QMR 6.3 Future of Medicine

8/13/2019 QMR 6.3 Future of Medicine

1/36 1 Volume 6, Issue 3 | September 201

QMRQUEENS MEDICAL REVIEW

Volume 6 IssSeptember 2


2/36


3/36

CONTENTSRECENT EVENTS

4 Letter rom the Editors EDITORSINCHIEF5 Health Human Resources Planning and HOLLIS ROTH CFMS Lobby Day

7 Why WebMD and Related Sites are Good or Patients MARK BROUSSENKO9 Dr. Google is Bad or Patient Care ALLISON R OSEN

10 Annual Physical SARAHTASSIR BENCHARIF11 Senior Friendly Design and the Hospitals o the Future AMANDA LEPP13 Te Cutting Edge: Innovations in Robotic Surgery ALYSSA S. LOUI S15 Cancer Genetics BRANDEN DESCH AMBAULT17 Te Future In Your Hands: Recent Advances in TETYANA ROGALSKA

Prenatal Screening20 FAQs: A Medical Students Guide to Social Media EVE PURDY

22 Insidermedicine with Dr. Sanjay Sharma JENNI FER SIU ANDCODY LI24 Social Media with Dr. Anne Ellis HOLLIS ROTH

26 Health Care in the rue North: Not So Strong HEATHER JOHNSON

and Not So Free?

28 Healthcare Is Not a Driver o Economic Growth YAN XU30 alking Heads SARAHTASSIR BENCHARIF

31 IntraDermal Column BRANDON WORLEY

33 Marching Orders or Sad Days ANONYMOUS33 Directions BRANDON WORLEY

34 Te (Medical) French Revolution TETYANA ROGALSKA

POINT/COUNTERPOINT

FEATURES

INTERVIEW

BOOK REVIEW

OPINION

INTRADERMAL COLUMN

CREATIVE SUBMISSIONS

FFQM CONTEST WINNER

The Queens Medical R eview gratefully acknowl edges

the financial support of Queens Alma Mater Society

Cover art provided by Stefania Spano


4/36

Letter From the EditorsDear Readers,

Te uture, finally, has arrived. Not the uture o hovercars and moon resorts we are stilwaiting or those. No, this is the uture o robotic surgery (Alyssa Louis, 2016), cures orcancer (Branden Deschambault, 2016), and live-weeting rom the classroom (Eve Purdy2015). In this issue, we explore the long-anticipated, the unoreseen and the inevitable, allwithin the context o medical education and practice.

Regardless o whether you are interested in economics (Yan Xu, 2015), prenatal screening(etyana Rogalska, 2016) or the view rom the street (Sarah-assir Benchari, 2016) theuture has you covered. Inside this issue, you will have the opportunity to arm yoursel tohandle the debate over online diagnostic resources (Broussenko vs Rosen, Point-Coun-terpoint, 2016), dealing with Insidermedicine (Jenn Siu, 2016), or what it is like to simplystroll through a hospital o the uture (see Amanda Lepp, 2015). I your uture holds someree time or reading, check out Chronic Condition, reviewed by Heather Johnson (2015)or Hollis Roths (2016) recap o the CFMS lobby day! All this and more is inside you never

know what the uture holds.

Beore we set you loose, we would like to extend our sincere gratitude to our antastic teamo writers and contributors, the editors who worked tirelessly to prooread their work, andour incredible aculty advisor, Dr. Duffin, who makes the impossible seem routine. Butmost o all, we would like to thank you, our readers. Without your interest and enthusiasmthere really would be no uture.

Tank you, and we hope that you enjoy this issue!

Live long and prosper,

Mark Broussenko Allison Rosen

QMR20122013 TEAM:

EDITORSINCHIEF

Jennifer Kwan

William Reginold

CHAIRPERSON

Mark Broussenko

MANAGING EDITOR

Allison Rosen

TREASURER

Alexander Gregor

IRSTYEAR REPRESENTATIVE

Riaz Karmali

LAYOUT

Janette Speare

WEBSITE

Clarissa Sugeng

FACULTY ADVISORDr. Jacalyn Duffin

20132014 TEAM:

EDITORSINCHIEF

Mark Broussenko

Allison Rosen

CHAIRPERSON

Jennifer Siu

MANAGING EDITORS

Tetyana Rogalska

Steven Tong

Genevieve Rochon-Terry

LAYOUT

Louisa Ho

FACULTY ADVISOR

Dr. Jacalyn Duffin



QMR RECENT EVENTS

Health human resources planning was a key ocus at theCanadian Federation o Medical Students (CFMS) an-nual Lobby Day in Ottawa in early February. Queens Med-icine sent a small but strong contingent o students led byWilliam Reginold (CFMS Political Advocacy CommitteeRepresentative), Branden Deschambault (Aesculapian So-ciety VP Junior External), and Ontario Medical StudentsAssociation Political Advocacy Committee members Chris-

tine Le and Hollis Roth.

Lobby Day officially began with the National Political Ad-vocacy Committee Meeting on Saturday, February 2. CFMScommittee members rom each medical school presentedon ongoing advocacy projects ranging rom student reten-tion policies to local surveillance o determinants o healthby geospatial inormation system mapping. Other studentdelegates arrived in Ottawa on Sunday February 3 and spentthe afernoon and evening immersed in an intensive train-ing day. Students were ortunate to receive a keynote addressrom Dr. Joshua epper (VP Education o Sunnybrook Hos-pital, ormer CFMS President, and ormer Assistant Depu-ty Health Minister or Ontario). Student delegates also re-ceived briefings outlining politics on Parliament Hill and adetailed discussion o the issues the CFMS had decided toaddress.

Lobby Day has traditionally ocussed on one or two issues,reerred to as asks, to achieve maximum impact. Tis yearthe first ask dealt with improving ederal government in-centives or residents and physicians who practice medicinein remote and rural areas across Canada. Te second ask

requested the ederal government take a leading role in es-tablishing a pan-Canadian study on health human resourcesplanning.

On Monday February 4, medical student delegates, led byCFMS President Robin Clouston (Memorial University, 13)and CFMS Vice-President Advocacy Tomas McLaughlin(University o oronto, 13), met with Members o Parlia-ment and Senators rom across Canada. Between meetings,students reconvened at an established headquarters to de-

brie and ollow up with MPs or Senators who had request-ed urther inormation. Students also had the opportunity

to tour Parliament, observe Question Period, and networkwith colleagues rom different medical schools.

Health human resources planning proved to be the star othe day, with many MPs flummoxed to learn that Canadahas no system or tracking physician demand. Currentlyonly physician supply is tracked by the Canadian Instituteor Health Inormation and no inormation is available topredict what specialties will be in demand in different areaso the country as the population changes. Te CFMS be-lieves that this prevents graduating medical students rommaking ully inormed decisions about their utures when

selecting residency programs and stressed that without sucha centralized system in place, the growing and alarmingtrend o unemployment amongst highly qualified physi-cians will continue [1-3].

Students also requested an improvement to a loan or-giveness program or new amily physicians practicingin remote and rural communities that was announced in2011[4] and amended to include medical residents in 2012Te CFMS has heard rom medical students that the higher

HOLLIS ROTH, CLASS OF 2016

Health Human Resources Planning

and CFMS Lobby Day

Hollis Roth (Queens), Darrin Wiebe (UBC Island Medical Program), andJimmy Yan (Western) meet with Elizabeth May (Green Party MP Saanich-Gul Islands).


6/36Queens Medical Review | qmr.qmed.ca 6

QMRRECENT EVENTS

interest charged on Canada Student Loans upon gradua-tion compared to that on private bank lines o credit meansthat many students will have paid off their Canada StudentLoans using their lines o credit beore they become eligibleor loan orgiveness, which they believe limits the impact othis program. Te CFMS proposed that repayment on theinterest and principal o the ederal portion o Canada Stu-dent Loans be deerred until the completion o residencytraining or all residents, regardless o their area o special-ization. Tis change would enable residents and new physi-cians to take advantage o the governments loan orgivenessprogram i they practice in remote or rural areas and wouldnot restrict this program solely to amily physicians.

Tese two ideas were generally well-received. InterestedMPs and Senators were encouraged to send letters o sup-port to the Health Minister, the Honorable Leona Aglukkaq(regarding human health resources planning) and to theMinister o Human Resources and Skills Development, theHonorable Diane Finley (regarding changes to the CanadaStudent Loans Program). Several MPs requested more in-ormation in preparation or raising these issues in Ques-tion Period at the House o Commons. A significant media

presence resulted in two articles on Lobby Day appearingin Te Hill imes [5-6]. Many MPs and Senators tweetedabout their meetings under the hashtag #cmslobby, andTomas McLaughlin spoke about health human resourcesplanning on the CBCs Te Current [7].

Overall, the consensus was that this years Lobby Day wassuccessul. Health human resources planning was the mostwell-received, while requesting changes to repayment othe ederal portion o Canada Student Loans proved to bemore complicated than anticipated, as many MPs broughtup Return o Service agreements, which the CFMS does notsupport. Te importance o health human resources plan-ning to graduating medical students, combined with the actthat all Canadians, regardless o their geographical locationshould have access to the health care services they requirewill ensure that health human resources stays in the ederal

spotlight or years to come.

References

1. Royal College o Canada. Royal College Speaks Out about Un-employed Specialist Doctors in Canada, 2012. Print.2. Amy Dempsey. Health Care Checkup: Why cant Newly Grad-uated Specialist Doctors in Canada Find Jobs? Te Star, secNews: GA: 2012. Print.3. Dr. Brian Goldman. Will Operate or Food? Te UnemployedDoc Paradox. CBC, 2012. Audio.Canadas Economic Action Plan. Government o Canada An-nounces Student Loan Forgiveness or Family Doctors and Nursesin Rural Communities. Ed. Federal Government o Canada, 2012Print.4. Plecash, Chris. Med students call or ederal action on healthhuman resources management. Te Hill imes Policy Briefingsec. Health: 22. 2013. Print.5. Fry, Hedy. A sustainable supply and needs-based HHR strate-gy is not just a numbers game. Te Hill imes Policy Briefing, secHealth: 28. 2013. Print.6. Canadian Broadcasting Corporation. Patients without Doctorand Doctors without Jobs. Te Current, 2013. Audio.7. Canadian Federation o Medical Students. Te Right Physiciansin the Right Places: A Plan to Improve Access to Health HumanResources in Canada, 2013. Print.

Summary of CFMS Lobby Day 2013 Asks:

Ask #18:

Te CFMS calls upon the Government o Canada to deer repayment o the principal and interest accrued on the ederalportion o medical graduates Canada Student Loans until the completion o their residency training, so that physiciansmay take ull advantage o existing government incentive programs or rural practice.Ask #28:

Te CFMS calls on the ederal government, in conjunction with provincial and medical organizations, to create a Pan-Ca-nadian study on Health Human Resources, including needs-based projections o physician supply and demand.

Branden Deschambault (Queens), Christine Le (Queens), and StephanieKwolek (McMaster) meet with Wayne Marsten (NDP MP Hamilton East-Stoney Creek).



QMR POI N T /COUN T ERPOI N T

Point: Why WebMD and Related

Sites are Good for PatientsMARK BROUSSENKO, CLASS OF 2016

Apatient coming to terms with anovel diagnosis is entering a mar-ket where he or she aces a mountaino diagnoses, terms, and barriers. Any

sort o catch up mechanism is going tobe a bare bones affair; it isnt reason-able to expect that decades o medicalscience can be distilled into a para-graph long blurb. But, or a patientwho has been just recently diagnosed,even a cursory summary can be betterthan nothing.

Te common argument is that siteslike Dr. Google and WebMD do moreto righten and conuse patients thanthey help. Very ofen, physicians willdismiss these sites as offering com-pletely implausible differentials, orcompletely incongruous suggestions(i.e. either a ractured emur or lung

cancer). But is this really the case?Perhaps early version o these sitesmay have been a little rough aroundthe edges, but the year is 2013 andsurely weve learned to Google influ-enza without also contracting a caseo incurable breast cancer. I wanted tocheck i our ears about patient-orient-ed online resources are as well-ound-ed as the we would like to believe.

As a test, I picked a condition that isdifficult to diagnose symptomatically(mild hypothyroidism) but one witha large list o possible findings. I thenpicked something else almost com-pletely unrelated (colorectal cancer)and tried to come up with a list osymptoms that might give that differ-ential on WebMD. Sure enough, it waspossible to come up with a presenta-tion where those two were the mostlikely candidates afer about an houro trying. Even the most hypochon-driac patients would be hard pressedto come up with enough symptomsto produce a very clearly wrong di-erential. In general, the things thatcame up were very consistent withwhat medical students learn as possi-ble alternatives; it even gave me somethings that I hadnt heard about, but,

on urther research, ended up beingcorrect. In this case, WebMD came upwith a better differential than an ad-mittedly green medical student.

What about something easier; could turn my headache into a brain tumorOne o the first things that you learn inmedical school is how difficult it is to

narrow down a single diagnosis basedon just history and physical symptom afer all, thats why we come up withdifferentials, not diagnoses. Could trick WebMD into telling me that had brain cancer? Te answer, in short

was no. No matter how many things said Yes to, the most serious thing got was a warning to consult a physician immediately; I had answered yeto a question that indicated that I wapotentially in need o urgent medicacare (or reerence, the question waare you currently bleeding rom youreyes?). I suspect that, on the balancethat would constitute a air reason toconsult a medical proessional withsome sense o urgency.

Tis hedging is, perhaps, the mospoignant criticism o WebMD; rather than definitively suggesting outlandish diagnoses, it tells you to goelsewhere ar too ofen. Almost halo the stems lead to some variant osee a doctor. Certainly, some o these

Patients in healthcare suffer rom what economists call an inormation gap. Essentially, the gap between the inormation avail-able or understandable to a provider and a patient is nearly insurmountable physicians train or years, i not decades, and haveto continue learning about their fields or the duration o their practice in order to stay current.

sites like Dr. Google and

WebMD do more to frighten

and confuse patients thanthey help...

Very often, physicians will

dismiss these sites as offering

completely implausible

differentials...

WebMD came up with a

better differential than an

admittedly green medical

student...

...we come up with

differentials, not diagnoses...

...it tells you to go elsewherefar too often...



QMRCATEGORYPOINT/COUNTERPOINT

are triggered by very obvious warningsigns (such as chest pain with radiationor MIs, severe, sudden migraines withaphasia, and so orth) but many othersseem a bit more subjective. Given theissue o emergency room overcrowdingand wait times, it may not be particu-larly prudent to urge every concernedcitizen to run to their nearest hospitaland wait or hours, especially i all theycomplain about is soreness in their legafer going or a run (compartmentsyndrome this is not).

Tat said, there are certainly very manyadvantages to having searchable, inter-active resources available or patients.

Te diagnoses suggested by WebMDcover the common presentations o themost common diseases there arentvery many things that come up that areparticularly rare which fits well withthe primary care ideology o commonthings are common. Other similar sites,

such as Dr. Google and MedLine Plus,also have searchable glossaries o com-mon medical terms (useul or every-one) as well as guides to walk patientsthrough their symptoms and checklistsor things to prepare ahead o time ormedical appointments. While they ar-ent perect, these sites offer patients abetter sense o agency and give some

level o preparation or navigating thecomplexity o the healthcare system,two benefits that easily outweigh therare suspicion o Shy-Drager or whathave you (not that, I bet).

While they arent perfect,

these sites offer patients a better

sense of agency and give some

level of preparation for

navigating the complexity ofthe healthcare system...



QMR POINT/COUNTERPOINT

Counterpoint:

Dr. Google is Bad for Patient CareALLISON ROSEN, C LASS OF 2016

Authority Masked

Tis situation is one o many reasons why the ability o pa-tients to access unlimited inormation on the internet canhave highly negative consequences. On the internet, allinormation can be published, regardless o validity. Ques-tionable claims can seem valid under the guise o a flashywebsite containing pictures o attractive doctors and stirringpatient testimonials. Alarmist newspaper headlines shoutclaims that may have long been disproved, but which en-dure online. Te anonymizing and equalizing power o theinternet can sometimes make it difficult or even the mosterudite investigator to spot a valid source o inormation.

The Snowball Effect

One o the important benefits o the internet is the way itbrings patients together. Tose suffering rom rare diseasescan find others in the same situation online, which can bea huge source o emotional support. Physician-vetted sitescan provide clear, accurate inormation to patients, as wellas links to a myriad o support groups. However, the samereason this tool is so positive can also lead patients downdangerous paths.

A group o patients suffering rom skin conditions that haveremained undiagnosed by physicians have ound solace inonline communities and orums, where many claim to haveMorgellons disease. Tis is an unrecognized condition, yetwhile most doctors view it as a delusional parasitosis, it isnot inconceivable to imagine that patients with undiag-nosed symptoms may eagerly latch on to the diagnosis andthe large, supportive communities that exist online, perpet-uating the belie that doctors are hiding this disease rompublic recognition.

Empowered, but not Engaged

Te internet, notes physician Jeff Benabio, contains a wealtho inormation, but a dearth o knowledge. More and morephysicians are no longer expected to internalize the wealtho medical inormation in its entirety. Rather, physicianshave received years o training that equip them to assesstreatment modalities and evidence. When primary evidenceis placed in the hands o the consumer, the inormation caneasily overwhelm. Placing trust and authority in the physi-cian by virtue o the specialized training he or she has re-ceived removes the burden placed on the patient to engagewith knowledge outside his or her skill set. Just as we trust

car repair people to fix our cars, patients, too, are well ad-vised to consider the advice o their physicians.

A core competency we learn as uture physicians is HealthAdvocate. We encourage patients to take control over theirown health and to partake in decisions that affect them. DrGoogle and the inrastructure the internet provides or ac-cess to resources certainly empowers the patient to advocate

on his or her own behal. But the tools or effective, inormedadvocacy are not and indeed cannot be provided by theinternet alone. I a patient is directed by his physician tospecific online resources, they are more likely to be helpuland accurate than websites the patient may find through in-dependent browsing. While paternalism is a ading conceptin medicine, it is important not to lose the recognition o theimportant skill and knowledge set the physician brings tothe table. Importantly, this perspective is, in the end, betteror the patients health.

Imagine you are a new parent returning home afer an appointment with your amily doctor. You have been told that you aredue or a booster vaccine, but you want to make sure you do what is best or your child, so you try to find out more on your ownYou turn to Google, and on the first page o results, hal o the ten websites make the alarming claim that not only do vaccinesnot work, but they are dangerous, and your doctor is pressured by drug companies to encourage you to take this dangerous drugHow do you deal with this inormation?

...tools for effective, informed advocacy

are not and indeed cannot

be provided by the internet alone



QMRFEATURE

Annual PhysicalSARAHTASSIR BENCHARIF, CLASS OF 2016

Steve Frances upcoming 50th birthday signalled a long-standing need: a visit to his amily doctor or a completephysical exam.

It was time to screen or prostate cancer.

France, now 53, got the works: every system was examined.His thorough amily doctor even checked his knee reflexes.

Instead o any prostate anomaly, the blood drawn during the40-minute physical exam revealed an underactive thyroid.

Te annual physical examination France received is on-hold, afer a cash-strapped Ontario government reached areorms agreement, effective January 2013, with the prov-inces doctors. Te agreement includes a savings o $100million over two years rom physician-influenced services,like annual physical exams. Until March 2014, healthy pa-tients between the ages o 18 and 64 will receive a period-ic health visit, billable at $50, instead o the annual healthexam, priced at $72.20. It is a shorter exam tailored to thepatients health, slated to replace the head-to-toe physical.

Tis change is driven by evidence as well as dollars, says Dr.Chris Simpson, President-Elect Nominee or the CanadianMedical Association and Chie o Cardiology at QueensUniversity.

Te annual physical exam doesnt reduce rates o cardiacdisease and cancer, says Dr. Simpson. Its a low-yield examin every single patient.

Chance findingslike Frances underactive thyroidduring an annual physical exam are rare, he says. Tat alarmwas sounded over 30 years ago in the first report by the Ca-

nadian ask Force on Preventive Health, known then as theCanadian ask Force on the Periodic Health Examination,which was established to examine the periodic health exam.

Whereas the value o immunization in health protectionhas been established or many conditions, the value o theroutine check-up in preventing disease is uncertain, wrotethe authors o the 1979 report published in the CanadianMedical Association Journal. We recommend that the an-nual check-up, as practised almost ritualistically or several

decades in North America, be abandoned.

Te response amongst amily doctors to the OMAs changeis mixed, says Dr. Simpson. Some amily doctors have saidthey will continue to do the ull physical exam and incur anyassociated financial loss, he said.

For other amily doctors, these official changes are a reflec-tion o what they have already been doing or years.

Annual physical means a whole pile o different things,says Dr. Walter Emrich (Meds 76), a amily doctor who hasbeen in private practice or over 30 years. He says his phys-ical exams have always been patient-ocused, akin to the pe-riodic health exam, and that each physician develops theirown approach.

Ive done thousands o physicals in my lie. I think I oundone thyroid cancer by doing a thyroid examination, saysDr. Emrich. Examining the thyroid hasnt been somethingthats given me a lot o return, so I remember that (case)quite distinctly.

Tat patient was grateul or the exam, says Dr. Emrich.

For France, an underactive thyroid means he takes a thy-roid hormone pill every day, which he says has significantlyimproved his energy levels. Despite this finding rom a ullexam, he approves o the targeted approachthat amilydoctors can do preventative medicine hinges on the wrongul assumption that every patient has a amily doctor to seehe says, listing liestyle changes as being more important.

Tough this reorm is based on current available evidenceDr. Simpson stressed that its important or the medicalcommunity to remain vigilant about measures imposeddue to fiscal priorities. He adds that its important to con-tinue assessing the effectiveness o the periodic health examduring its stint to determine the uture orm o annual visits

Tis is an area where it will be better, yes, he says, o thetargeted visits. Tis doesnt mean that every time the gov-ernment wants to make a change we just accept it.

That patient was grateful for the exam...



QMR FEATURE

Senior Friendly Design and

the Hospitals of the FutureAMANDA LEPP, CLASS OF 2015

Abuilding reflects the cultural values o its times. A hun-dred years ago, hospitals were built as grand structuresdesigned to convey the ideals o charity and hygiene, and toprovide a home or scientific medicine. Te hospitals o to-day are similarly challenged to create and renovate physical

environments to meet a number o requirements, reflectingkey issues o the present day. Examples o these include in-ection control, efficiency and accessible health care. Te lasto these requirements, accessibility, has been pushed to theoreront by the ever increasing segment o the populationwho are rail and elderly. Statistics Canada estimates that,by 2050, twenty-five percent o the population will be abovethe age o 65 [1]. Going by present values, approximately athird to hal o this population will experience some orm odisability [2]. Hospitals o the uture will need to be able toaccommodate the physical and cognitive needs o this pop-ulation.

A change in the way hospital buildings look and unctionis already being set in motion. Te Senior Friendly Hospi-tal Care report, published by the province o Ontario, notesthat many older structures were constructed at a time whenbuilding codes placed little emphasis on universal access[3]. Te report makes recommendations or hospitals inthe province to help promote the saety, independence andunctional well-being o rail patients. In particular, it sug-gests that hospitals make use o existing senior-riendly de-sign resources when planning their physical environments,and that they conduct regular audits by personnel trainedin this area.

St. Michaels Hospital in oronto is one hospital that has tak-en these recommendations to heart and has started trans-orming its space to become more senior riendly. Over thepast year, the hospital, affectionately known as St. Mikes,

has carried out senior riendly physical environment audits

in over 80 areas across the hospital and identified opportunities to make the building more accessible. Waiting roomsclinic space, hallways, reception, common space, and bothpatient and public washrooms were all scrutinized. RoberFox, Vice President o Planning at St. Mikes, reports thatmany areas where improvement can be made were identi-fied in the audit. We have been looking at all o our publicspaces and clinical areas, and identiying a list o opportunities that we can work on over time as a priority. Many othe changes that were recommended in the audit are alreadybeing put into place. We have worked with our acilitymanagement team to begin to refinish floors in patient area

in a matte, non-glare finish. Tis change helps seniors withvisual impairments, as glare on flooring can be distractingand lead to alls. We have provided senior ocused input toa recent project that designed new signage and wayfindingcues in o one our hospital wings. A recent renovation in theCIBC Breast Centre used a number o the design principlesto enhance the waiting room or seniors.

Te audit o the physical space has enhanced more generainitiatives to address the health care needs o the rail elderly. Mr. Fox is enthusiastic about the positive change that ibeing stimulated by the evolving physical space. We havebeen actively engaged in this work this past year, and arefinding that these standards provide excellent ideas abouhow to enhance the environment or seniors, beyond ac-cessibility considerations. Conducting audits has helpedraise awareness o all o our teams too. Looking at the physical environment through the lens o senior riendly care

We shape our buildings; thereafer they shape us. Winston Churchill

Many of the changes that were recommended in

the audit are already being put into place.

...accessibility has been pushed to the forefront by

the ever increasing segment of the population who

are frail and elderly...

Waiting rooms, clinic space, hallways, recep-

tion, common space, and both patient and public

washrooms were all scrutinized.



QMRFEATURE

has been beneficial in stimulating the staff at St. Mikes torecognize the particular vulnerabilities o rail patients inthe hospital.

Mr. Fox anticipates that adaptations that are being madethroughout the hospital will be o use to other individualswho use the space. Many o the changes will make a di-erence or, and enhance the comort and experience o, allpatients and visitors to the hospital. Similarly, the improve-ments will assist our staff, physicians and volunteers to con-duct their duties and or those with disabilities themselves.

It is easy to see that many o the changes that have beenrecommended as a result o applying senior riendly designprinciples will benefit users o the hospital who are not parto this population as well. Some o the changes that haveuniversal applicability include the addition o built-in visualclues to highlight exit doors and handrails, signage that isuncluttered, logical and contains simple language, and reg-ularly-spaced seating areas.

Te initiatives underway today to make changes to the phys-ical environment o Ontarios hospitals may, in the end, helpto make hospitals o the uture a saer and more comortable

place or all.

References

1. Canadians in Context Aging Populations. Human Resources and Skills Development Canada. http://www4.hrsdc.gcca/[email protected]?iid=33 (accessed March 19, 2013).

2. Canadians in Context People with Disabilities. Human Re-sources and Skills Development Canada. http://www4.hrsdc.gcca/[email protected]?iid=40 (accessed March 19, 2013).3. Senior Friendly Hospital Care across Ontario: Summary Repor

and Recommendations.

...adaptations that are being madethroughout the hospital will be of use

to other individuals who use the space...



QMR FEATURE

The Cutting Edge:

Innovations in Robotic SurgeryALYSSA S. LOUI S, CLASS OF 2016Fellow Sci-Fi enthusiasts - or really anyone who hasseen an episode o Te Jetsons, Futurama, or Dr. Who- would agree that there is an undeniable relationship be-tween robots and the uture. However, robots are no longera ar-etched idea or fiction, and are currently infiltratingoperating suites in a revolutionary way. It is estimated thatthere are more than 2,500 robots operating in 42 countriesworldwide [1]. Tese robots, unlike the sentient humanoids

o pop-culture, are actually robot-assistive devices and mustbe ully controlled by an operator. Te aspiring surgeonsamong us need not worry about job prospects.

Te most advanced generation o surgical robots, the Da-Vinci Surgical System, can be ound in major academic cen-tres in cities around the globe. Tis includes about a dozenhere in Canada and over a thousand more in the US, wherethe technology was rapidly adopted afer FDA approval in2000 [1]. Te most common procedure perormed with theDaVinci is radical prostatectomy, but it has been cleared toperorm a wide variety o urological, general laparoscopic,

gynecologic, transoral otolaryngeal, thoracoscopic and car-diovascular surgeries [1].

Compared to traditional laparoscopic instruments, whichoffer only 4 degrees o reedom, each o the three manip-ulator arms o the DaVinci has 7 degrees o reedom, withlarger range o motion than offered by human hands (Figure1) [2]. Te ourth arm o the DaVinci houses a high definition camera with two lenses to offer 3D vision with up to12x magnification o the surgical field. Te arms are con-trolled by the surgeon, who remains seated comortably inront o a binocular display at a nearby console with handcontrolled manipulators and oot pedals or changing armsand moving the camera. Te commands are intuitive andthe responses precise. o pick up a suture, the surgeon mussimply make a pinching motion with their index and orefinger, and the orceps will mimic that motion seamlessly

o retract a portion o tissue, the surgeon can use one o thearms, then lock it into position and still have two additionaarms to perorm the operation. Perhaps the two most noveeatures are the ability to scale the surgeons motion smalleror delicate tasks, and built-in tremor filtration.

Tough it has dominated the market, Intuitive SurgicalsDaVinci Surgical System is just one o many robotic-assist devices that has been developed. Similar eatures weredeveloped in the AESOP and ZEUS, but production hasince been stopped due to a merge between parent companyComputer Motion and Intuitive Surgical. Te Raven, a twoarmed robot that runs with open source sofware is currently ound only in a handul o academic centers and has noyet gained FDA approval, but would cost just a raction othe DaVincis 1.8 million dollar price tag.

Figure 1: Schematic o DaVinci Surgical System. Te robotic arms are placedat the bedside while the surgeon sits at the console controlling the arms(lef). Degrees o reedom offered by DaVincis endowrist instruments topright compared to laparoscopy and a human arm (right)[2].

[the DaVinci] has been cleared to perform a wide

variety of urological, general laparoscopic,

gynecologic, transoral otolaryngeal, thoracoscopic

and cardiovascular surgeries [1].

...the three manipulator arms of the DaVinc

has 7 degrees of freedom, with larger range of

motion than offered by human hands...



QMRFEATURE

Tere have been a number o robotic devices developedwith the intention o use or a single procedure. For exam-ple, the PROBO was developed specifically or prostaticresection, and is semi-autonomous, requiring only a targetvolume and position to be input by the surgeon. An ortho-

pedic robot, the ROBODOC uses pre-treatment C imageregistration and pre-operative planning sofware to maxi-mize range o motion and alignment or joint replacementsurgery. Te Acrobot system has similar eatures [3].

One prime example o the potential or revolutionary appli-cation o robotics in surgery is the NeuroArm, which was

developed here in Canada. Te NeuroArm is a magneticresonance compatible robot that is able to unction withinthe bore o the MRI, allowing or real-time intra-operativeimaging during neurosurgery. Similar MRI-compatible ro-botics have been developed or percutaneous prostate can-cer treatments.

A pervasive criticism o robotic-assist devices is that they

are not capable o touch sensation, and as a result, mightnot be suitable or surgery on delicate tissues where the sur-geons ability to eel resistance is critical to avoid damage.However, two recently developed devices - the Sofie and theMicroSurge - include orce-reflecting eedback to allow thesurgeon to gauge the amount o resistance offered by the tis-sue. Te haptic eedback developed to communicate tissueresistance might also be applied as a saety eature in orderto prevent entry o the robot into a predetermined region(ie. to avoid delicate structures like nerves).

A possible application o robotic devices is tele-surgery.Since the current robotic systems are remotely controlled,there is the possibility or the surgeon to operate rom adifferent room, in a different city, perhaps even on a di-erent continent. Operating rom a different continent wasdemonstrated in the Lindbergh Operation, a trans-Atlan-tic cholecystectomy perormed in 2001. Tese long-distanceoperations echo some o the original motivations behindthe development o robotics by NASA, but could have im-plications in difficult to reach communities [4].

Te allure o cutting-edge, technologically advanced surgery

is not lost on patients, who currently ace a three-monthwait or a robotic prostatectomy in Ontario. However, thejury is still out on whether or not robotic procedures pro-vide superior patient outcomes, making it difficult to as-sume the costs o operating and maintaining the robots, notto mention the steep learning curve or surgeons. Roboticsurgery has infiltrated only a handul o residency programsacross the country, and survey data suggests that residentsview the presence o robotics as an unavourable addition totheir surgical education [5]. On the topic o robotic surgeryand training, Dr. Joel Nelson, a urologist at the University oPittsburgh Medical Center, offers an eloquent analogy: Te

difference between iger Woods and the local club champi-on is not the putter, the irons, or the woods, it is in skill andconsistency. Tis could serve as a caution or those seekingthe newest, rather than the best, treatment [6]. Neverthe-less, as sales continue to increase and new procedures arebeing developed with robotics, we may expect to see morerobots in Canadian operating rooms as we enter post-grad-uate training.

References

1. Intuitive Surgical - da Vinci products http://www.intuitivesurgical.com/products/products_aq.html. Accessed May 2, 2013.

2. alamini MA, Hanly EJ. echnology in the operating suiteJAMA : the journal o the American Medical Association. Feb 162005;293(7):863-866.3. Camarillo DB, Krummel M, Salisbury JK, Jr. Robotic technology in surgery: past, present, and uture. American journal o surgery. Oc2004;188(4ASuppl):2S-15S.4. Berlinger N. Robotic surgery--squeezing into tight places. TeNew England journal o medicine. May 18 2006;354(20):2099-2101.5. Robinson M, Macneily A, Goldenberg L, Black P. Status o robotic-assisted surgery among Canadian urology residents. Cana-dian Urological Association journal. Jun 2012;6(3):160-167.6. Nelson JB. Debate: Open radical prostatectomy vs. laparoscopic vs. robotic. Urologic oncology. Nov-Dec 2007;25(6):490-493.

The NeuroArm is a magnetic resonance

compatible robot that is able to function

within the bore of the MRI...

...force-reflecting feedback [allows] the

surgeon to gauge the amount of resistance

offered by the tissue...

...the jury is still out on whether or not robotic

procedures provide superior patient outcomes...



QMR FEATURE

BRANDEN DESCHAMBAULT, CLASS O F 2016

Cancer Genetics

Introduced in 2000 by the Ministry o Health and Long

erm Care (MOHLC), genetic services intended toscreen Ontarians or hereditary breast/ovarian cancers havebeen widely adopted and used. Identification and reerralo patients suitable or genetic screening (based on amilyhistory) is meant to utilize criteria published by the Predic-tive Cancer Genetics Steering Committee in 2001 [1]. Onceidentified as a carrier o a BRCA mutation, women and mencan participate in genetic counseling programs with specialattention to surveillance and prevention. Regular mammo-grams or magnetic resonance imaging, as well as prophylac-tic bilateral mastectomy or salpingo-oophorectomy mark-edly reduce the risk or malignancy in these populations [2].

Tese programs are widely available. Carroll et al. in 2008ound that awareness o the program exceeded 90% amongamily physicians, gynecologists and oncologists in Ontario(n=1427) [3]. Use o the services varied based on a numbero intriguing actors such that older, urban physicians withgreater knowledge o the reerral criteria were more likelyto reer [3]. Moreover, nearly hal o the physician respon-dents were unsatisfied with the notification provided by theMOHLC [3]. Te next question becomes, how does this

bias in reerrals translate into patient outcomes? A hint may

emerge rom 2012 data published by Vanstone et al. romthe London Regional Cancer Program. Among patients diagnosed with breast cancer beore the age o 52, afer 1997and reerred to their Cancer Genetics Clinic (n=1017), theauthors identified 63 women with BRCA1 and BRCA2 mutations detected afer diagnosis. O these, a remarkable 41(or 65%) had amily histories that made them eligible orgenetic screening or hereditary breast cancer prior to diagnosis, as per the MOHLC criteria [2]. For example, 24had three or more cases o breast or ovarian cancer in theiramily [2]. Te knee jerk reaction is to blame the amily physician or missing the reerral criteria. However, the author

astutely point out a number o contributory actors or thisunortunate situation, including women without primarycare providers, time constraints, out-o-date knowledge othe reerral criteria, and incomplete amily histories provided to primary care providers [2]. o remove these barriers togenetic services access they suggest the development o patient-centered, computerized amily history collection toolswhich are not without precedent [4], and have been shownto increase reerral to cancer genetic specialists [5].

It truly is an exciting time to be a medical oncologist. Researchers are discovering candidate molecular targets aster than thetargets can be investigated. Genetic counseling or the prevention o hereditary breast and ovarian cancer (BRCA1/2 mutations)has become an established component o comprehensive cancer risk management in Ontario. Furthermore, targeted therapieshave already demonstrated real clinical benefit or specific populations. Te success stories include erlotinib (arceva; Genen-tech) and gefitinib (Iressa; AstraZeneca) or patients with epidermal growth actor (EGFR) mutations in non-small cell lungcancer (NSCLC), as well as cetuximab (Erbitux; Bristol-Myers Squibb-Eli Lilly) and panitumumab (Vectibix; Amgen) or thetreatment o reractory metastatic colorectal cancer (CRC) that is EGFR-expressing, but Kirsten rat sarcoma viral oncogene ho-molog (KRAS) wildtype. Tese therapeutic advances have necessitated the development o companion diagnostic tests, so as toensure those treated are most likely to benefit. Te floodgates or targeted cancer prophylaxis and treatment using the insightsafforded through genetic profiling seem primed to swing open. Indeed, discussing the highly anticipated Integrated MolecularProfiling in Advanced Cancers rial (IMPAC), Dr. Lilian Siu, Senior Staff Physician in Drug Development Program at Princess

Margaret Hospital recently conveyed, Most importantly, we are tracking to ensure all these profiling efforts ultimately translate

into higher clinical trial accrual rates and better cancer outcomes due to target-drug matching. In this optimistic and orwardthinking research environment, it is a useul thought experiment to look back at the accessibility o those genetic services alreadyin clinical use, so as to ensure they are being delivered according to the standards o the Canada Health Act.

Tis article will briefly explore the current clinical use o oncology genetic profiling services in Ontario and Canada. As wecontinue to discover and commercialize knowledge o cancer susceptibility genotypes, along with mutations that promote tumor

ormation, applying the lessons learned in the early clinical applications o targeted molecular therapies will help ensure equitableaccess or patients and effective use by Canadian physicians.



QMRFEATURE

Beyond prophylaxis, it is also worthwhile to examine thecurrent clinical use and effectiveness o genetic testing ortargeted molecular therapies. Health echnology Assess-ments done by the MOHLC have previously recognizedthe cost-effectiveness o EGFR mutation testing or pre-dicting which patients with advanced or metastatic NSCLCwill respond to gefitinib (first-line) or erlotinib (second- orthird-line) [6]. Similar conclusions were reached or thevalue o determining KRAS status in predicting responseto cetuximab and panitumumab monotherapy, as well ascetuximab-plus-irinotecan combination therapy in patients

with advanced CRC [7]. Only a handul o provinces actu-ally offer patients with NSCLC routine EGFR mutation test-ing and unding or first-line gefitinib [8]. It can take weeksto obtain results o mutation testing, raying patient nervesand in the ace o potential clinical deterioration, possiblynecessitating initiation o chemotherapy during the delay[9]. Despite this, there are indications that the situation maybe improving. Results rom a recent pan-Canadian studyinvolving five regional diagnostic centres indicated that themedian time or the testing centers to receive samples orEGFR mutation testing was 7 days and the median time orreporting o results was 11 days [10]. Tis demonstrates the

easibility o the regional testing model and provides ratio-nale to continue enhancing efficiency. In the case o EGFRmutations in NSCLC, this could include unding or in-house testing, upstream involvement o respirologists andthoracic surgeons in the testing process, thereby ensuringadequate tumor tissue is collected at biopsy, or the imple-mentation o more sensitive and less time-intensive detec-tion modalities [9].

Access to personalized cancer prevention and treatmenthas undoubtedly progressed in leaps and bounds in the last1015 years. Ongoing Canadian research initiatives, such asthe aorementioned IMPAC trial, will continue to enhancethe knowledge and tools available to physicians, inevitablynecessitating a scaling up o the currently-available clinicalgenetic services in Ontario and Canada. As we go orwardinto this new rontier o personalized cancer care, we shouldproactively apply the lessons learned to clinical practice, soas to ensure maximum benefit or all Canadians.

References

1. Predictive Cancer Genetics Steering Committee. Ontario physicians guide to reerral o patients with amily history o cancerto a amilial cancer genetics clinic or genetics clinic. Ont Med Rev2001;68(10):2430.

2. Vanstone M, Chow W, Lester L, Ainsworth P, Nisker J, Brack-stone M. Recognizing BRCA gene mutation risk subsequent tobreast cancer diagnosis in southwestern Ontario. Can Fam Physician 2012;58:e25866.3. Carroll JC, Cappelli M, Miller F, Wilson BJ, Gruneld E, PeetersC, Hunter AG, Gilpin C, Prakash P. Genetic services or hereditarybreast/ovarian and colorectal cancers - physicians awareness, useand satisaction. Community Genet. 2008;11(1):4351.4. Carmona RH, Wattendor DJ. Personalizing prevention: the USSurgeon Generals Family History Initiative. Am Fam Physician2005;71(1):36.5. Vig HS, Armstrong J, Egleston BL, Mazar C, oscano M, Brad-bury AR, et al. Cancer genetic risk assessment and reerral pat

terns in primary care. Gen est Mol Biomarker 2009;13(6):735.6. Medical Advisory Secretariat. Epidermal growth actor receptor (EGFR) genetic testing or prediction o response to EGFR-targeted (KI) drugs in patients with advanced non-small-cell lungcancer: an evidence based analysis. Ont Health echnol AssessSer [Internet]. 2010 Dec [cited 2013 02 27];10(24) 148. Availablerom: http://www.health.gov.on.ca/english/providers/programmas/tech/reviews/pd/EGFR_20101209.pd7. Medical Advisory Secretariat. KRAS testing or anti-EGFRtherapy in advanced colorectal cancer: an evidence-based andeconomic analysis. Ont Health echnol Assess Ser [Internet]2010 Dec [cited 2013 02 27]; 10(25) 149. Available rom: http:/www.health.gov.on.ca/english/providers/program/mas/tech/re

views/pd/kras_20101213.pd8. BC Cancer Agency (bcca). BCCA Protocol Summary or FirstLine reatment o Epidermal Growth Factor Receptor (EGFR)Mutation-Positive Advanced Non-Small Cell Lung Cancer (NS-CLC) with Gefitinib. Vancouver, BC: BCCA; 2010.9. Hirsch V, Melosky B, Goss G, Morris D, Morzycki W. A personalized approach to treatment: use o EGFR tyrosine kinase inhibitors or the treatment o non-small-cell lung cancer in CanadaCurr Oncol 2012;19(2):7890.10. sao MS, Ionescu G, Chong D, et al. Population-based pan-Ca-nadian EGFR-mutation testing program [abstract e18017]. J Clin

Oncol [Internet]. 2011[cited 2013 02 27];29. Available rom: http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_de-tail_view&conID=102&abstractID=82932

It can take weeks to obtain results of mutation

testing, fraying patient nerves and in the face of

potential clinical deterioration...



QMR FEATURE

The Future In Your Hands: Recent

Advances in Prenatal ScreeningTETYANA ROGALSKA, CLASS OF 2016he ability to obtain genetic inormation rom the humanetus during pregnancy is a relatively recent innovation,with technological advances continuing to increase the res-olution and ease o prenatal diagnosis at a remarkable rate.Te first prenatal diagnosis o an abnormal karyotype wasreported in 1967 [1], with trisomy 21 (Down syndrome) be-ing diagnosed or the first time a year later [2]. Since then,the development and refinement o genome-wide molecular

tests , as well as the introduction o non-invasive methods,has broadened the scope o prenatal screening. Now, preg-nant mothers have increased accessibility to inormed andmeaningul reproductive choice. While technological prog-ress holds great promise or comprehensive and saer prena-tal diagnosis, more research is still required to understandthe clinical relevance and applicability o many genetic find-ings achieved by these methods.

Aneuploidy, an abnormality o the number o chromo-somes in an individuals genome, is a major ocus o prenatalscreening as it is a significant cause o perinatal morbidity,mortality, and developmental delay. In Ontario, prenatalscreening is currently used to detect three types o aneu-ploidy: trisomy 21, trisomy 18, and open spina bifida [3].O these, trisomy 21, also known as Down syndrome, is themost common chromosomal abnormality worldwide, witha prevalence o 14.3 cases per 10,000 births in Canada [4].

Screening or chromosomal abnormalities is accessible topregnant women o all ages and is typically perormed inthe first trimester. It involves both ultrasonographic teststhat examine etal nuchal translucency as well as maternalserum screening or markers such as ree beta-human cho-rionic gonadotropin (hCG) and pregnancy-associated plas-ma protein A; together, these tests detect 85-90% o trisomy21s [5]. A definitive diagnosis can then be made through aninvasive procedure such as chorionic villus sampling (CVS)at 11-14 weeks gestation or amniocentesis afer 15 weeks.

Te collected etal cells are cultured and the karyotype isdetermined either by microscopic examination o bandedmetaphase chromosomes or (more requently) by quanti

tative-fluorescent (q)-PCR, a rapid test targeting the moscommonly involved chromosomes. Despite their useulnesin diagnosis, however, both o the above invasive techniquesinvolve a significant procedure-related risk o miscarriage approximately one in three hundred cases [6]. Consequently, only women with a positive screening result, a historyo affected pregnancies, or advanced age are recommendedor amniocentesis or CVS. In addition, classical cytogenetic analysis by metaphase karyotyping or q-PCR can takeup to two weeks due to the requirement or cell culturing[7]. ogether, these limitations have led to the innovation onovel methods that address both the saety and timeliness

o diagnosis.

One o the techniques approaching the oreront o prenatagenetic testing is array genomic hybridization, which useschromosome microarrays (CMAs) to detect genomic gainsand losses. CMAs have been very successul in postnatal diagnosis, with the Canadian College o Medical Geneticistendorsing it as a first-line laboratory investigation or pa-tients with various cognitive abnormalities [8]. However itis controversial whether prenatal use o CMAs are an effec-tive prenatal test. In act, both the Society o Obstetricianand Gynecologists o Canada and the American Collegeo Obstetricians and Gynecologists recommend against itsuse as a universal method o prenatal diagnosis but ratherin a much more selective subset o pregnancies where etastructural abnormalities have been detected on ultrasoundor etal magnetic imaging [9-10].

In Ontario, prenatal screening is currently used

to detect three types of aneuploidy: trisomy 21,

trisomy 18, and open spina bifida...

Despite their usefulness in diagnosis...

invasive techniques involve a significant

procedure-related risk of miscarriage...

...it is controversial whether prenatal use

of CMAs are an effective prenatal test...



QMRFEATURE

In CMA, fluorescently labeled sample DNA rom the pa-tient is hybridized onto known DNA targets and the relative

signal intensity ratio o the DNA is compared to a reerencesample to detect genomic gains and losses [11]. In additionto being able to detect large, chromosomal gains or loses,CMAs are also able to detect genomic imbalances in therange o 50-100 kb as opposed to 5-10 Mb by standardkaryotyping and thus dramatically increase the resolutiono genetic analysis [12]. Studies have shown array genomichybridization detecting pathogenic abnormalities in 4-16%o etuses with an abnormal ultrasound but normal karyo-type [13-14]. With no requirement or cell culture, thesetests also have a much shorter turnaround time. Yet despite

their efficiency and the additional capacity or inormation,chromosome microarrays have not yet superseded the useo q-PCR as the principal cytogenetic tool in prenatal test-ing.

Te greatest obstacle to the wider application o array ge-nomic hybridization technology is distinguishing between

benign and pathogenic copy number variants. In any giv-en population there is variation in copy number variantsamongst normal individuals. Te use o CMAs in pregnan-cies at low risk or structural abnormalities would likelyover-estimate the risk o disease in the etus [11]. As such,while array genomic hybridization holds great promise as agenome-wide, high-resolution platorm or prenatal testing,urther research is required to understand the physiologicalimplications o copy number variants across gene regions.

In addition to more sensitive testing, considerable success-es have been reached in the collection o etal DNA itsel.Te 1997 discovery o cell-ree etal (cff) DNA in maternalblood [15] has opened possibilities or non-invasive accessto etal genetic material or the assessment o single genemutations, etal chromosome abnormalities, and even theentire etal genome. While conventional methods o obtain-ing etal samples, such as amniocentesis or CVS, put the e-tus at risk or injury or death, collection o cc is perormedthrough a simple blood draw rom the mother. Te use ocirculating cff DNA is already an established option or the

diagnosis o etal sex and Rhesus (Rh) D antigen status byquantitative PCR. A reliable determination o etal sex canbe made as early as 7 weeks gestation (much earlier than ispossible by ultrasound) while diagnosis or Rh blood groupallows or the identification o etuses at risk or hemolytic

disease. Moreover, current research on mutations associatedwith hemoglobinopathies [16], etal alloimmune thrombo-cytopenia [17], and beta-thalassemia [18] suggest upcom-ing possibilities or the diagnosis o these disorders rommaternal blood.

Detection o aneuploidy rom cell-ree etal DNA in mater-nal blood has also achieved remarkable success in the shortsixteen-year span since its discovery. While etal sequencesrom chromosome 21 are indistinguishable rom that o ma-ternal origin, the detection o etal trisomy 21 has becomepossible simply on the basis that a woman carrying a etuswith Down syndrome will have a higher proportion o chro-mosome 21 DNA ragments in her total plasma cell-reeDNA than a pregnant woman carrying a etus with the nor-mal number o chromosomes [11]. With the use o massiveparallel sequencing (MPS) techniques (a high throughputapproach to DNA sequencing), the detection o etal Downsyndrome rom cff DNA has reached an overall sensitivity

and specificity o 99% [19]. Furthermore, 2012 marked theyear that researchers first reported being able to determinethe whole-genome sequence o a etus rom cell-ree DNAin maternal plasma [20]. Tis discovery, along with thosedescribed previously, suggests exciting possibilities or theuture o prenatal genetic testing. Te detection o chromo-somal abnormalities, single gene mutations, as well as ge-netic polymorphisms rom an early maternal blood test areincreasingly tangible prospects or the near uture, with theuse o cell-ree etal DNA or the routine screening o an-euploidies expected to be introduced in the next two to fiveyears [21].

Certainly, these advances in prenatal diagnosis pose import-ant ethical challenges concerning the autonomy rights o u-ture children, the discovery o unintended genetic anoma-lies, as well as equity o access to new standards o care. It isclear that the potential as well as the complexity o prenatatesting is continually increasing, and while we cant yet pickand choose genes or rock-stardom or mathematical apti-tude, we have certainly entered the arena.

...further research is required to understand the

physiological implications of copy number vari-

ants across gene regions...

...[CMAs] dramatically increase the

resolution of genetic analysis...

...the detection of fetal Down syndrome f

rom cff DNA has reached an overall

sensitivity and specificity of 99%...



QMR FEATURE

References

Jacobson, C.B. and Barter, R.H. (1967) Intrauterine diagnosis andmanagement ogenetic deects. American Journal o Obstetrics and Gynecology,99: 796807.Valenti, C. et al. (1968) Prenatal diagnosis o Downs syndrome.Lancet, 2: 220.Ontario Ministry o Health and Long erm Care. Prenatal Screen-ing Ontario: Conditions screened. Available at: http://www.pre-natalscreeningontario.ca/Deault.aspx?cid=14&lang=1. AccessedFebruary 26, 2013.Institute o Health Economics. Alberta SE Report: First and sec-ond trimester prenatal screening or trisomies 13, 18, 21 and openneural tube deects. September 2012.Wald, N.J. et al. (2003) First and second trimester antenatalscreening or Downs syndrome: the results o the Serum, Urineand Ultrasound Screening Study (SURUSS). Health echnologyAssessment, 7: 177.

Evans, M.I. and Andriole, S. (2008) Chorionic villus sampling andamniocentesis in 2008. Current Opinions in Obstetrics and Gyne-cology, 20: 164168.Shaffer, L.G. and Bui, .H. (2007) Molecular cytogenetic and rap-id aneuploidy detection methods in prenatal diagnosis. AmericanJournal in Medical Genetics Part C: Seminars in Medical Genet-ics, 145C: 8798.Canadian College o Medical Geneticists. CCMG Position State-ment: use o array genomic hybridization technology in constitu-tional genetic diagnosis in Canada. January 2010.Society o Obstetricians and Gynecologists o Canada. (2011).SOGC-CCMG Joint echnical Update: Use o array genomic hy-bridization technology in prenatal diagnosis in Canada. Journal o

Obstetrics and Gynecology o Canada, 33 (12): 1256-1259.American College o Obstetricians and Gynecologists. (2009)

ACOG Committee Opinion No. 446: Array comparative genomichybridization in prenatal diagnosis. Obstetrics and Gynecology114: 11611163.Hui, L. and Bianchi, D.W. (2013) Recent advances in the prenatainterrogation o the human etal genome. rends in Genetics, 29(2): 84-91.Friedman, J.M. (2009) High-resolution array genomic hybridization in prenatal diagnosis. Prenatal Diagnosis, 29: 2028.Kuehn, B.M. (2008) Prenatal genome testing sparks the debateTe Journal o the American Medical Association, 300:16371639yreman M. et al. (2009) High resolution array analysis: diagnos-ing pregnancies with abnormal ultrasound findings. Journal oMedical Genetics, 46: 531541.Lo, Y.M. et al. (1997) Presence o etal DNA in maternal plasmaand serum. Lancet, 350: 485487.raeger-Synodinos, J. et al. (2011) Prenatal, noninvasive and pre-implantation genetic diagnosis o inherited disorders: hemoglobinopathies. Expert Review o Molecular Diagnostics, 11: 299312

Scheffer, P.G. et al. (2011) Noninvasive etal genotyping o humanplatelet antigen-1a. British Journal o Obstetrics and Gynecology118: 13921395.Shammas, C. et al. (2010) TalassoChip, an array mutation andsinglenucleotide polymorphism detection tool or the diagnosis o betathalassaemia. Clinical Chemistry and Laboratory Medicine, 4817131718.Chiu, R.W. and Lo, Y.M. (2012) Noninvasive prenatal diagnosisempowered by high-thoroughput sequencing. Prenatal Diagnosis32: 401-406.Kitzman, J.O. et al. (2012) Noninvasive whole-genome sequencingo a human etus. Science ranslational Medicine, 4,:137ra76.

Jong, A. et al. (2011) Advances in prenatal screening: the ethicadimension. Nature Reviews, 12: 657-663.



QMRFEATURE

FAQs:A Medical Students Guide to

Social MediaEVE PURDY, CLASS OF 2015 | Twitter: @purdy_eve | Blog: manuetcorde.wordpress.com

The Basics

What is social media? Social mediais more than just status updates aboutwhat you ate or dinner. It is any orm

o electronic communication throughwhich users create online communi-ties to share inormation, ideas, per-sonal messages, and other content (i.e.videos). Tis broad definition includespopular sites such as Youube, Face-book, witter and LinkedIn, but alsoless high profile modes o communi-cation such as blogs, slidesharing sites,podcasts etc.

What is the fundamental difference

between Facebook and witter?Face-book is a profile site designed to unc-tion as an online portolio o person-al current events whereas witter isa vehicle designed to share nuggetso inormation (



QMR FEATUREwho are willing and able to answerquestions. For example, this is a twit-ter conversation I had with Dr. Leve-ridge days beore our urology exam.

Another excerpt o an interaction witha nephrologist about an FSGL case

Following conerences: As medical stu-dents it is near impossible to find thetime or money to attend academicconerences. Te good news is thatthese conerences are now being live

cast through witter and live eed web-sites. For example, the InternationalConerence on Emergency Medicinesaw 400 individuals engaging in con-versation related to conerence con-tent through more than 4500 tweets[6]. Tis means that we can ollowalong in class! Ermoutside o classtime, I mean.

What is FOAM? FOAM stands or

Free Open Access Meducation. It isthe result o the continuously growingcollection o online resources relatedto medical education. You will see thisbuzzword thrown around in the socialmedia world but just know that it is acatchall phrase or the online sophis-ticated, cutting edge learning resourc-es available to clinicians and students

[7]. It can be accessed by anyone, any-time, anywhere. Some even argue thatFOAM is the uture o medical educa-tion and lielong learning [7].

Doesnt it waste time? Tere is nodoubt that using social media or ed-ucation takes time, particularly at theoutset when there is a steep learningcurve but it absolutely does not haveto waste time. When used appropri-ately, social media tools can be usedto bring together resources to helplearn efficiently. Setting time limitsor social media use, being aware othe amount o time you spend loggedin and having an objective or your

time on social media are ways to avoidwasting time.

Professionalism

Can I get into trouble?Yes.

How do I avoid getting into trouble?Te same way you avoid getting introuble in all other public domains oyour lie. Tink careully about whatyou say, how you say it and be hyper-

vigilant about breaching patient confi-dentiality. Tink beore you hit send.I you are wondering i you shouldpost, dont. Pass it along to a riend orcolleague to get eedback beore shar-ing your thoughts with the world. Youare accountable.

Should I use my real name or havea social media alter ego?Real name.You are accountable regardless o the

name you choose. Using a social me-dia alter ego can allow you to distanceyoursel too much rom that account-ability. I you dont eel comortableputting your name to a post, then thebottom line is you shouldnt be post-ing it.

Should I wear a stethoscope in myFacebook profile picture? Likeeverything social media, it is a per-sonal choice. Beore making any sociamedia decision it is key to ask, Whyam I doing this? I the answer to that

question is constructive (i.e. to im-prove my learning, to help my peersto add to the body o knowledge on atopic) then go or it. I the answer tothat question is selfish (to show off toriends and amily) then think twiceo me the picture is less importantthan the sum total o how proession-ally we engage with others online be-cause - stethoscope in the profile picor not - we are still medical students

with an obligation to represent theproession well.

References1. CMA. (Feb 2011). Social media useby physicians. Canadian Medical Association. Retrieved March 17, 2013http://www.cma.ca/advocacy/social-me-dia-use-physicians2. Budd, L. (2013). Physician tweet thysel: a guide or integrating social mediainto medical practice. British ColumbiaMedical Journal. 55(1): 38-40.

3. Forgie, S. E., Duff, J. P., & Ross, S(2012). welve tips or using witter as alearning tool in medical education. Medical teacher, (0), 1-7.4. Ellis, A. (2013). Te power o social media in academic medicine and health careQueens Department o Medicine. Re-trieved March 17, 2013. http://deptmedqueensu.ca/announcements?id=335. Westaer, L. (2012). FOAM partyTe Short Coat. Retrieved March 172013. http://shortcoatsinem.blogspot

ca/2012/09/oam-party-uture-o-medi-cal-education.html6. Neill, A., Cronin, JJ., Brannigan D.OSullivan R., & Cadogan, M. (2013). Teimpact o social media on a major inter-national emergency medicine conerenceEmerg Med J. online ahead o press.7. Cadogan M. (2013). FOAM. Lie inthe Fast Lane. Retrieved March 17, 2013

http://lieintheastlane.com/oam/



QMRINTERVIEW

Insidermedicine with

Dr. Sanjay SharmaJENNIFER SIU AND CODY LI, CLASS OF 2016

What are some of the features of

Insidermedicine?

Insidermedicine acts as the platormo all o our evidence-based inorma-tion. On the website, we publish dai-ly medical evidence-based news andresearch in video and text. Te web-site is divided into sections useul orpatients, students, and doctors. Tereare several resources including, I Ihad.. which eatures leading medicalexperts suggesting what they woulddo i they had a certain condition, and

I I knew..., which eatures physiciansrom around the world providing ca-reer and personal advice to medicalstudents and trainees. Te website alsoincludes video interviews eaturingleading researchers and their new dis-coveries.

Where did the inspiration to start

this company come from?

Tis whole project began 6 or 7 yearsago when I realized that many patientsdont get a lot o great patient inorma-tion; [and when they] go online, thereare many different sources available orpeople trying to sell them things. So Iasked mysel i there was a better wayo creating inormation. Around thistime, there was a V show based out

o New York that created political sat-ire clips every day and this served asan inspiration or what the vehicle or

knowledge dissemination might looklike. Our next goal was to create digitalcontent on a daily basis and get onlineand disseminate it. With any start upbusiness, it begins with support romriends and amily. I recruited my wie,Susan, who became the on-air person-ality. Every day we would come homerom clinic, Id sit down and write thecontent and Susan would memorize it.Wed go to the basement and create the

videos, then upload them to the web-site.

Since then we have grown tremen-dously with over 6,000 videos andmany in multiple languages. OurYouube channel has over 1.5 millionviews. We still create online contenteveryday, but now we have 3D andwhiteboard animation to enhancethe stories and between 10-12 peopleworking ull time or Insidermedicine.

Our staff includes doctors, animators,graphic artists, videographers, pro-grammers, I specialists and medicalwriters. Te MedSkool platorm isin 10-15 universities now and about3-4,000 optometrists come to us orContinuing Medical Education cours-es in the orm o Optocase.

Te Insidermedicine Project is a medical news, content, knowledge-translation, and communications company that providesservices to educational, government, research, and commercial organizations. It is a physician-led initiative with a vision oreaching patients, medical doctors, and students world-wide with daily evidence-based health and medical news. We sat downwith Dr. Sanjay Sharma, ounder o Insidermedicine and a Proessor o Ophthalmology and Epidemiology at Queens Universityto learn more about his company and its role in the uture o medicine.

Other resources provided through

Insidermedicine

Optocase.com:A continuing education programor optometrists eaturingmultimedia video modules with on-line Q&As.

SuwenMD:An iPhone app to teach English toChinese medical students. Contains1,000 videos in English and Chi-nese.

MedSkool 2.0:

A ocused project or medical stu-dents based on the LMCC objec-tives.

IMTouch Eye:

An iPad app eaturing 3D anima-tions used to enhance patienteducation or Optometrists andOphthalmologists.

Researcher Services: Provides re-searchers with assistance in writinggrants and encourages knowledgetranslation through resources andassistance with press releases, ex-planatory videos, animations, andcustom websites.



QMR INTERVIEW

One branch o Insidermedicine isMedSkool 2.0, a multimedia resourceor educating medical students.

How does such a resource enhance amedical students education?

For the past ew years, a lot o myresearch has ocused on knowledgetranslation and patient education.Many studies have shown that stu-dents retain more inormation whentopics are presented in a way thatstimulates multiple senses. A personis able to integrate knowledge in theirworking memory more efficiently and

more permanently through the sum-mative effects o multiple sense stimu-lation compared to inormation givenin the traditional ormat o text or au-dio. We did a randomized study [1] onmedical students who used MedSkool2.0. We randomized medical studentsto either the digital content or the tra-ditional text and we were able to showthat the people who were randomizedto the video content perormed about

10% better on their scores, and theirefficiency was incredible. Tey spentabout 80% less time on the material.Additionally, about 90% preerred thedigital content over traditional text.

In what ways do you hope that Insid-ermedicine will play a role in the fu-ture of the relationship between phy-sicians and their patients?

In health care there is a pent up de-mand rom patients who are empow-ered and want to learn more abouttheir conditions. Te question is howto create a solution that not only em-powers patients, but can also be im-plemented into the medical system.At Insidermedicine, weve ocused oncreating distribution channels that will

disseminate the content and inusethe evidence-based message into thedoctor-patient discussion. We aim todo this at 3 different time points: 1) inthe waiting room - we have IPV (In-

ternet Protocol elevision) networks,similar to the news screens seen at theairport, where patients can view ma-terial as they are waiting to see theirdocto,. 2) while in the doctors office- an iPad platorm with 3D animationand media content that the local doc-tor can play, 3) when a patient goeshome, they ofen orget or might mis-understand what was said at the office;we have repackaged the content ontowebsites that are available or patients

to replay the content. Right now wehave created an iPad app with 30-40animations, and this is growing. Temore people embrace these technolo-gies, the aster we will see the transi-tion into the medical field.

Tere are many medical informa-tion resources available online. Whatmakes Insidermedicine unique from

other medical social media websites?How do you decide which articles tocover in your news segments?

Te voice that we occupy is evidencebased. We look at peer-reviewed lit-erature every day. Because we are es-tablished as a news and knowledgetranslation organization, we have ac-cess to embargoed inormation romjournals such as NEJM and JAMA aew weeks or days beore they are pub-

lished. All o the articles we receive arereviewed by members o our editorialboard, which consists o expert medi-cal doctors, researchers, and qualifiedbiostatisticians and epidemiologists,who decide whether the research istopical, important, and scientifical-ly sound. We have also built a strongrelationship with many o the big, re-

search-intensive universities aroundNorth America, who we help to gettheir messages out to the public.

How do you maintain balance in yourlife? Do you have any advice for med-ical students?

Ultimately, you have to ask yourselwhat you want to do with your lie andthis comes rom two things: 1) strongpassion or what you want to do, and2) being very efficient with your timeto do it. For me, I came rom an artscommunity where I played in lots obands and had many opportunities

to be creative. I have always enjoyedcreating new things. I have a back-ground in medicine and epidemiol-ogy. So what I am doing now allowsme to combine my areas o expertisein terms o medicine, education, busi-ness, and art all in one place.

We live in interesting and almostdaunting times. You have invested alot o time, effort, and dollars into your

medical education to enter a systemwhere the model is always changingHealth care might look dramaticallydifferent in 5 to 10 years, so it is im-portant or you to start thinking aboutwhat things are potentially going tolook like and what skill sets you aregoing to need. Te more you can equipyoursel with different tools, the moreyou will be prepared or the changesthat come.

References:

1. Steedman M., Abouammoh M., Sharma S. Multimedia learning tools or teach-ing undergraduate ophthalmology: resultso a randomized clinical study. CanadianJournal o Opthalmology/Journal Canadien dOphtalmologie. Volume 47 Issue 1

February 2012 Pages 66-71.



QMRINTERVIEW

Interview with Dr. Anne EllisHOLLIS ROTH, CLASS OF 2016 HOLLIS_ROTH

QMR: How did you get involved in so-cial media?

Ellis: I was getting ready to go to amajor international conerence and ithad been suggested to me, repeatedlyover the years, that being involved insocial media rom a proessional pointo view would be a helpul thing. I wasvery reluctant at first, but it becameapparent as I started looking aroundthat there are a lot o health care pro-essionals who have proessional wit-ter and Facebook pages. I actually ullythought that one o my research assis-tants would be the main person popu-lating my witter eed, but I was pleas-antly surprised. For me, its just been a

great way to not only keep up my ownknowledge base, but also to pass alonginormation to other researchers, col-leagues, and patients.

QMR: Is there one orm o social mediathat you preer?

Ellis: Te one that I really suggestthat everybody (i youre going to doone thing) do is LinkedIn, but i youwant to be more active and engagedwith social media, it really is a bit oa personal preerence. For me, witterhas worked, but a lot o my colleaguesstrongly preer Facebook.

QMR: Did your employer give you anyguidelines when you first started usingsocial media?

Ellis: No, I figured it all out on myown. KGH now has a social mediapolicy that is airly clear-cut. Tere is awhole lot o common sense involved.I you wouldnt want your patient,your next-door neighbor, or your col-league to read what you just said, thendont post it.

QMR: In terms o medical studentsand their social media presence, weveall heard stories o people having theirFacebook pages looked at when apply-

ing to residency how do you eel aboutthat?

Ellis: Im o two minds, because I dovalue the role o social media and Idont think we should send the mes-sage that its a bad thing. But I dontthink its ever too early to start usingsocial media responsibly. I youreshowing the poor judgement o dis-playing your worst as well as your bestonline, then I dont know that neces-

sarily you deserve to be called to taskor that, but I think its something youshould always be cautious about.

QMR: What advice would you give tocolleagues who havent dipped their toe

yet in the water o social media?

Ellis: I think that the very easiest andsimplest way is to join witter and lurkYou dont need to commit to postingtweets all the time. You join, you figure out the people you want to ollowand you just start logging in and seeing whats out there. I think, o all th[different orms o] social media thais the most controllable, its witterAlternatively, i you just want to havan online presence, then LinkedIn canbe used very interactively, but it workjust fine as a static picture. It just depends on what youre trying to get ou

o it, but i youre actually trying to bengaged, I think witters the easiest.

QMR: Do you find that youre using social media ofen when you teach?

Ellis: I just started this year: this yearclass is a bit o an experiment to sehow well that would work. I think iwould work better i we had a universal hashtag or the undergraduatmedical students, rather than just thallergy/immunology subspecialty paro it.

Dr. Anne Ellis (@DrAnneEllis) is an Associate Proessor and Division Chair o Allergy and Immunology in the Department oMedicine at Queens University. She is also the Director o the Environmental Exposure Unit and a clinician scientist (Meds 99MSc. McMaster University, 2008). A prolific user o social media, Dr. Ellis was kind enough to meet with the QMR to discuss theincreasing role o social media in medical education and medical practice.

I dont think its ever too

early to start using social

media responsibly...

...if youre actually trying

to be engaged, I think

Twitters the easiest......there are a lot of health care

professionals who have

professional Twitter and

Facebook pages...



QMR INTERVIEW

QMR: How do you interact with pa-tients using social media?

Ellis: Sometimes I will get very speci-

ic questions tweeted at me, and thatsharder to deal with, because it is hardto give sound medical advice in 140characters. I try to be correct in what Isay, and keep it relatively general, andgood patients will say in their tweet tome that they realize that tweets arentmedical advice - they just want myopinion. But i I get the eeling thattheres going to be any negative conse-quences o trying to eedback that way,its easy enough to ignore [the tweets].

When I get witter eedback that im-plies that the patient didnt understandwhat I was saying, I make sure I ollowup on those because I definitely dontwant them miscommunicating to oth-er people.

QMR: How do you see social media a-ecting the practice o medicine in theuture?

Ellis:Its not going away and its beingincreasingly used by patients, prac-titioners, and academics alike, so Ithink the sooner you realize its parto the abric and start to adapt romthe perspective o a medical student,the better. We do a lot o teaching oncritical appraisal o literature articles[in medical school], but we dont yetteach critical appraisal o Internet sitesor social media. Tats harder, butI think i you arent even starting off

with guidelines, youll never be able toeffectively use it. I dont think socialmedia is a ad in any way.

QMR: Youve talked about how useuyouve ound witter and Facebook inthe uture do you want to change or ex-

pand how youre using social media?

Ellis: Right now Im happy with whatIm doing. I things ever slowed downin my lie, I think itd be great to ex-periment with blogging (its been re-quested o me several times). Ive com-promised by doing guest editorials orother sites, but blogging looks like areally neat way to engage people.



QMRBOOK REVIEW

Health Care in the True North: Not

So Strong and Not So Free?HEATHER JOHNSON, CLASS OF 2015

Medicare is the third rail o Cana-dian politics, writes Jeffery Simp-son, ouch it and you die. Indeed,the publicly unded single-payerhealth care system is so intrinsic to

the Canadian identity that 85% oCanadians believe it to be the mostimportant national symbol. We maycomplain about wait times, pooraccess to primary care, and paltryunding or drugs and non-medicallyessential services, but any attempt tosubstantially change the system hastraditionally been met with fierce re-sistance. In Chronic Condition, Globeand Mail columnist Jeffery Simpsontakes us on a sprawling tour o theCanadian health care system in whichhe provides compelling arguments orthe need to reorm.

Canadians spend an above-averageamount o money on health care, with-out seeing above-average results. Wehave a Chevrolet health-care systemby international comparative stan-dards, but the Canadian public thinkswe have a Cadillac, says Simpson. Notonly are we receiving a comparative-ly poor return on our investment, but

the investment is only going to be-come more costly with time. Healthcare spending currently accounts or42 to 45 percent o provincial budgets;in twenty years, it will account or anestimated 55 to 65 percent. Withouta concomitant increase in revenue,health care will soon begin to squeezeout other programs as it takes up agreater share o government spending.

Given the choice between cutting ser-vices, introducing private delivery o

services, and raising tax revenue, mostCanadians would (albeit reluctantly)choose the last and thereby maintainthe status quo. It has also been sug-gested that efficiency gains couldhelp to curb rising costs. Simpson ar-gues that these strategies alone cannotsave our system. Efficiency gains areofen difficult to achieve, and couldactually increase costs. Pouring moregovernment money into the systemollowing Roy Romanows entreaty to

buy change did more or physicianincomes than it did or patient out-comes. According to Simpson, Cana-dians must recognize that we cannotafford to continue blindly down thepath we are on; hard choices must bemade and new options must be ex-plored, though these need not neces-sarily compromise our core values.

Tough we love to compare ourselvesto the United States since it makes uslook good, Simpson correctly identi-fies the utility in doing so there aretoo ew lessons to be learned. Early on

Chronic Condition: Why Cana-

das Health-Care System needs to beDragged into the 21st Century. By Je-

ery Simpson. Allen Lane: 392 pages;$32.

Medicare is the third rail

of Canadian politics...

We have a Chevrolet

health-care system by

international comparative

standards, but the Canadian

public thinks we have a

Cadillac...

Health care spending

currently accounts for 42 to 45

percent of provincial budget...

Canadians must recognize

that we cannot afford to

continue blindly down the

path we are on...

Canadas system is deep

but narrow, covering

hospital and physician

services but little else...



QMR BOOK REVIEW

in the book he alludes to how Medicarecompares to publically unded healthcare systems in other countries; hisexpansion on the subject (nearly 300pages in) is arguably the best part othe book. Canadas system is deep butnarrow, covering hospital and physi-cian services but little else, while oth-er systems offer more comprehensivecoverage or ar less money. Sweden,whose public health care system hasundergone dramatic reorm in recentdecades, is discussed at length. Toughtheir reorms are not wholly applicableto the Canadian context, Simpson be-lieves that certain measures such as re-

warding high-perorming regions, in-troducing privately delivered services,and implementing user ees are worthconsidering.

Tese last two ideas are not new inCanada, but they remain controversial.

In a system where patients experienceno direct economic penalty or seeing

their physician, there is little to stopthem rom clogging the system withrivolous complaints. A small user ee,Simpson argues, would decrease suchwasteulness and instill Canadians witha greater sense o accountability ortheir use o the system. It is difficult topredict, however, how much waste wecan reasonably hope to avoid, and withthe exemptions that would have to bemade or low-income individuals so asto preserve equality o access, imple-menting user ees would lead to only amarginal increase in revenue.

When discussing health care in Cana-da, private can eel like a dirty word,but it is not always clear what the termrepresents. It may reer to services be-ing paid or out-o-pocket, yet mayalso reer to services that are privatelyadministered but still publically und-ed. Despite popular belie, it is not syn-

onymous with or-profit. Simpsonstreatment o the subject, the discussion

o which has a tendency to devolveinto heated rhetoric, is measured andthorough. He neatly summarizes theChaoulli decision and its implicationsand proposes ways in which privatelydelivered services might be integrat-ed into our system without weakeningMedicare.

For anyone interested in the uture ourhealth care system, health proessionaor patient, Chronic Condition is worththe read i you have the time. Simp-sons lengthy description o the historyo Medicare in the first hal o the bookis convoluted, conusing, and mostly

unnecessary. It is in the second hal thatSimpson hits his stride, and thoughstill redundant at times, he gives a clearpicture o where we are and where wemight go. Chronic Condition is nota prescription or Medicare, thoughmany o Simpsons suggestions areworth exploring, but rather a call orCanadians to wake up and realize thatthe patient is not doing as well as wewould like to believe and is only goingto get worse.

...there is little to stop [patients]

from clogging the system with

frivolous complaints...

When discussing health care

in Canada, private canfeel like a dirty word...

QMR 6.3 Future of Medicine

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