#Social Medicine – A review of social media and the CanMEDS roles

Dr. Anju Anand, Assistant Professor of Medicine, University of Toronto

January 20, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

(Photo credit wordpress.com)

Ready, set, tweet!

What a tweet it was!

Ok, enough bad puns. It speaks to my initial discomfort with the world of social media. If anyone could draw me out of my fear and into a new realm of embracing social media in medical education and patient care, it was Dr. Anju Anand (@thelungdr). We were thrilled to have Dr. Anand speak about social media in the context of the CanMEDS roles. From Medical Expert, to the intrinsic roles of Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional, it touches on every aspect. The take home messages? Social media use in medical education is essential, we must use it professionally, and Twitter is our greatest forum. Here's how (in more than 140 characters):

1) Promote patient care: With the wealth of un-vetted misinformation on the internet, we must engage to make accurate information available. We can communicate directly with individuals or patient groups about a medical topics and provide opportunities to share online resources with them in the office, and at home. Dr. Anand's personal success in the Cystic Fibrosis community is a website which provides accessible, accurate and timely information, educational tools, the latest research, and inspirational stories to the patient community.

2) Promote greater public health: The most industrious use in  I have seen is the dissemination of patient education materials in the form of whiteboard talks. Toronto's own family doctor Dr. Mike Evans is well-known for his YouTube whiteboard talks on behavioural modification for smoking cessation, primary prevention, cancer care, and many more. He calls this "Medical school for the public". He takes stories and engages patients with an active whiteboard illustrating the talk in a multimedia fashion, reinforcing the learning points. Another similar example is University of Toronto's "Healthy Debate" website, which brings easy-to-understand information about the health care system to the public, helping people make informed decisions about their own health. Lastly, behind the scenes, but easy to access, infectious diseases like Influenza and Zika are tracked globally in real time, helping to catch patterns that foresee epidemics, and allowing dissemination of information to local authorities.

3) Promote learning: Faculty and trainees are accessing different tools for reviewing the latest literature and debating evidence. Online journal clubs, like the University of Toronto Respirology and Sleep accredited journal club live tweets their meetings, involving authors who can provide background details to allow critical appraisal of their studies. Blogs like this one disseminate talks to the broader community who share common interests. My favourite - listening to The Rounds Table podcasts hosted by UofT's Healthy Debate, where recent research papers are presented with a critical appraisal and provided a context.

4) Create a global community: Through networking, Dr. Anand shared examples of connections she has made through Twitter with other Cystic Fibrosis physicians and researchers who otherwise would not have met. Barrier-free, open access, instant connection to anyone sharing your clinical, education, or research interest. There is a whole community committed to free and open access medical education on Twitter (#FAOMed). The opportunities are boundless, and imagine the perspectives you have to gain. You can start the connection at a conference. Most now have live tweeting of sessions allowing people to connect.

As the audience engaged in a debate about the potential drawbacks of widespread social media use by trainees, Dr. Anand reminded us of the core principles of responsible use:

1) Maintain professionalism: The rules of engagement are "Don't lie, don't pry, don't cheat, can't delete, don't steal, don't reveal." And avoid all patient-identifying data. Be aware of your regulatory body policies at the local, provincial/state, national level. They share common principles, but some will have unique rules.

2) Own your "digital shadow": Given it's ubiquity, you are bound to find your name somewhere on the internet if you search, and it may not be as you intended. Don't let others speak for you. Set your own stage and be clear in how you want yourself represented to protect your professional identity.

My colleagues took to Twitter to continue a thought-provoking dialogue over the weekend after this talk. While Twitter can be used to disseminate and translate knowledge among health care professionals and patients, how do we ensure the integrity of information, how does this affect research Impact Factors, and what does this mean for print medical journals? One thing is for sure, sharp critical appraisal skills are needed now more than ever.

I admit, I had begun my conversion before this talk, but Dr. Anand solidified my commitment to using social media in medical education. You can follow us on twitter @CEEPAoM. But I remain weary of the potential for addiction and it's effect on mental health. First, if you love information, social media is never-ending. Set your limits. There is an app for purchase that will allow you to access your account for limited hours, similar in concept to parental controls (remember that bag of Doritos - impossible to have just one). Second, there are malicious trolls out there. If you engage in controversial topics, for example tobacco control, be prepared for nasty followers. Block and report them for your own mental health.

Resources:

DocMikeEvans Whiteboard talks @docmikeevans

Healthy Debate hosted by The Rounds Table @roundstable

Evidence-based medicine in the era of social media: Scholarly engagement through participation and online interaction

Twitter's Role in Scientific Publication and Communication INFOGRAPHIC

Melvin, L and Chan, T. Using Twitter in clinical Education and Practice

Ontario Medical Association Social Media Primer

College of Physicians and Surgeons of Ontario Position on Social Media - Appropriate Use By Physicians

Budd L, Fiddler L, Anand, A. Gaining Competence Through Social Media. CMAJ. 2016;DOI:10.1503/cmaj.160255

Bio – Anju Anand, MD

 Dr. Anju Anand is a Staff Respirologist and Sleep Medicine specialist at St. Michaels Hospital in Toronto and Assistant Professor at the University of Toronto. She is also the Education Site Director for Respirology at St. Michaels Hospital. She completed her medical and Respirology training at the University of Toronto and two subsequent fellowships in cystic fibrosis and sleep medicine. Her academic interests revolve around using technology to enhance education and she has been involved in moderating and creating numerous websites for patient education (eg torontoadultcf.com), blogs, e-modules for trainees and for the inception of @respandsleepjc (#rsjc)- an online Royal College Accredited Twitter-based journal club. Her upcoming research involves using Twitter as a tool for educating patients with Cystic Fibrosis online. 

The Infectious Nature of Classical Music

Dr. Dan Petrescu, Division of General Internal Medicine, University Health Network

January 10, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

The Scene of the Death of Mimi, from Puccini’s opera “La Bohème”
(Photo credit AllPosters.com)

This week, Dr. Dan Petrescu dimmed the stage lights to take us on a beautiful journey through opera and infectious diseases. Two seemingly divergent topics paired naturally as he expertly guided us through Four Acts – a metaphor for the theme. The beautiful aesthetic of watching and listening to operatic clips in a darkened hospital auditorium in the middle of our busy clinical work day and high-stakes meetings slowed us down, and allowed us pause to listen, breathe, alert our calming senses, and quiet our activating fight-or-flight reflexes. A stark departure from the typical noon medicine rounds on infectious diseases.

To begin, Dr. Petrescu introduced us to the influence of magical thinking in understanding illness. We saw how delirium and febrile hallucinations preceding the death of a child were believed, at the time, to be an assault afflicted by a supernatural being, depicted in Schubert's Opus 1, a musical rendition of Johann Wolfgang von Goethe's poem Erlkönig.

From delirium, we moved on to syphilis and tuberculosis. Mental illness has long been portrayed in music and art, but who would have thought to look for infectious diseases? Learning about the historical context of opera story-telling to understand the societal perceptions of illness in various eras gave us deeper understanding into how communities have stigmatized disease throughout history, such as TB and syphilis. Violetta in Verdi's La Traviata was portrayed glamorously as a thin, pale, diaphoretic, debutante consumed by tuberculosis and sensuous desire, at centre stage surrounded by admirers, on the verge of nuptials. In contrast, we felt the squalor and isolation of Mimi in Puccini’s La Bohème amidst the poverty of her bohemian, disenfranchised and forgotten artists, taking her last breath. The critical event that shaped the latter portrayal was the scientific influence of bacteriology, and the discovery of Mycobacterium tuberculosis as the infectious agent causing consumption, and the airborne means of transmission leading to a shift from admiration, toward isolation and stigma. On a simplistic level, we can use this to illustrate where infection control and isolation practices in public health were born. But on a deeper level, can we use this study in contrast to better understand our community of patients and see illness through their eyes, and see what it means to them? Where the stigma comes from and why they may not align with our proposed treatments?

Reminiscent of how close reading of literary passages is taught in narrative medicine to heighten the listening, observation, and critical thinking skills of healthcare professionals, the study of opera can be seen as another form of close reading. Ranging from discussing music and composer history, to uncovering illness perceptions and biases, to the concrete analysis of key transitions, instrumental voice and themes to indicate mood and meaning, the opportunities to make opera relevant to medicine are immense. And just as one need not be an English major to incorporate narrative medicine into practice, musical training is not a requirement for one's medical practice to benefit from the study of music and opera. It is so commonplace that many medical humanities courses and programmes have emerged throughout North America, combining the study of arts and humanities with medicine. Our very own Drs. Linda and Michael Hutcheon, from the University of Toronto Departments of English and Medicine were early leaders, lecturing internationally on opera and medicine.  It is no wonder that many of us in the audience were classically trained musicians, and why the majority of medical school applications that I read have Royal Conservatory of Music Certification alongside the competitive GPA and volunteer hours.

Infectious disease as portrayed in the arts may now be more obvious to me, but what about other illnesses, like cancer? Verdi's portrayal of tuberculosis resembles that of Susan Sontag's description in Illness as Metaphor, whereas in her historical review, cancer was abhorred, despised, and people were considered to be stricken by dread and shunned. Is this stigma what persists in some communities today, the ones from which emerge the protests: "Don't tell mom she has cancer?" As though receiving the diagnosis would lead to her death, independent from the disease process itself.

The audience was engaged again this week, stimulated, and the inevitable question was indeed answered in closing the talk: Why does paying attention to opera matter in medicine? Opera is a classic, overly indulgent and melodramatic characterization of all that is the best and the worst of human nature and relationships. It is a rich backdrop for delving deeply into people's motivations and choices, a study into human psychology. In health care, one of the professions most reliant on understanding human nature, this deeper understanding of opera can engender empathy, and strengthen our doctor-patient relationships. Dr. Petrescu left us with some of his wisdom. Humans have long sought to understand life and death, illness and misery, and have found meaning and expression through the arts and music. Opera is a rich genre that heightens our senses to the knowledge of the time. The doctor-patient human relationship suffers if we don't step back and listen.

Resources:

Sontag, S. Illness as Metaphor. Vintage Books, 1979

Hutcheon, L and Hutcheon, M. Opera: Desire, Disease, Death. U of Nebraska Press, 1996

A complete medical education includes the arts and humanities

Opera and Medicine Bodily Charm: Living Opera

Physicians in opera - reflection of medical history and public perception

Bio – Dan Petrescu, MD

Dan Petrescu is a graduate of the Internal Medicine and Infectious Diseases training programmes at the University of Toronto. He currently practices both Internal Medicine and Infectious Diseases at Markham Stouffville Hospital and is a Clinical Assistant in the Division of General Internal Medicine at Toronto Western Hospital, attending on the CTU. He takes a special interest in the interaction between the humanities and medicine and has given presentations across the GTA on topics ranging from interesting clinical cases, to classical music as it relates to Infectious Diseases, to the history of vaccines and anti-vaccination movements.

Art of Medicine, Unplugged

Dr. Robert Fowler, Sunnybrook Health Sciences Centre
October 25, 2016

Posted by Nadine Abdullah, MD, MEd, FRCPC

Unplugged medicine: meaning intimate, bare, without extra accompaniments, where the art of the physical exam supersedes limited technological resources. In his compelling manner, Dr. Fowler walked us through his journey, from First World critical care where the art of medicine often falls off to the reliance on machines and numbers, down unexpected paths.

He first experienced working in an outbreak during SARS in Toronto, and at the time made connections with colleagues who were experiencing similar outbreaks elsewhere. A network of clinical researchers was born that would set the stage for international collaboration as globalization of disease grew. Not long after, he received calls from colleagues in other countries to help study their outbreaks; H1N1 in Mexico, MERS-CoV in Saudi Arabia. He established himself as a leader in researching and managing outbreaks, and was sought out for his knowledge. This led to a sabbatical at the World Health Organization (WHO) in Geneva where his task was to review lessons learned from these past outbreaks, and to establish international standard protocols for future outbreaks. He employed the principles of clinical epidemiology to define acute respiratory illness outbreak terminology to improve the reporting of disease, and enhance global collaboration.

During his term, word came of a potential Ebola outbreak in West Africa, and he naturally traveled there with his colleague to see firsthand what was emerging. They found themselves immersed in providing clinical care and managing the outbreak. He described the makeshift setup of a hospital, transfer of sick health care staff, patients and rudimentary supplies from one hospital to this new centralized "facility" to provide ongoing care to the population. In the course of observing the evolution of this illness in individual patients, Dr. Fowler and his colleague noted the impact of dehydration on mortality, and began to institute aggressive IV hydration protocols, with point of care blood testing, oxygenation, and management of target organ damage. Despite limited resources, they began to collect formal data, and through careful documentation and analysis, demonstrated that they could see a 50% reduction in mortality with basic supportive medical care.  The unprecedented high mortality previously documented in Ebola was not simply the result of an inevitably fatal virulent disease, but due in large part to the consequent treatable dehydration, resultant metabolic derangement, shock and organ failure.

Early publication of their data in the New England Journal of Medicine led to widespread understanding of the disease and its management, and put Ebola on the radar of governments and agencies allowing them to recognize need and mobilize resources, eventually halting the outbreak.

Dr. Fowler and his colleague's work has set a new standard for live epidemiological research while simultaneously providing emergency medical care in a devastating outbreak. The individual patient and global population impact is measurable; the timeliness incomparable to the vast clinical research we pore over in medical journals. Their work will serve global health immensely when the next outbreak hits.

This talk was not merely a physician's biography and resume of academic achievements. It was a captivating narrative about the blending of science and humanistic medicine. It illustrated the impact of applying the science of clinical epidemiology to global health. When time was up, and groups lingered to talk more, the discussion turned to the practical personal impact and sacrifice, an intimate experience of leading care amidst a frightening health crisis, and returning to the comfort of a First World health care system. As with our last lecture on MAID by Dr. Gary Rodin, this talk exemplified how the Medical Expert role is inseparable from the intrinsic CanMEDS Roles, this time with a particular emphasis on the Collaborator, Leader and Scholar Roles. But it also had several take-home messages for the learners and junior faculty seeking mentorship and role models for career planning. Here are some lessons I took away:

1. Take advantage of the clinical experiences around you; they will prepare you to be a leader in future unexpected roles.
2. Take a sabbatical that will give you an opportunity to be part of a global collaboration. You might find yourself being the right person, in the right place, at the right time.
3. Get out of your comfort zone. It gives you new perspective from where you work.
4. Remember the importance of giving back. We have developed critical skills and knowledge that can impact the health of a broader, more vulnerable population than that we serve daily.

I wondered; do we spend enough time explicitly teaching and modelling these lessons as educators? Were the senior attending physicians present who had formerly taught and supervised Dr. Fowler thinking with pride that they might have contributed in small part to inspiring this passion? Were the students and residents inspired to think how their future careers would unfold?

A month later, the buzz lingers in the air. Inspired by this talk, what stories about their careers will they in turn be talking about in twenty years?

Bio – Rob Fowler, MD

Dr. Fowler is a General Internist and Critical Care Physician at Sunnybrook Health Sciences Centre, Adjunct Scientist at the Institute for Clinical and Evaluative Sciences (ICES), Associate Director of the Clinical Epidemiology and Health Care Research graduate program of the Institute of Health Policy, Management and Evaluation at the University of Toronto, and a senior Scientist at Sunnybrook Research Institute. He was a WHO consultant during the 2014 Ebola outbreak in West Africa. He has an active research program focused on clinical outcomes of critically ill patients, holds a number of peer-reviewed grants, and has published widely.  More recently, he was appointed to the Order of Ontario.

Resources

NEJM paper: Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea

Fighting Ebola from day one

WHO Ebola Diaries

Medical Assistance in Dying (MAID): Conversations about the Unspeakable

Dr. Gary Rodin, Princess Margaret Cancer Centre, University Health Network

September 29, 2016

Posted by Nadine Abdullah, MD, MEd, FRCPC

The last phrase in Dr. Richardson’s original description of this series, “complex clinical environments”, prompted a timely topic for our inaugural lecture this year: Medical Assistance in Dying (MAID). Our learners asked how to deal with a request from a patient for MAID. How do we approach this in our own practice, and how do we teach about it in medical education?

Our goal was to create a safe space, recognizing and respecting we each hold our own thoughts on MAID that we bring to the discussion. Given the reality of the current legislation enacted June 17, 2016 rendering MAID legal in Canada, provided certain conditions are met, the focus of our discussion was to move beyond moral and ethical debate, to engage and prepare for the challenges in conversations we will have in our duty to our patients. How do we do this?

Dr. Rodin led us briefly through an understanding of Canadian MAID legislation and the UHN protocol for context. He used a case based approach drawing on patients from his practice to highlight the types of conversations that we should be prepared to have.  He noted the analogy to patients requesting futile treatment, where similar motivations are at the root, being a desire for control and a sense of agency over the process of illness and death. Immediate attention should be made to ensuring we address present symptoms and consider alternatives to MAID, including pain control, discussing psychosocial aspects of despair, and ensuring access to comprehensive palliative/supportive care. If a desire remains, we need to ensure competence, lack of coercion, and persistence of a sustained value system.

Early experience with MAID in Canada has shown that a significant number of requests do not proceed after thoughtful conversations between patients and their physicians about their motivations, and supporting their complex needs. Dr. Rodin left us with a framework for a therapeutic approach to speaking with patients. We need not fear our patients asking for assistance dying, but embrace the conversations we can lead that remind us of our role in humanistic medicine. As Flegel and Patrick remind us, if we become more comfortable discussing death with our patients as part of our ordinary medical practice, conversations with patients about MAID will become less frightening CMAJ, 18(10).

As a medical educator, I experienced this talk as an informal interactive session where students, residents and attending physicians were engaged, eagerly asking difficult questions. In the discussion prompted by those questions, I saw a contextualization of our CanMEDS Roles. To have these conversations, we need a solid foundation as a Medical Expert, while simultaneously enacting our intrinsic roles of Communicator, Collaborator, Health advocate, Leader, and Professional. But did the students and residents see this? Do we need to explicitly label the CanMEDS Roles in this teaching format in order for learners to see and incorporate them? Would that enhance and reinforce the learning, or interfere with the organic nature of this format? Did the involvement of attendings in the audience impact the outcome in a shared learning environment? We are interested in your thoughts, as we look to answer these questions over the year.

Bio - Gary Rodin MD

Gary Rodin is the University of Toronto/University Health Network Chair in Psychosocial Oncology and Palliative Care and Head of the Department of Supportive Care at Princess Margaret Cancer Centre in Toronto, Canada. Dr. Rodin is also the Director of the Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC) and a Professor of Psychiatry at the University of Toronto.  He leads a clinical and research program on the psychosocial dimensions of advanced and terminal disease and on the development and evaluation of novel interventions to improve the quality of life and the quality of dying and death in this population.   He has published widely in these areas and is recognized internationally for his efforts to improve the rigor of research and the effectiveness and availability of psychosocial and palliative interventions. He is a key leader in the development of MAID guidelines for UHN.

Resources:

Canadian physicians are encouraged to consult with their provincial regulatory college and Canadian Medical Protective Agency (CMPA) in cases of discomfort addressing MAID, maintaining the right of conscientious objection, and if proceeding with MAID referral.

CPSO policy 2016

CMPA policy 2016

CanMEDS Framework

Flegel K and Patrick K. Discussing death with the living. Canadian Medical Association Journal 188(10) · May 2016

Welcome to the Art of Medicine, Toronto Blog

Posted by Nadine Abdullah, MD, MEd, FRCPC

The "Art of Medicine” lecture series at the Toronto Western Hospital, University Health Network and University of Toronto was the inception of Dr. Lisa Richardson in 2012. The original aim was to foster and support the “creativity, compassion, empathy, imagination, innovation, lateral and critical thinking of health care providers in complex clinical environments.”  These noon rounds were a core component of the Internal Medicine CTU curriculum attended by medical students, residents, Department of Medicine faculty members, and allied health care professionals, and were situated alongside other didactic and interactive rounds on common medical topics such as heart failure and pneumonia. With this lecture series, Dr. Richardson led a cultural shift in our medical education and practice at Toronto Western Hospital. This fall, she moved her practice to the Toronto General Hospital site. I was honoured when she asked me to take over leading the lecture series.

As the new Lead for the Art of Medicine thematic program at the HoPingKong Centre for Excellence in Education and Practice (CEEP), I will continue the "Art of Medicine" lecture series with the vision to advance the breadth and depth of a holistic medical education experience, with the goal of improving patient care. The rounds will continue to create a space for exploration and engagement, placing an emphasis on themes not traditionally taught in the mainstream noon hour rounds curriculum, aiming to provoke a deeper thinking of our practice, to incorporate a better understanding of care at the bedside, and in the broader context.

The first year theme for 2016-2017 will explore inseparable physician identities: how we employ the Intrinsic CanMEDS Roles through creativity and social engagement to achieve fulfilment in our professional lives, self-actualization for our personal well-being and resilience in our practice, while providing exceptional patient care.  Keynote speakers will be invited to share with us their productive professional endeavours outside of their day-to-day patient care practice, and how their activities have shaped their careers and patient interactions. As physician scientists, authors, journalists, artists, social advocates, academic collaborators in the 3^rd world, global health leaders, activists, and social media enthusiasts, these highly engaging speakers will explore how they came to find their passion, how it has enhanced their compassion and drive for better patient care, and stimulate the audience to find their own passion to bring to the bedside and beyond.

I would like to thank Dr. Rodrigo Cavalcanti, Director of CEEP, and Dr. Herbert Ho Ping Kong for the opportunity to lead this program.  This blog will chronicle the talks we host, and my thoughts on how they fit into our educational programming and practice. Consent from speakers will be obtained. The views voiced are my own, and do not necessarily reflect those of the institutions with which I am affiliated. The blog is in the public domain; please contribute in a respectful way, and let us know what you think.

Members of our Toronto academic and hospital institutions are welcome to join us at our rounds. To be added to the mail list, please contact our administrative assistant at sarah.meilach@uhn.ca.