playing an Facebook2 and many of Google’s products, such as the Android Aimportant role in making available innovative, cost- operating system.3 In addition to its use in private industry, open effective solutions for the medical community. Source code is source also provides a platform for programmers to produce the set of instructions that make up a computer program. “Open free software, thereby enabling the creation of alternatives to source” refers broadly to any program built from source code that commercial products for various applications. In medicine, one is openly published and licensed. Such software can be adapted or exciting example of this phenomenon is the electronic medical used in its original form and is licensed for use for any purpose, record (EMR) system. including for-profit enterprise. It is typically available free of In general terms, EMR systems are computer programs that charge and maintained by a community of contributors who physicians use in the patient care setting to record information volunteer their time to create and improve it. Everyone benefits about patients and encounters, typically using the SOAP from open source as it continues to underpin the majority of the note format (Subjective, Objective, Assessment, and Plan). internet’s web servers.1 Much of the world’s commercial software EMR systems have many features, ranging from appointment scheduling to chronic disease management, but they act primarily Correspondence as a computerized replacement for paper records.4 Because EMR Matthew Toom, [email protected] systems are associated with increased efficiency and improved

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 21 COMMENTARIES patient outcomes, they are well–received by physicians and are user practices. So while there is no reason to expect that OSS is increasingly essential to care delivery.5 This is exemplified in inherently less secure than closed source software, it is imperative Canadian primary care adoption rates which have doubled to 54% for any EMR system that due diligence is followed. Users must since 2006.5 Such systems represent a significant expenditure be properly trained, and the services of a competent technical of healthcare funds, worth an estimated $54 billion US globally support provider are required to configure and operate the system in 2014.6 For many Canadian physicians, EMR systems are securely. an expense worth thousands of dollars per year, and choosing The most obvious benefit of open source EMR software is between an open source and a commercially developed EMR that it is free in the sense that anyone can immediately access it system can be a difficult decision. online, download it, and use it without paying anything. There are By nature, open source medical software is designed for no licensing fees. Commercial EMR systems available in British open data standards in an effort to achieve interoperability, or Columbia are subject to recurring licensing fees that are typically seamless interfacing between systems. Consider that commercial in the range of $3,000 Canadian annually.11 While the cost analysis EMR vendors have a vested interest in keeping user data locked for an EMR system includes far more than just licensing fees, down in their own proprietary format specific to their EMR there is evidence that OSS leads to an overall reduction in costs.12 software.7 This helps them to retain subscribers, as customers are The market for EMR systems has traditionally been likely to encounter difficulties if they try to switch to a different dominated by commercial products, but there is a free, Canadian– EMR. Similarly, companies that develop EMR software will often made open source EMR option that is widely used across the have a monopoly on the provision of technical support, leaving country called Open Source Clinical Application Resource the end user threatened by the possibility that the company might discontinue support or go out of business. They could also impose requirements on how and where patient data is stored, sometimes Because EMR systems are requiring that it be stored on their networks. With an open source associated with increased EMR system, technical support is available from competing efficiency and improved providers at negotiable rates. “ Despite the lack of profit motive for open source patient outcomes, they are well programmers, there exists a sophisticated worldwide community received by physicians and are of developers of OSS. They are motivated for diverse and often complex reasons, ranging from passion for a particular subject becoming an increasingly essential area to a desire to enhance their résumés.8 Such individuals are component of care delivery. often industry professionals seeking to satisfy a niche software requirement, making them uniquely well-suited as designers. (OSCAR) McMaster. The project was spearheaded by a Canadian Indeed, physicians themselves contribute to open source EMR physician, Dr. David Chan, and developed by the Department of systems. Family Medicine at McMaster University. Since its inception in Privacy and security are perhaps the most crucial aspects 2001, OSCAR has grown significantly and now has organized of a software product designed to record and store medical user groups, commercial technical support providers, and support information. By definition, open source code is openly published. from major institutions such as McMaster University. The OSCAR This is tremendously valuable in that it enables total transparency community is comprised of clinicians and software designers, so of implementation and enhances security by facilitating the peer physicians who choose OSCAR for their clinic will not be alone. review and subsequent validation of the design of a software As of 2012, OSCAR EMR has more than 700 clinical users in system.9 The only way to verify with certainty how patients’ British Columbia and has been favourably received.13 medical information is handled is to refer to the source code. In OSCAR is a feature–rich EMR system built on Java and closed source, the code is compiled into binaries and its inner MySQL. It includes a component called MyOSCAR, which workings are thereby obscured. Thus clinicians who use an functions as a Personal Health Record (PHR) that enables patients open source EMR system are granted total disclosure regarding to participate more closely in their medical care. OSCAR stores its functioning before opting to use it, whereas users of closed patient data such that it may be migrated to a different system source software are not. These users instead enter into a trust if desired, and it allows the clinician to make decisions about relationship with the provider of their software. OSS encourages how the data is stored and managed. Furthermore, OSCAR has good practices from the outset, as programmers are influenced support for provincial billing and laboratory services, allowing by the awareness that their work will be accessible to others for efficient exchange of information. Because it is web–based it and subject to external audit. There is less temptation to rely on can be used on any platform capable of supporting a web server or discredited practices sometimes seen in closed source, such as modern web browser. This means patient records can be created security through obscurity, or achieving security by relying on or accessed on virtually any platform, including Apple OS X, secrecy of design instead of accepted best practices.10 Beyond Microsoft Windows, Linux (an open source operating system), the software itself, most of the security of patient data in EMR or even a smartphone. In 2012, OSCAR received certification systems actually depends on network configuration, data storage from Canada Health Infoway, indicating that it meets or exceeds aspects such as physical storage location and encryption, and standards for privacy, security, and interoperability.14

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Of course, opting for an open source EMR system has its 10. Scarfone K, Jansen W, Miles T. Guide to General Server Security. National Institute of Standards and Technology. Report number: 800-123, 2008. drawbacks. Commercial EMR software is typically provided 11. Physician Information Technology Office. About EMRs: Vendors [Internet]. directly from a vendor as part of a streamlined solution that also [Cited 2013 Oct 1]. Available from: http://www.pito.bc.ca/about-emrs/ includes installation and support. Clinicians who choose OSS vendors/ 12. Webster PC. The rise of open-source electronic health records. Lancet 2011; must find a reputable technical support provider and might need 377(9778): 1641-1642. to make more complex decisions about system configuration. 13. OSCAR Canada Users Society. About OSCAR: User Base [Internet]. Overall, it is probably the more technical option, and the additional Vancouver, British Columbia: OSCAR Canada Users Society; 2013 [cited 2013 Oct 1]. Available from: http://oscarcanada.org/about-oscar/brief- autonomy desired by some could be seen as excess decision overview/index_html#user-base overhead by others. Furthermore, there are no guarantees. While 14. Canada Health Infoway. OSCAR EMR version 12.1 achieves Canada Health technical support providers for OSS might guarantee the quality Infoway certification [Internet]. Toronto, Ontario: Canada Health Infoway; 2012 [updated 2012 Dec 6; cited 2013 Oct 1]. Available from: https://www. of their support services, they cannot reasonably make guarantees infoway-inforoute.ca/index.php/news-media/2012-news-releases/oscar- pertaining to the software itself. This is typically not the case with emr-version-12-1-achieves-canada-health-infoway-certification commercial vendors. As such, clinicians must have a high degree 15. Physician Information Technology Office. Funding [Internet]. Vancouver, British Columbia: Physician Information Technology Office; 2013 [cited of trust in OSS in order to justify choosing it. If they encounter 2013 Oct 1]. Available from: http://www.pito.bc.ca/funding/ any software–related problems, only the open source community 16. Figurski M. PITO: Why no open source? B. C. Med. J. 2008; 50(3): 122. and third–party technical support providers will be available for assistance. Finally, in British Columbia, the Physician Information Technology Office (PITO) offered substantial subsidies totaling $108 million Canadian for EMR adoption.15 However, only commercial EMR systems were chosen by PITO to be eligible for funding so clinicians who selected an open source system such as OSCAR would not have received financial assistance.16 Thinking beyond EMR systems, as technology continues to influence medicine, it is important to be aware of open source. Today’s medical students are savvy and demanding users of technology, and the concept of open source is inherently appealing to a generation that is familiar with free software services and willing to adopt the latest technologies. Going forward, OSS will continue to help drive down costs both for those who use it and for those who do not, as commercial software must be sufficiently good to justify its expense if viable free alternatives are available. However, there is still opportunity to enhance collaboration between healthcare providers and open source developers to better meet the needs of patients and to find new applications for open source in medicine. By working together we can help to ensure that open source advances medical practice by driving innovation through the creation of quality, cost-effective software solutions.

REFERENCES 1. Netcraft Ltd. September 2013 Web Server Survey [Internet]. Bath, Somerset: Netcraft Ltd.; 2013 [updated 2013 Sept 5; cited 2013 Oct 1]. Available from: http://news.netcraft.com/archives/2013/09/05/september-2013-web-server- survey.html 2. Protalinski E. Why Facebook hasn’t ditched PHP [Internet]. [updated 2013 Feb 27; cited 2013 Oct 1]. Available from: http://www.zdnet.com/blog/ facebook/why-facebook-hasnt-ditched-php/9536 3. Vaughan-Nichols SJ. Linus Torvalds on Android, the Linux fork [Internet]. [updated 2011 Aug 8; cited 2013 Oct 1]. Available from: http://www.zdnet. com/blog/open-source/linus-torvahlds-on-android-the-linux-fork/9426 4. Skolnik NS. Electronic Medical Records. New York: Springer; 2011. 5. PricewaterhouseCoopers. The emerging benefits of electronic medical record use in community-based care. Canada Health Infoway. 2013. 6. Research and Markets. Global Healthcare Information Technology. Research and Markets. 2009. 7. Kantor GS, Wilson WD, Midgley A. Open-source software and the primary care EMR. J. Am. Med Inform Assoc. 2003; 10(6): 616. 8. Bonaccorsi A, Rossi C. Why open source software can succeed. Res Policy 2003; 32(2003): 1243-1258. 9. Fokkink W, Hoepman JH, Pang J. Increased security through open source. Commun ACM. 2007; 50(1): 79-83.

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 23 COMMENTARIES

Smartphone Use in the Emergency Department

Kerry E. Walkera, BSc, BEd aVancouver Fraser Medical Program 2014, Faculty of Medicine, University of British Columbia

ABSTRACT Smartphones, belonging to patients and physicians, are increasingly prevalent in Emergency Departments. These phones have tremendous clinical and educational potential through the use of recording tools, clinical applications, and information search engines. When using smartphones in the Emergency Department, users must respect the privacy and confidentiality of those around them and refrain from disrupting others or spreading infection. Reviewing current policies and guidelines reveals no consensus regarding smartphone use in the Emergency Department. The Canadian Medical Protective Association offers suggestions regarding consent, documentation, and protection of information that are of substantial use to the clinician.

KEYWORDS: health attitudes, cellular phone, hospital emergency services, mobile technology, hospital policy

INTRODUCTION legal ramifications if the correct steps are not undertaken to ensure that consent is provided and information is stored in a secure manner. A hoa, that’s a huge needle! Let me take a video of that,” recent example of a detrimental effect of smartphone use occurred at a “ exclaimed a 15-year-old in a pediatric Emergency Lower Mainland Hospital, where a patient used a phone to livestream WDepartment (ED). He reached for his smartphone just a video of the emergency team responding to a cardiac arrest, despite as I was about to inject anesthetic into his hand prior to suturing a the drawn curtains.13 This situation illustrates how a violation of laceration. privacy and confidentiality can occur and would likely result in As a fourth year medical student, I have spent the past few significant emotional distress for those involved. months in various EDs across Canada. Throughout these rotations, I have become increasingly aware of the prevalence and use Patient Use of Smartphones in the Emergency Department of smartphones in the ED by both physicians and patients. The Patient use of smartphones, including camera and video functions, can aforementioned encounter prompted me to evaluate the use and be helpful in determining a diagnosis or management plan. Examples potential impact of smartphones in this setting. I have encountered include the following: one patient presenting with non-specific erythematous lesions showed a picture of lesions Issues Surrounding Smartphone Use in the Emergency that began as a target shape, which ultimately led to the diagnosis Department of erythema multiforme; a parent with limited English language As I reviewed hospital policies regarding mobile device use in their capabilities brought a video of her infant having an incidental brief EDs, I noted an abundance of websites stating “Please turn off your tonic-clonic episode in the context of a documented fever, contributing 1 cellular phone,” “Phones must be turned off while you are in the to the diagnosis of a febrile seizure; multiple patients have taken 2 3 Emergency Department,” “Do not use your cell phone in the hospital,” photographs of their medical imaging to aid in follow-up care; and in 4 and “Cell phone use is strictly prohibited in the hospital.” Clearly one instance, a patient with short-term memory difficulties used his the use of mobile devices, including cell phones and smartphones, in smartphone to record physician instructions. It has been found that some EDs across Canada has been discouraged. The rationale behind mobile device discharge instructions improve communication with these policies includes the potential for breaches of confidentiality, patients over paper instructions.14 Smartphone use in this context is 5 6 spread of infection, and interference with equipment. However, acceptable by patients without excess concern regarding privacy.15 there is ongoing debate about the significance of any interference.7 Patients talking or using their phones can interrupt the interview and Physician Use of Smartphones in the Emergency Department 8 clinical exam, especially with the prevalence of phones in the ED. Just as patient use of smartphones is becoming more apparent in the ED, In a department where confidentiality and privacy have long been so is that of physicians. I have witnessed many emergency physicians 9,10 scrutinized, smartphone use can easily result in infringement on using smartphones in a manner that has notably contributed to my 11,12 both counts and can negatively impact patient care. Documenting learning and to patient care.16 As previously mentioned, documented case findings for educational or publication purposes has potential for case findings can be used to educate medical learners as well as the greater community through publications. Other utilities include Correspondence 17 Kerry Walker, [email protected] sending medical imaging to off-site consultants for opinions, using

24 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com COMMENTARIES

18,19 medical applications for references and medication doses, and using a smartphone in a clinical setting. communicating with team members in different areas of the hospital.20 21 With increasing acceptance of use, some specialties have transitioned REFERENCES from communication via a paging system to smartphones22 as this may increase productivity.23 1. SickKids. [Internet]. Toronto: The Hospital for Sick Children (SickKids); 1999- 2014. Visiting SickKids - Emergency; 2008 [cited 2013 Oct 7]; [about 5 screens]. Available from: http://www.sickkids.ca/VisitingSickKids/emergency/ Guidelines Surrounding Smartphone Use in the Emergency 2. Welcome to BC Children’s Hospital. [Internet]. Vancouver: BC Children’s Department Hospital; 2013. Emergencies; 2005 [cited 2013 Oct 7]; [about 3 screens]. Available from: http://www.bcchildrens.ca/Services/EmergencyServices/default. In light of increased functionality of smartphones throughout hospitals htm and EDs, many hospitals have been revising their technology 3. St. Michael’s. [Internet]. Toronto: St. Michael’s Hospital; 2013. Emergency policies to allow for use within a set of guidelines,24 with some even Department - Procedures; 2013 [cited 2013 Oct 7]; [about 2 screens]. Available from: http://www.stmichaelshospital.com/programs/emergency/procedures.php 25 producing their own applications for smartphones. Discussions 4. Vancouver Costal Health. [Internet]. Vancouver: Vancouver Costal Health; about the legalities and ethicalities of these matters are ongoing,26,27 2013 Vancouver General Hospital (VGH) - Jim Pattison Pavilion - Emergency and there are limited studies looking at the subject solely in the ED. Department; 2013 [cited 2013 Oct 7]; [about 3 screens]. Available from: http:// www.vch.ca/402/7678/?site_id=471 5. Singh A, Purohit B. Mobile phones in hospital settings: a serious threat to infection control practices. Occupational Health and Safety [Internet]. 2012 Mar Smartphones are useful [cited 2013 Oct 8]; Available from: http://ohsonline.com/articles/2012/03/01/ mobile-phones-in-hospital-settings.aspx instruments for both the health 6. van Lieshout E, van der Veer S, Hensbroek R, Korevaar J, Vroom M, Schultz M. Interference by new-generation mobile phones on critical care medical care practitioner and patient equipment. Crit Care. 2007 Sep; 11(5):1-6. “ 7. Tri J, Hayes D, Smith T, Severson R. Cellular phone interference with external in the Emergency Department which cardiopulmonary monitoring devices. Mayo Clin Proc. 2001 Jan; 76(1):11-5. 8. Kwon NS, Colucci A, Gulati R, Shawn L, Kasahara Y, El Bakhar A, et al. A contribute to diagnosis, management, survey of the prevalence of cell phones capable of receiving health information productivity and medical education. among patients presenting to an Urban Emergency Department. J Emerg Med. 2013 Apr; 44(4):875-88. 9. Moskop J, Marco C, Larkin G, Geldeman J, Derse A. From Hippocrates to Various associations have produced guidelines about the use of HIPAA: privacy and confidentiality in emergency medicine - part I: conceptual, technology in health care, none of which address the possibility of moral, and legal foundations. Ann Emerg Med. 2005 Jan; 45(1):53-9. spreading infection.28 Currently, the American College of Emergency 10. Moskop J, Marco C, Larkin G, Geldeman J, Derse A. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine - part II: challenges Physicians (ACEP) maintains its policy that cell phones and other in the emergency department. Ann Emerg Med. 2005 Jan; 45(1):60-7. recording devices are a significant confidentiality risk and should be 11. Olsen J, Sabin B. Emergency department patient perceptions of privacy and regulated for the protection of patients and staff.24 The U.S. Food and confidentiality. J Emerg Med. 2003 Oct; 25(3):329-33. 12. Karro J, Dent A, Farish S. Patient perceptions of privary infrigements in an Drug Administration encourages the use of regulated mobile medical emergency department. Emerg Med Australas. 2005 Mar; 17(2):117-23. applications in health care delivery.29 The Canadian Association of 13. Lund A. Commentary [Internet]. Message to: Kerry Walker. 2013 Dec 6 [cited Emergency Physicians (CAEP) does not have a current policy in place 2013 Dec 8]. [1 paragraph]. 14. Choi S, Ahn J, Lee D, Jung Y. The effectiveness of Mobile Discharge Instruction regarding this matter. In contrast, the Canadian Medical Protective Videos (MDIVs) in communicating discharge instructions to patients with Association (CMPA) has produced multiple documents regarding lacerations or sprains. South Med J. 2009 Mar; 102(3):239-47. technology use in health care. These include articles on privacy, 15. Sikka N, Carlin KN, Pines J, Pirri M, Strauss R, Rahimi F. The use of mobile phones for acute wound care: attitudes and opinions of emergency department encryption, medico-legal risk, online communication, and the use of patients. J Health Commun. 2012; 17(Suppl 1):37-42. photography and video for education.30-34 For those affiliated with the 16. Tews M, Brennan K, Begaz T, Treat R. Medical student case presentation University of British Columbia, there are professional standards,35 performance and perception when using mobile learning technology in the emergency department. Med Educ Online. 2011 Oct; 16. which are similar to the CMPA guidelines. 17. Demaerschalk B, Vargas E, Channer D, Noble B, Kiermam T, Gleason E et al. Smartphone teleradiology application is successfully incorporated into a telestroke network environment. Stroke. 2012 Nov; 43(11):3098-101. CONCLUSION 18. Mina MJ, Winkler AM, Dente CJ. Let technology do the work: Improving prediction of massive transfusion with the aid of smartphone application. J Smartphones are useful instruments for both the health care practitioner Trauma Acute Care Surg. 2013 Oct; 75(4):669-75. and patient in the Emergency Department which contribute to 19. Demaerschalk BM, Vegunta S, Vargas BB, Wu Q, Channer DD, Hentz JG. diagnosis, management, productivity and medical education. Caution Reliability of real-time video smartphone for assessing National Institutes of Health Stroke Scale Scores in acute stroke patients. Stroke. 2012 Dec; 43(12):3271-7. must be taken to ensure that the rights to privacy and confidentiality 20. Franko O, Tirrell T. Smartphone app use among medical providers in ACGME of all parties involved are respected and the devices are not vehicles training programs. J Med Syst [Internet]. 2011 Oct; 36(5):3135-9. for infection spreading. Appropriate patient use of smartphones may 21. Koehler N, Vujovic O, McMenamin C. Healthcare professionals’ use of mobile phones and the internet in clinical practice. J Mob Technol Med. 2013 Apr: 2(1):3- require education on current policies. The policies regarding the use of 13. the phones in EDs vary between hospitals and governing bodies; thus 22. American Academy of Pediatrics [Internet]. Elk Grove Village: American for medico-legal implications, physicians should be aware of the policy Academy of Pediactrics; 2005. More pediatric hospitalists using text messaging to communicate; 2012 Oct 21 [cited 2013 Oct 8]; [about 3 screens]. Available that applies to them. If using phones for documenting information, from: http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/More- physicians should follow guidelines for obtaining consent and ensure Pediatric-Hospitalists-Using-Text-Messaging-to-Communicate.aspx?nfstatus=4 that the information is as secure as possible. The CMPA guidelines are 01&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription= ERROR%3a+No+local+token quite comprehensive, and I recommend they be reviewed by anyone (References continue on Page 33)

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 25 NEWS AND LETTERS

Medicine in the Fast Lane

Shelly Fana, BSc aPhD Candidate, Neuroscience, Faculty of Medicine, University of British Columbia

KEYWORDS: social media, blog, medicine 2.0, misinformation, forums, resource

n a sweltering July morning, Evermoreconfused, a and “expertise” from self-proclaimed homeopathic health gurus user of the popular social news and entertainment site, — hardly the best current evidence to consult for treatment. The OReddit, logged on as usual. Quickly navigating to r/keto, current running joke, “everything diagnosed online is cancer” has a subreddit devoted to the high-fat low-carb ketogenic diet, he a sinister side: those inept at handling uncertainty may be at risk typed out this post: “Doctors and Smart People Of r/Keto, a friend of developing “cyberchondria”5, where frequent health-related wants to start keto but has both Graves’ and Hashimoto’s Disease. searches of symptoms and illness increase anxiety. Is it safe for her to try this diet?” Furthermore, the “open” nature of social media allows vocal Within minutes, comments poured in. “I don’t really see individuals to disseminate and propagate misleading information, why not. I have graves,” one commenter noted, “The only thing to the point of swaying public opinion on a medical matter. “Big I could see would be the iodine in salt.” “She needs to talk to her pharma” conspiracies whittle patients’ trust in pharmaceutics, doctor,” said another, “but I found these two links that seem to with some discontinuing medication in favor of alternative suggest a lower carb diet can have positive benefits.” medicine. The anti-vaccine movement dissuades parents from Welcome to the age of diagnostics by social media, vaccinating their children with the unfounded claim of vaccine- where easily obtainable health information is reshaping the face induced autism. From June 2007 to October 2013, nearly 1300 of evidence-based medicine (EBM). As of September 2013, people succumbed to vaccine-preventable diseases6; herd WebMD, the leading health portal in the United States, boasted an immunity is increasingly threatened, as demonstrated by several average of 138 million visitors per month1; an estimated eight in recent outbreaks of measles. ten Internet users have gone online for health information within Unfortunately, eliminating all misinformation online the past year.2 Social media is drastically changing the flow of is impossible; however, a physician’s hand of guidance may medical information and attitudes, for better or worse. help. By jumping into online discourse, physicians can direct In terms of public education, Medicine 2.0 is a blessing patients to high-quality medical resources, dispel medical rumors and a curse. Health information is abundant, free and easily and discourage self-diagnosis. By building new knowledge accessible, allowing patients to educate themselves through repositories, such as a freely accessible medical Wikipedia, articles, podcasts and videos. Twitter streams of physicians are physicians could further help isolate signal from noise.7 Physician- never-ending sources of bite-sized health news and information.3 initiated “ask me anything” interviews on online forums propel “Sugar: the bitter truth”, a lecture by Dr. Robert Lustig has two-way discussions of physician-patient relationships, health garnered over 4 million views on YouTube4 and generated lively care, pharmaceuticals and public health, often with a degree of discussion on forums, illustrating the power of social media in honesty unachievable in face-to-face interactions. An exceptional increasing public awareness of health and disease. Science of example is Dr. Steven Novella who runs the blog Neurologica Eating Disorders, a popular science blog, candidly discusses and the podcast Skeptic’s Guide to the Universe. Since 2005, Dr. the neuroscience, genetics and treatment of eating disorders Novella has expertly used social media to debunk pseudoscience without shame or stigma, providing a community for patients to in medicine, including myths related to autism and genetically support one another while educating themselves. Examine.com, modified organisms. In this sense, social media is one of the best a user-curated website moderated by biomedical students, offers venues for physicians to educate the general public and build trust. comprehensive information on exercise and supplements with It is up to the physician’s discretion to abide to the same citations of Pubmed-listed literature. ethical principles in an online setting as he or she would offline.3 However, due to its user-generated nature, Medicine 2.0 It is relieving to note that even under anonymity, most physicians is abundant in non-peer-reviewed publications with untraceable adhere to the principles of EBM; that is, they do not offer diagnoses sources. As such, a patient-initiated search often yields anecdotes online based solely on a list of symptoms — those who do are quickly reprimanded. Furthermore, any advice offered in blogs Correspondence or other online media is appended with the disclaimer “opinions Shelly Fan, [email protected] here are for medical education purposes only and not intended as

26 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com NEWS AND LETTERS medical advice.” leaseID=801330&CompanyID=WBMD In its current state, Medicine 2.0 is a double-edged sword: 2. Fox S., Duggan M. Health Online 2013 [Internet]. Pew Internet & American Life Project; 2013 [updated 2013 Jan 15; cited 2013 Dec 28]. Available while it promotes access to medical information to most of the from: http://pewinternet.org/Reports/2013/Health-online.aspx population, it is also a source of rumors and conspiracies that 3. Dimov V. Social media in medicine: How to be a Twitter rockstar and help may ultimately damage public health. Nevertheless, as Dr. your patients and your practice. Cited 2013 Dec 28. In: CasesBlog [Internet]. David Shaywitz noted in his Forbes blog, “I reject the view that Blogspot.ca. 2011. Available from: http://casesblog.blogspot.ca/2011/10/ Internet and social media are somehow degrading the culture social-media-in-medicine-how-to-be.html 4. Lustig R. Sugar: the bitter truth. Cited 2013 Dec 28 [Internet]. Youtube. of medicine… instead, I see emerging modalities as offering 2009. Available from: http://www.youtube.com/watch?v=dBnniua6-oM the profession an urgently needed chance to radically update 5. Fergus TA. Cyberchondria and intolerance of uncertainty: examining when its approach, and interact with patients, data, and each other in individuals experience health anxiety in response to internet searches for important new ways.”8 As an increasing number of physicians medical information. Cyberpsychol Behav Soc Netw. 2013 Oct;16(10):735- adopt an online presence professionally, we can expect Medicine 9. 6. Anti-vaccine Body Count [Internet]. 2007. [updated 2013 Dec 14; cited 2.0 to grow and flourish as well. 2013 Dec 28]. Available from: http://www.jennymccarthybodycount.com/ Note: aggregated count sourced from cdc.gov. REFERENCES 7. Giustini G. How Web 2.0 is changing medicine. BMJ 2006 Dec 21;333:1283. 8. Shaywitz D. Four reasons doctors worry about social media #getoverit 1. WebMD Health Corp. WebMD Announces Third Quarter Financial Results . Cited 2013 Dec 28. In: Forbes [Internet]. Forbes.com; 2013. Available [Internet]. Acquire media; 2009 [updated 2013 Oct 29; cited 2013 Dec 28]. from: http://www.forbes.com/sites/davidshaywitz/2013/04/14/four-reasons- Available from: http://investor.shareholder.com/wbmd/releasedetail.cfm?Re doctors-worry-about-social-media-getoverit/

Maintaining Professionalism Online: An Interview with Dr. Kevin Pho

Kiran Dhillona aVancouver Fraser Medical Program 2016, Faculty of Medicine, University of British Columbia

KEYWORDS: Kevin Pho, online, reputation, social media, review, ratings

aintaining professionalism in online spaces can be 44% of adults online are researching their doctors on the challenging for physicians, and can present difficulties Web.2 Most physicians are a bit apprehensive about being Min maintaining separation between physicians’ personal visible online despite already having an online presence— and professional lives. The UBCMJ spoke with Dr. Kevin Pho, in most cases from physician rating sites or media stories. an expert in social media use for healthcare providers, about Doctors may not like what they see, especially if they have some practical guidelines for maintaining an online presence. poor reviews, or have a negative news story written about Kevin Pho, MD, is an internal medicine physician and co- them. author of Establishing, Managing, and Protecting Your Online It’s important for doctors to take control of how Reputation: A Social Media Guide for Physicians and Medical they appear online since that’s often the first impression Practices. He is also founder and editor of KevinMD.com. patients have of them. Why do you feel an online reputation is important for What do you think is the best way for medical practices to doctors? brand themselves on social media platforms? According to the Pew Internet and American Life Project, There are essentially two ways to establish an online reputation. The first is to ‘claim’ profiles on existing physician rating sites. All of them allow you to do so - Correspondence Kiran Dhillon, [email protected] some for a fee. There is value in that approach as it allows

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 27 NEWS AND LETTERS

you to correct inaccurate information about you and your where a doctor successfully sued a site for a negative practice. rating. Also, don’t sue patients. All that does is bring more However, there’s a downside. Many physician media attention to the criticism, which can then appear ratings sites are for-profit, and some sites force physicians on Google searches. That can make a bad online situation to agree to skewed terms of service agreements in order to even worse. correct information. Finally, ask more patients to rate you online. Dozens The second approach is to proactively create content of studies have found that the majority—up to 90% – of online. I recommend first spending about 45 minutes and physician ratings are positive. So ask all your patients to creating a LinkedIn profile, which is essentially a digital rate you online – don’t just cherry-pick the good ones. If translation of your resume. LinkedIn profiles often get you’re a proficient physician, this action makes negative ranked high on search engine results. ratings look more like outliers. Next, create a profile on Google Places for Business. Any general advice and tips for maintaining professionalism There is a bit of friction with Google Places, since you online as a medical student or physician? have to verify your practice via a postcard or a phone call. But it’s well worth it, since Google Places listings show up Hospitals and medical societies have created social prominently on Google searches. media guidelines that govern online professionalism. It Now that you have a presence online, you can either boils down to what I call the ‘elevator test.’ If you’re on stop there or explore other social media platforms. What are a social network, imagine yourself in a crowded hospital your social media goals? Do you want to educate patients, elevator. Whatever you post on a social network needs to connect with colleagues, or speak up about health policy? be appropriate if it is said aloud in that elevator. You should spend time on social media platforms to best A special mention on Facebook: About 35% of achieve those goals. The more platforms you engage in, doctors receive friend requests from patients, and 40% the bigger your online presence will be. accept them.3 I don’t think that’s wise - the personal information typically shared on Facebook isn’t necessarily What is your take on the roles and implications of physician what you want to share with patients. rating sites such as ratemyMD.com? With Facebook specifically, I agree with most If you look at every other industry, whether it’s guidelines’ suggestion to separate personal and professional books, movies, restaurants or hotels, people want to know identities. You can keep a personal Facebook profile, what others are thinking .The same goes for health care. but only ‘friend’ close friends or family members. Then The difference is that the physician rating industry is you can have a separate Facebook page which is open to fragmented and its content is of questionable reliability. the public and can be valuable in sharing reliable health Physician ratings bring a transparency that the information to those who seek it on Facebook. consumers demand, so they’re here to stay. The industry The UBCMJ would like to thank Dr. Kevin Pho for providing needs to evolve into a more central ‘clearinghouse’ of his insight on this topic. For more tips and information on ratings, perhaps married to objective quality measures. maintaining professionalism in online settings, check out We’re far from that ideal today. Kevin’s book Establishing, Managing, and Protecting Your How should physicians respond to online reviews of Online Reputation: A Social Media Guide for Physicians and themselves or their practices? Medical Practices. First, they should listen to the reviews. Often, review sites are the only way patients can offer any feedback. REFERENCES Once patients leave my exam room, I don’t know what 1. Pho K. Maintaining professionalism online [online]. Message to Kiran they thought about me, the medical assistant or nurses, Dhillon 2014 Nov 7 [cited 2014 Nov 8]. or whether there was enough parking. But all of these 2. Fox S. Health Topics: Doctors or other health professionals [Internet]. influence the patient experience and many issues that Pew Internet & American Life Project; 2011 Feb 1. Available from: http:// www.pewinternet.org/Reports/2011/HealthTopics/Part-3/Doctors-or-other- contribute to a negative rating can be easily corrected. health-professionals.aspx Second, resist the temptation to respond to negative 3. Mathews AW. Should Doctors and Patients Be Facebook Friends? [Internet]. reviews immediately. It’s rare that an online argument The Wall Street Journal; 2013 Feb 4. Available from: http://online.wsj.com/ results in anything productive and, in fact, it can violate news/articles/SB10001424127887324900204578283900262408308 patient privacy. Instead, post a standard reply asking that the patient call the clinic - take the conversation offline. If that dispute can be successfully resolved, the patient may even take his comment down, or post an addendum saying, ‘Hey, this clinic is actually listening to what I have to say.’ Third, don’t sue. There are few successful lawsuits

28 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com NEWS AND LETTERS

Telehealth: Connecting with BC Physicians Online

Pretty Vermaa aVancouver Fraser Medical Program 2016, Faculty of Medicine, University of British Columbia

KEYWORDS: medeo, telemedicine, telehealth

elemedicine is a rapidly expanding sector of healthcare emergency department visit costs and $20 million in inpatient costs. delivery being used worldwide that has now come to British Approximately 73% of telehealth clinical sessions were provided Columbians through businesses like Livecare, Telus Health, in the areas of mental health (including psychiatry, addictions, T 1 and Medeo. Medeo is one of two Vancouver-based companies and forensic mental health), internal medicine, and oncology, with that allows you to connect with a physician using your computer, the highest per capita use in Northern areas such as the Yukon, phone, or tablet.1,2 Northwest Territories, and Nunavut.5 Patients with a valid Medical Services Plan register with Medeo Corp believes their service will be particularly useful Medeo online, and are then ready to schedule an appointment with a for patients with reduced mobility due to age or chronic conditions, BC family physician. Before the appointment, patients type in their to those in rural and remote locations in Canada with limited access symptoms, medications, allergies, general medical information, and to specialist care, and in connecting rural and urban physicians.2 are encouraged to attach photos or other necessary files for review. However, as the Canadian Medical Protection Association points If their general practitioner is not registered with Medeo, they can out, it also presents new medico-legal issues around information choose from Medeo’s database of registered physicians on call. To security, privacy, and patient consent.6 Initial studies in other ensure information safety, Medeo uses “bank-grade Canadian data provinces have found patients improved in health management centers to provide a secure connection for the patient-physician behaviours, psychological well-being, and self-rated health, while interaction and for all patient data”.2 The virtual clinic is open others have noted that limitations to telemedicine provision include from 7am-10pm on weekdays and 9am-3pm on Saturdays but is risk to the patient-physician relationship and increased as opposed closed on Sundays. For senior citizens, Medeo is available through to decreased appointment time due to technological barriers and a specialized tablet designed for use by this age demographic, the loadtime.6,7 Finally, it can be difficult to assess certain clinical Claris Companion. In addition, there is a Medeo iPhone app to help parameters without being at the bedside, as was found in glaucoma users connect to the service.2 care, for instance.8 The Cochrane Library found that though people “Any interaction that requires a physical examination, Medeo self-monitoring at home or having video consultations were will not work for,” states Medeo spokesman James Basnett.3 In satisfied with the experience, there is not yet enough evidence to contrast, Livecare simulates a physical exam as patients are required speak to the effects on health outcomes or costs of the expensive to visit specialized clinics where technicians can record vital signs and necessary technology. Cochrane, in conclusion, noted that and collect other diagnostic information that allow physicians to further research is needed.9 make diagnoses.4 Medeo intends its services for visits involving In the year 2014, it looks like telemedicine is coming to prescription reviews, specialist referrals, patient education, medical British Columbians. Are you on board? questions, or chronic disease follow-up. Telehealth extends far beyond one-to-one patient care: Medeo’s services, for instance, allow colleagues to collaborate across the province to provide coordinated patient care.2 With 60 Medeo physicians registered as REFERENCES of summer of 2013, it appears telehealth companies have found a 1. LifeSciences BC. BC Industry News Business in Vancouver- BC taps into growing 3 new way to connect physicians with their patients. telehealth technology trend [Internet]. 2013 [cited 2014 Feb 1]. Available from: Telemedicine has been growing in use across Canadian http://www.lifesciencesbc.ca/newsroom/bcnews/news07231303.aspx provinces, with usage being tracked by the Canadian Telehealth 2. Medeo. Medeo [Internet]. 2013 [cited 2013 Nov 12]. Available from: https:// medeo.ca/ 5 Report. The 2013 report states that eight Canadian jurisdictions, 3. Bennet, N. The virtual walk-in clinic is now open [Internet]. Business in including British Columbia, currently use desktop and mobile Vancouver. 2013 Jun 5 [cited 2013 Nov 12]. Available from: http://www.biv.com/ video conferencing for clinical consultations with patients, and article/20130605/BIV0112/130609977/the-virtual-walk-in-clinic-is-now-open 4. Livecare. Livecare [Internet]. [cited 2014 Feb 1]. Available from: http://www. with this use, health regions saved an estimated $915,000 in livecare.ca/ 5. Canada’s Health Informatics Association. 2013 Canadian telehealth report Correspondence [Internet]. Toronto: COACH;2013 [cited 2013 Nov 5]. Available from: Pretty Verma, [email protected] (Continued on page 30)

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 29 NEWS AND LETTERS

On the Future of Open-Access

Kabir Toora, BHSc aMPH Candidate, School of Population and Public Health, Faculty of Medicine, University of British Columbia

KEYWORDS: open-access journals, PLoS, Bohannon, DOAJ, future of research and publishing

n October 2, 2012 John Bohannon submitted his research Science article. to a journal for peer review concerning a novel anti-cancer The question is, why is this important? Magazine-type Omolecule: a process with which many health researchers publications, such as the Canadian Medical Association Journal, are familiar. Within the next two months he was notified of its Annals of Internal Medicine, and the British Medical Journal, are acceptance after passing the peer-review process. Unlike most of slowly moving towards a repository model, like the one used by his peers, however, Mr. Bohannon was disappointed to receive the the open-access journal PLoS One. In fact, some have simply added news. parallel open-access versions. The shift is towards more data and The paper was, in his words, “bogus.” It was a piece of terrible more research. There is no question that open-access is the future of writing and an example of terrible science. Mr. Bohannon works the literature. The point of contention will be the quality of the work. for Science and, under the watchful eye of the magazine, created, This work will be the basis of future research and guide physician incorrectly interpreted, and strategically falsified an entire research decision-making. It is imperative that evidence-based medicine not paper as a sting operation. He submitted his article to 304 open- suffer due to diminishing research standards. access journals and even went through the trouble of putting it The onus is on the scientific community to ensure transparency through Google Translate twice so the grammar was appropriately and accountability. There must be a crackdown on predatory abysmal. Unfortunately for him (and for open-access journals), the publishing and assurance of a thorough peer-review process. The paper was accepted 157 times for publication, a “success” rate of full potential of open-access publishing has yet to be realized. Open- almost 52%.1 access publishing will maintain its momentum in the next few years; Open-access journals are a relatively new concept. The it is up to us to ensure it is on the right trajectory. Database of Open-Access Journals (DOAJ), which indexes all journals of this type, was founded in 2003. Between 2000 and 2009 REFERENCES there was more than a six-fold increase in the number of open access 2 1. Bohannon J. Who’s afraid of peer review? Nature. 2013 Oct;342(6154):60-5. journals. At the time of this publication the DOAJ consists of 9804 2. Laakso M, Welling P, Bukvova H, Nyman L, Bjork BC, Hedlund T. The 3 journals. Some journals are completely free. The bulk of them, development of open access journal publishing from 1993 to 2009. PLoS One. however, carry article-processing charges (APCs). This is how 2011;6(6):e20961. these journals remain profitable. Submission is free. However, if the 3. The Directory of Open Access Journals [Internet]. 2013 [cited 2014 Jan 11]. article is approved for publication, there is an APC which can be up Available from: http://www.doaj.org 4-6 4. Solomon DJ, Bjork B-C. A study of open access journals using article processing to $3900. There are many benefits to this model as opposed to the charges. J Am Soc Inf Sci Technol. 2012:63(8):1485-95. traditional publishing model. There are, however, unique challenges 5. Haug C. The downside of open-access publishing. N Engl J Med. 2013;368:791-3. as well. 6. Beall J. Predatory publishers are corrupting open access. Nature.2012;489:179. Indexability is the major benefit of open-access journals. This provides free access to the literature instead of requiring (Continued from page 29) https://www.coachorg.com/en/communities/resources/TeleHealth-Public-FINAL- subscriptions. Unfortunately in this model, the APCs present a web-062713-secured.pdf barrier to researchers with limited funds, especially in developing 6. Canadian Medical Protective Agency [Internet]. Ottawa: CMPA; 2013. countries. There are inherent problems to a profit-driven publishing Telemedicine - challenges and obligations;2013 [cited 2013 Dec 30]. Available from: https://oplfrpd5.cmpa-acpm.ca/en/safety/-/asset_publisher/ model, which are amplified in health research. One of the largest N6oEDMrzRbCC/content/telemedicine-challenges-and-obligations stumbling blocks is the balance between quantity and credibility. 7. Jaglal SB, Haroun VA, Salbach NM, Hawker G, Voth J, Lou W, et al. Increasing Large repositories such as the DOAJ carry a vast number of articles. access to chronic disease self management programs in rural and remote communities using telehealth. Telemed J E Health. 2013 Jun; 19(6):467-73. With no shortage of submissions the only limit to revenue is the 8. Kassam F, Yogesan K, Sogbesan E, Pasquale LR, Damji KF. Teleglaucoma: quantity of articles the editors are willing to publish. It can be argued improving access and efficiency for glaucoma care. Middle East Afr J Opthalmol. that there is a motive for lowering the bar, as exemplified in the 2013 Apr-Jun; 20(2):142–9. 9. Curell R, Urquhart C, Wainwright P, Lewis R. Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Cochrane Correspondence Database Syst Rev. 2000, Issue 2. Kabir Toor, [email protected]

30 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com NEWS AND LETTERS

Developing Digital Educational Tools for Medical Students: An Interview with Dr. Stan Bardal on the UBC Formulary App

UBCMJ Staff

KEYWORDS: formulary, apps, technology, electronic health records, pharmacology, digital medicine

r. Stan Bardal, UBC MD Undergraduate Program Prior to undertaking the development of the Formulary App, Affiliated Senior Instructor and Pharmacogenetics Dr. Bardal had already been involved in initiatives to integrate Dresearcher, described the development of a digital educational components into the UBC medical curriculum. pharmacological Formulary App for UBC medical students and Virtual Patients, a decision-tree computer program, allows his thoughts on digital medicine in an interview. students to choose pharmacological therapeutic managements for The UBC Formulary App will contain information on 150 patients’ chronic conditions. “It gives students an idea of what “Must See, Must Know” drug classes to guide student learning happens when you make bad prescribing decisions before go[ing] throughout the four-year medical curriculum. Expanding on UBC on the wards” (S. Bardal, personal communication, October 10, Undergraduate Medical Education Associate Dean Dr. DeWitt’s 2013). idea of having a checklist for students to track required drug Beyond enhancing medical education, Dr. Bardal views classes as they encounter them, Dr. Bardal has developed the App digital medicine as “tremendously useful for both health care as an educational resource that “eventually will include anything providers (HCPs) and patients.” He suggests that the development you’d want to know about a drug,” from mechanism of action to of devices for patients to monitor their health—from blood glucose to cardiovascular distress indicators—will be increasingly digitally integrated with their HCPs’ records. Digital medical Dr. Bardal has developed the devices can also empower and inform patients to more closely App as an educational resource monitor and take better care of their own health. Moreover, the “harmonization of [electronic] health records” (EHRs) into a that “eventually will include common digital platform accessible by various HCPs combined “ with the integration of PharmaNet, the provincial database for anything you’d want to know about a prescription drugs, would significantly improve future patient drug,” care (S. Bardal, personal communication, October 10, 2013). Regarding the impact of device use on HCP-patient cost and coverage (S. Bardal, personal communication, October interactions, Dr. Bardal lightheartedly advised students and 10, 2013). HCPs: “Don’t forget to look at your patient! [….] It’s not very In response to the expectation that students “will be confidence-inspiring for the patient if the diagnosis is coming wandering around on the wards looking for some kind of drug off the iPhone, so don’t forget there’s a patient in the room, too. guidance and tapping their phones,” the Formulary App will serve They’re a lot more complicated than a device, so that’s the tricky as a portable pharmacology resource for UBC medical students part!” (S. Bardal, personal communication, October 10, 2013). during their studies and clinical encounters (S. Bardal, personal communication, October 10, 2013). With a Teaching and Learning Enhancement Fund grant, Dr. Bardal has designed the App, and UBC VFMP 2016’s Matthew Toom has developed the IT aspects, including the ability to input further information and update the Formulary. The App will be released for Android devices on January 14, and for Apple devices the same date if there are no delays.

Correspondence [email protected]

UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com 31 GLOBAL HEALTH

Dispatch: Waiting at the Doorstep – Learnings from India

Saama Sabetia aVancouver Fraser Medical Program 2014, Faculty of Medicine, University of British Columbia

ABSTRACT Gender disparity is a major issue pervading many aspects of life in India, particularly education. My volunteer experience at a school in India enabled me to understand the problems caused by lack of access to education by rural women in particular, and the importance of the empowerment of women in any global health effort. Education increases the likelihood that women will earn an income, promotes healthy decision-making in the household, and ultimately contributes to better health outcomes for their families and communities.

KEYWORDS: education, empowerment, women, health, India

he gave birth to a baby girl. No worse a crime than this had her the education of females—future mothers and the primary educators thrown out of her house, waiting at the doorstep, praying for of their children. Many male family members become ambassadors Sher husband’s mercy. Down the street sits a widow, wailing, for the Institute and play key roles in supporting graduates upon their languishing over the confiscation of her land by her in-laws. It is return. dusk. Around the corner, a girl sits outside her school staring down Trainees reside at the Institute for the six-month duration at her feet, dejected, struggling with the reality that she will have to of the curriculum. This allows them to be free from the barriers to forfeit her education as her younger brother is now starting school education that they face in their home communities such as early and household duties need tending to. arranged marriages, household duties, and the responsibilities of Gender disparity is a frequently encountered issue in India. It caring for children and elders. Additional barriers include poor access is deeply ingrained into the way of life of many communities around the country. The purpose of this article is not to dwell on the problem Against all odds, many of these but rather to describe a first-hand experience of strides being taken to counteract the effects of this pervasive issue and to contribute to the perseverant women have indeed health and sustainable development of rural communities through the found a voice and have become empowerment of women. “ effective contributors to their Deep in the heart of India, within Madhya Pradesh—one of the poorest states in the country—lies the Barli Development communities. Institute for Rural Women, a non-governmental organization (NGO) to schools due to lengthy commutes, lack of adequate infrastructure where I volunteered for one month. For almost three decades, the such as roads and transportation, and the risks of such travel for Institute has provided free education and vocational training to unaccompanied women. The curriculum includes a literacy program, several thousand tribal women. These are indigenous rural villagers classes on personality development, workshops on health and whose livelihood comes mainly from agriculture, forestry, and hygiene, vocational training in agriculture and solar cooking, and raising livestock. Most applicants, aged fifteen to thirty years, come classes on tailoring and embroidery. to know of the program by word of mouth when graduates return My role was to develop and deliver workshops on to their villages with newfound skills and capabilities. Priority is immunizations, anemia, and the prevention of water-borne illnesses. given to the most economically disadvantaged such as orphans, the With the assistance of three other international volunteers and an divorced, widows, and dropouts. Parental consent must be obtained interpreter, we provided live demonstrations to supplement the for admission whenever possible and married women are encouraged material. I will never forget the light in the eyes of a student who to gain support from their husbands. Parents and husbands also attend shyly thanked me after my last session and expressed that it has the school for a three-day course on gender equality, collaborative been her lifelong dream to become a doctor and teach others about decision-making, healthy conflict resolution, and the importance of health. It was difficult to absorb these words. A bright young woman stood before me with the exact same goals and desire to serve her Correspondence community as I remember having at her age. I was never any more Saama Sabeti, [email protected]

32 UBCMJ | FEBRUARY 2014 5(2) | www.ubcmj.com GLOBAL HEALTH deserving of attaining this dream than she was, yet I had the mere education and put their new skills to work with the support of their luck of being born into starkly different social circumstances that families. The transformation is stunning. The majority of students facilitated my path. Most of these women will not go on to post- arrive illiterate, unsure of themselves, and uncertain about interacting secondary education, and not just due to the high cost of tuition. Many with people from different villages and castes, let alone foreign of them will still face some of the same barriers and resistance from volunteers. After six months, they graduate with a practical fund their communities upon their return as their newfound assertiveness of knowledge and skills, the capacity to generate income, and most can appear to challenge male authority, despite the Institute’s efforts importantly, the confidence to exercise leadership skills and play a to educate families. role in healthy personal, family, and community decision-making. However, many will return to complete their secondary Many of them will return to their communities to become “Area Coordinators”, promoters of literacy and health, and educators regarding prenatal care and vaccinations, significantly increasing childhood immunization rates in their home communities upon their return.1 This tangible example of how knowledge can empower one to grow and to advocate for positive change in the community has reinforced for me the importance of effective patient education that can guide healthy decision-making in their everyday lives. Against all odds, many of these perseverant women have indeed found a voice and have become effective contributors to their communities. The beauty of the situation here is that the issue at hand is not one that requires years of research seeking out some panacea, or miracle drug. The vital “resource” for health development in India, and numerous other countries with gender disparities, consists of living, breathing entities eager to be invested in, to be given a voice. They are already there, waiting at the doorstep.

ACKNOWLEDGEMENTS The author would like to acknowledge The Barli Development Institute for Rural Women, Indore, Madhya Pradesh, India.

REFERENCES Demonstration of proper washing methods, Barli Development Institute for 1. McGilligan, JP. Barli Development Institute for Rural Women. Oxford: George Rural Women, Indore, India Ronald, 2012.

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