Tag Archives: medicine

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Andrew and Akshay - Hacking Health

photo credit: Victor Panlilio

Dr. Akshay Shetty (centre right) is an Internal Medicine Resident at the University of Calgary Dr. Won Hyung A. Ryu (centre left) is a Neurosurgery Resident at the University of Calgary
Dr Aleem Bharwani is Director for the Medical Teaching Unit, Internist, and assistant prof at the University of Calgary

For budding young physicians, it’s almost a rite of passage: you finish your residency, accrue research along the way and then enter the clinical workforce. But a small wrinkle has crept into this tried and tested formula. More than ever, physicians in training are disrupting their medical education to foster innovation and improve the field of health care through non-conventional means, but often at the expense of their own traditional careers. ...continue reading

Diane_photoDiane Kelsall is Deputy Editor, clinical, at CMAJ, and Editor of CMAJ Open

 

As clinicians, we are taught about patient-centred care, where the needs and desires of the patient are foremost. For those of us who work as medical teachers, we are told to focus on the goals of our students in a learner-centred curriculum. We work in multi-disciplinary teams in hospitals and clinics, where it seems, at the very least, paternalistic for the leader to be a physician.

Some of our traditional roles have been taken over by other health professionals—and we are often told that they provide the same or better service at a lower cost. Administrators and other health professionals run the hospitals and clinics we work in. Few doctors are in leadership at the government level, even for decision-making related to health care.

We are frequently blamed for rising health costs, and some of us are not welcome at the bargaining table where our own remuneration is discussed. People may view us as greedy or, increasingly, as lazy and not willing to sacrifice for the greater good.

Somehow over the years, things changed from the physician as “god” to the physician as No Good.

Why did this change happen? Could it have been a reaction to our casual assumption of money, control and entitlement? Or maybe our failure to play well with others? Did we destroy the mystique around our profession when we abandoned our white coats in favour of casual clothes? Perhaps it was when women entered the profession in large numbers? Or was it simply that health costs began to spiral out of control and a scapegoat was needed?

Few of us would wish to go back to the times when a patient may have been kept ignorant of a cancer diagnosis for “his good”, a nurse had to step back to allow a doctor to go ahead through a door, or throwing surgical instruments across the operating room was condoned.

But surely there must be room for us—a physician-centred place—in the health care system.

There is such a place. That place is Medicine. And we are the experts, the only experts, in this millennia-old discipline. From its early days in ancient Egypt to the heady promise of gene and molecular therapy, the medical profession has advanced—and society has benefited.

Because of the life’s work of physicians over the centuries, we have a greater understanding of the human body and mind; what can go wrong and how to fix it. We now know that that cancer or diabetes or an infection does not have to be a death sentence. Indeed, the blind may see and the lame walk; some may even be raised from the dead.

To be able to do this work, we study for years (in some specialties for more than a decade)—and then we keep on studying to maintain our skills in the discipline where we are the experts, the only experts. There is no one else.

Because when patients are sick - really sick - they need a doctor. Yes, the doctor needs to be part of a health care team that works together. And yes, the doctor needs to respect the contributions of others and recognize the importance of involving the patient in his or her own health care. But a health care team without a doctor is missing expertise, expertise that can literally mean the difference between life and death, between illness and health.

But even when patients are not at death’s door, we bring our expertise to bear in addressing their current health concerns—major and minor—and work with them, in conjunction with our colleagues, towards a healthier future. We can listen, we can examine, we can diagnose, we can treat—and perhaps even heal.

Sure, we have made mistakes (big ones, on occasion) but, for the most part, we have tried to make the lives of our many, many patients better. People live better for longer, and are healthier.

And as such, we have earned the right to be key players in our health care system. At all levels.

We need to be included at decision-making tables—to participate as essential contributors. From the individual clinic to the hospital to government. Locally, provincially and nationally.

If health is the issue, we have the right to be there. To speak, to share our expertise—and to have our contribution respected. We need to be heard, along with the voices of our patients, our fellow health professionals and others.

To improve the health care of all Canadians, we, as doctors, need to be in our rightful place.

Patrick_ODonnellDr Patrick O’Donnell is a Clinical Fellow in Social Inclusion at the Partnership for Health Equity, a pilot project of the the University of Limerick’s Graduate Entry Medical School in Ireland

It was a one of those endless days in the medical library in my third year of studies that I had an epiphany. I had become pretty disillusioned with my life as a medical student and I was starting to doubt my reasons for choosing this path. I remember leafing through a fairly dull journal when I came across a series of reports on student electives to far-flung impoverished parts of the world. My attention was immediately seized and I quickly set about finding out how I could become part of the wave of idealistic students who go abroad every summer to help people less fortunate than themselves. To be able to marry my passion for travel with an interesting medical experience seemed like an incredible opportunity.

This was the start of a journey that led me to India, the Solomon Islands, Haiti and Nepal to take part in IHEs (international health electives) over the next four summers. They were all very different experiences, but I returned with the same positive feeling; “I have helped in a meaningful way”. These were experiences I could not have gotten at home, I felt. These were making me a better person and hopefully a better doctor in the future. The feelings they created in me and the reactions of those I told about my experiences on my return made me feel like I was definitely making good use of my knowledge and skills.

Looking back, I doubt I made a difference at all, as a recent CMAJ editor’s blog suggested. I was ill prepared and very naive. Language was a barrier to being any way useful in all four of the countries I visited. Often a member of staff (usually a qualified nurse or doctor) was assigned to translate for me as I chatted to patient in the clinics. This ‘baby-sitting’ was a waste of skilled professional time in services that were often overstretched to begin with. I didn’t know very much about the common conditions in these far-flung parts of the world, and often the little I did know related to advanced tests and expensive treatments unavailable in the countries I visited. I brought with me some old textbooks, antibiotics and some surgical supplies to donate to clinics. I had done a little general research on each country I visited, but still managed to encounter civil unrest in both the Solomon Islands and Haiti. I had no plan B, no formal emergency contacts and my medical school did not know anything about my exploits.

Don’t get me wrong, I had the time of my life, and the experiences I had and the people I met have moulded me as a person and a doctor.

That medical student worldwide are attracted to IHEs electives is not surprising. A recent study in Ireland on the attitudes of university students to global development reported that 83% of those surveyed felt it was important to do something to improve the world in which we live and 81% felt that traveling abroad to volunteer is the most effective action to take.

It is not surprising then that bright, enthusiastic medical students act on these impulses. I know I certainly felt as a medical student I had much more to offer on a developing country elective than my colleagues studying arts or business. I also know, however, that as a medical student I was less inclined to examine my reasons for travelling, my activities while away and the effects of my trip with a critical eye. I had never been to a homeless shelter or an addiction service in my own country, yet I was delighted to fly half way around the world to meet similarly marginalised patients in distant places.

I now have the benefit of age, experience and a higher qualification in global health and yet I am still conflicted on the issue. Do IHEs serve a purpose? What do students actually gain from them? Do they cause harm? Are they safe? Who is ultimately responsible for the students and their welfare while on IHE? These are some of the many difficult questions generated by the phenomena that are IHEs.

One area that is beginning to be looked at is the ‘host’ experience of these IHEs and their effects on health services in the developing countries visited. The studies that have so far been published do show despite all the expected problems with IHEs; such as cultural incompetence and language difficulties, there are benefits (Bozinoff et al. 2014, Kraeker and Chandler 2013). Most of the positive gains reported relate to improved partnerships between developed and developing country academic institutions and that concept of reciprocity that is often mentioned, but very hard to achieve in this context.

There are now a huge variety of resources for students to encourage practical preparation and that provide thought provoking scenarios that focus on the inevitable dilemmas faced on IHE. Many medical schools now have modules on global health and cultural competencies. Post-exposure prophylaxis kits for HIV exposure are much more widely available. Students are a lot better informed on world news and issues in foreign parts. Communication with home and emergency contacts are easier. All of these factors should make for better informed, safer and more knowledgeable IHE students.

Whether IHEs are truly successful as a life changing learning experience, however, rests with the attitude of the students themselves.

In addition to those mentioned in the previous blog, some international resources include:

The Ethics of International Engagement and Service-Learning (EIESL) project from UBC, Canada
Elective guidelines from the UCL Centre for International Health and Development
• Ethical scenarios on the Responsible Electives website
General advice and actions for volunteers

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Émilie Lacharité is Digital Content Editor at CMAJ (she is also a trained medical illustrator)

Perhaps you’re familiar with the profession, but many are not. Medical illustrators are educated in human anatomy and life sciences and have the skills and technical training to communicate scientific concepts in a visual way. They create animations, illustrations, 3D medical models, virtual simulations, medical games, interactive educational modules, and more. There is one accredited program in Canada, Biomedical Communications, at the University of Toronto (my alma mater).

Last week, I attended the Association of Medical Illustrator's 69th annual conference in Rochester, MN, home of the world-famous Mayo Clinic. Rochester is a tiny town but it boasts an impressive variety of leaders and experts in diverse fields. Our group of 400+ attendees got to hear from some of them, as well as other awe-inspiring speakers from around the globe.

There were so many great talks and I wish I could address them all but, alas, here’s a quick flyby:

Dr. Christopher Moir, pediatric surgeon at Mayo Clinic, gave a poignant and emotional talk about the successful separation of conjoined twins Abbigail and Isabelle Carlsen, which took place back in 2006. He explained that multiple imaging techniques ultimately still fell short in detailing the intricacies of the girls’ anatomical abnormalities (such as a common duodenum, and a messy network of bile ducts) in a way that was clear enough for the surgical team to feel confident with performing the operation. Medical illustrator Michael King was asked to step in and worked closely with pediatric radiologist Dr. Jane Matsumoto to provide a series of extremely accurate illustrations of the twins’ anatomy (see one sample below). These provided a crucial surgical planning tool for the team of 70+ people who separated the twins. The poster-sized print-outs were then used as reference on the day of the surgery. “Medical illustrators saved the lives of two girls”, said Dr. Moir.

Mayo Clinic conjoined twins' illustration

Again on the theme of medical planning tools, Mayo Clinic pediatric neurosurgeon, Dr. Nicholas Wetjen, explained a new approach used for surgical treatment of craniosynostosis (the abnormal fusion of one or more bones of the skull in infancy). A medical 3D animator (whose name I unfortunately did not catch), uses CT scan information from a child’s malformed skull, recreates it in 3D software, and essentially provides a virtual platform in which surgeons can break down the top portion of the skull into pieces - think puzzle pieces - and reconfigure the skull into a more natural shape. They then map out the new skull pieces with lettered codes on the child's skull and perform the operation. Their research on the technique has found it yields a better shape result with a single, shorter operation. Win, win. More details here.

Lee Aase, Director of Social Media for Mayo Clinic, shared his insights on the importance of being out there (here?) in the world of #socialmedia. He said the networking that happens on social platforms is what drove Mayo to the top, despite it being in a small city. And with its relatively minimal cost, the return on investment for being involved in social networking has the potential to be quite large.

In their talks, MK Czerwiec (aka Comic Nurse) and Johns Hopkins medical illustrator and instructor Lydia Gregg, shared with us the power of comics in medicine. Although they have been in the field for a long time, graphic novels and comics are now being recognized as an important and effective modality for knowledge transmission, especially for taboo or touchy subjects (e.g. bipolar disorder), the younger crowd (e.g. asthma education, retinoblastoma), or even for global topics such as a graphic novel on pandemics, published by the CDC. Comic Nurse MK Czerwiec, who is in fact a nurse, now does workshops with medical students to unleash their inner graphic art talent. For more on graphics in medicine, check out graphicmedicine.org.

Avid Twitter user Jen Christiansen, Art Director of Information Graphics at Scientific American, shared her insights on the difficulties of visualizing complex scientific information for both an educated lay audience and an expert audience within the same graphic. Not an easy task but she always finds beautiful solutions. She also challenged us to rethink how we depict the brain, an organ that may be better understood as a functional map rather than an anatomical one. See the Human Brain Project for more information.

There is a fascinating community of science+art lovers on the Internet. Some of the insiders helped us explore this world. There was Glendon Mellow, social media guru, talented artist, and blogger for the Scientific American blog Symbiartic, a lovely fellow with an under-appreciated sense of humour. There was also Julia Buntaine, founder and editor-in-chief of online magazine SciArt in America, who seems to know everything about science-based art. Follow #sciart, #scicomm on Twitter and check out scienceblogs.com for more.

A handful of fine artists shared with us how they have discovered a love for anatomy and medicine and garnered attention along the way. There was Lisa Nilsson, of the Tissue Series fame, who recreates anatomical cross sections entirely out of rolled-up narrow strips of paper (a technique called quilling). Artist Danny Quirk uses liquid latex and markers to dissect with a paintbrush directly on human subjects, giving us a dramatic peek inside (see below).

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Then, if all that wasn't enough, our minds were blown by a couple of speakers who have worked with the likes of National Geographic, BBC, Discovery Channel and, oh ya, George Lucas. The first was Viktor Deak, paleo-artist, who, as he put it best, "likes to make heads". In his small NY City home studio, he creates anatomically correct forensic reconstructions of fossil hominids, both in sculpture and as paintings or murals. This video pretty much sums up the greatness that is Viktor Deak.

The second mind-blowing presenter was Andrew Cawrse, who gave a few talks and workshops. Andrew started out as a visual effects guru working with the greats in California and while doing so he became obsessed with sculpting human anatomy. He eventually left Hollywood (!) in order to dedicate himself to teaching and his anatomical modelling company. His Sculpting for Surgeons class teaches cosmetic and plastic surgeons to pay attention to the aesthetics and proportions of anatomy as well as its function. "Be addicted to the human form," he said, "in order to recreate its beauty."

gustavo_gussoGustavo Gusso, MD, PhD, is Assistant Professor of General Practice at University of São Paulo, and the Former President of the Brazilian Society of Family and Community Medicine

 

“Soccer is the most important thing of unimportant things” is a common expression in Brazil. It is attributed to Arrigo Sachi, an Italian coach and to Nelson Rodrigues, a Brazilian writer. Brazil will not be the same country after July 8th 2014 when the national soccer team was almost destroyed by the Germans. During the preparation for World Cup the most frequently discussed aspect was the “the legacy”. But this was not what we expected. Many patients I saw this week were very upset- just as if they had suffered a major personal trauma. Brazil has never really been at World War. The feeling is not of anger against the Germans. Not at all. Everybody is in shock, or what “specialists” might call “post-traumatic stress disorder -population based”. All my consultations this week began by asking patients about the game. The most common words used were “shame” and “pathetic”. Many of them told me they dreamed that it was not true.

The first responses on social networks were the jokes even before the game finished. It is one of the ways Brazilians deal with trauma. But now everybody in trying to understand what happened. Planning beat improvisation is the most common theory. But isn’t soccer an art? It is as important to train the basics as in ballet or in painting but surely talent is the most important part? It seems that this day is over.

Soccer is now more a business than an art - just as medicine. Medicine chose the evidence based path. Improvisation is linked more to communication, especially of risks and benefits, in supporting a shared decision. One might say that “medicine was art for centuries, then become a science for decades, and now it is business”.   Maybe that is unfair and there is still a vestige of art and science, at least in some doctors. In São Paulo it is not easy to find them. The main goal for good students at the University of São Paulo, with some exceptions, is to open a nice private office as soon as possible and charge R$ 1000,00 reais (US$ 400,00) for each consultation that may last from 30 to 90 minutes - like the famous professors.

People feel one reason for this tragedy is the organization of soccer and its shady relations with sponsors and television. There is too much corruption in the Brazilian Soccer Federation (the last president left the country and lives in Miami). It seems that in Brazil the soccer stakeholders use methods that are decades surpassed. The coach, Felipão is totally outdated. The German team planned well. Their current coach, Joachim Löw, was the assistant of the former coach and was not sacked even though he lost two World Cups (2006 as assistant and 2010 as coach). For this World Cup they built a quiet hotel close to an isolated and beautiful beach and now intend to sell it.

In conclusion, the lesson for now is that improvisation is not, or should not be, the most important player in modern world. It is true for medicine, for soccer, and for any “value chain” that attracts billions of dollars. For medicine as in soccer, the big question is to know the right place for art and improvisation. It still remains behind the medical consultation even in the current business model.

And, now we need all our professional skill and evidence based medicine to deal with the national post-traumatic stress disorder. Or not.