Tag Archives: meded


Sarah Currie is a medical copy editor on CMAJ

The opposite of play is not work. It’s depression. — Brian Sutton-Smith

A little nonsense now and then is cherished by the wisest men.― Roald Dahl, Charlie & the Great Glass Elevator

Recess Rules

What happens when we play? What changes do we notice in our bodies? When we play a game with others, how do we experience those players? What physical or physiological responses to the actions or emotions involved do we notice? What is play? According to Jill  Vialet, author of the book 'Recess Rules', play is like pornography: you know it when you see it. The dictionary definition includes words like “aimless” and “frivolous.” Bernard Suits described playing a game as a voluntary attempt to overcome unnecessary obstacles. But we shouldn’t be so dismissive of play and its benefits and rewards.

People who play are more trusting; they are better self-regulators and can resolve conflict more effectively. Groups who play together have healthier interactions ...continue reading

glamour1Lauren Vogel is a news editor on CMAJ

What separates a good idea from an amazing one? A TEDMED2014 session I live streamed Wednesday provided plenty of clues. Although the speakers came from widely diverse backgrounds, ranging from journalism to ocean swimming, three strong threads – simplicity, specificity and daring – bound together the lessons they shared.

“Flat Out Amazing” ideas, it seems, start from simple answers to complex questions. Take the single-use syringe, for example ...continue reading

Andree RochfortDr Andrée Rochfort is Director of Quality Improvement at the Irish College of General Practitioners, Dublin

I frequently wonder how we can best prepare young doctors for their future medical roles and responsibilities, and how we can best support those already doing the doctor job.

We set out to care for others, to help others, to help others recognize their options and choices. We are set apart from patients during training. We learn to feel the expectations that “others” have of us; our peers, other health professionals, managers, professional bodies, medico-legal bodies, media, patients, patients’ relatives, our own relatives and non-medical friends. To this mix add in our self-expectations of ourselves. Combine these ‘perceived pressures’ then add our intrinsic sense of perfectionism and our pledges to others to do everything possible and we have a recipe for internal conflict! We feel guilt and failure when we cannot deliver perfect care with the selflessness we believe is expected of us. In reality we have to remember we are ‘human’ and we cannot work miracles. We do not have a magic wand. ...continue reading

chinese_studentsBy Deng Luo, MD PhD, Wen-Zhuo Ran, PhD, Yun Sun, MD, PhD, Hua Huang, MD, and  Wang-Yang Yi, MD.

Recently, a surprising survey of more than 3860 doctors in China has found that only 3% of respondents advised their children to pursue medical education. About 36.2% of the respondents kept a neutral attitude without encouraging or discouraging them from any particular career choice. By contrast, 58 percent of respondents came out strongly against the choice and did not encourage their kids to consider becoming a physician. It is time for us to wonder why this once respected profession has changed into a non-promising job.

Actually, great effort has been made by the government of China to expand medical education since 1998 and there are currently more than 159 institutions of higher education for medicine in China. ...continue reading

Domhnall_MacDomhnall MacAuley is an associate editor on CMAJ, currently at the The Cancer and Primary Care Research International Network (Ca-PRI) conference in Winnipeg

Cancer is now a major primary care research area, which is reflected in the increasing importance and impact of the Ca-PRI conference. David Weller (UK) described it as a "boutique conference", but it won’t be for much longer. Cancer has long been the preserve of specialists focused mostly on treatment, and epidemiologists analysing data principally from registries. Sick patients and sad stories tend to attract greatest sympathy, research interest, and funding. Cancer diagnostic research in primary care is difficult, the symptoms are often completely undifferentiated and it’s hard to pick up the clues in a context where most patients don’t have cancer.

Late cancer diagnosis concerns physicians and patients alike but measuring delay in diagnosis is not easy. We need to use agreed definitions and Jaim Sutton (UK) in her systematic review of studies on ovarian and colorectal cancer, identified considerable variation within in the broad categories of patient interval, primary care interval and diagnostic interval, definitions used in the Aarhus consensus statement. For future research to be meaningful, we need to use agreed definitions.

Willie Hamilton (UK) pointed out a huge knowledge gap where delay in diagnosis is concerned: there are time lines for cellular growth, and there are time lines for symptom development but we don’t know how they are connected. These differ between cancers and cancer site and, as Knut Holtedahl (Norway) reminded us, more aggressive cancers are easier to diagnose.

Greg Rubin (UK) presented data showing improvements in speed of diagnosis of cancer in primary care in the UK in response to the National Awareness and Early Diagnosis Initiative. There were some small but significant improvements in practices that used at least one of the following: significant event analysis, practice audit, risk assessment and a practice plan. This against a background of considerable systems-change. Similarly, Henry Jensen (Denmark) showed improvement with standardised cancer patient pathways. But, many patients don’t quite fit within the criteria relevant to the UK two week rule or the Danish pathway—many tend to have serious and vague symptoms that are not necessarily indicative of cancer. Greg Rubin (UK) suggested, in the subsequent discussion, that we may need to create diagnostic centres for those who don’t quite fit. And, as pointed out by a patients’ representative in the audience, it is also difficult for patients to know when to go to the doctor.

Looking at the wider aspect of preventive care, Eva Grunfeld (Toronto), in her keynote address, told us about the BETTER trial, a cluster randomised factorial controlled trial that enrolled 800 patients across Canada in primary care. The trial was conducted in good practices but there was still room for improvement. The core intervention was that patients were given a preventive prescription, and it was unique in that it addressed chronic diseases with a facilitator already in the practices. It was effective and, interestingly, it was also effective in patients who had who had mental health problem—an often hard-to-reach group. While the economic evaluation identified costs, the practices also gained incentive payments. Now that trial has been shown to be effective the team are looking at dissemination and "adaption for adoption". The programme has already been taken up in the North West Territories.

A particularly successful conference innovation was a session including ten 3-minute presentations to the full conference audience. No introduction, no moderation, just a time keeper. Great presentations across the spectrum of cancer care from sophisticated diagnostic models in developing countries to hugely contrasting diagnostic challenges with extraordinary delay in the developing world. And some fascinating insights. There is major projected shortfall in oncologists in the US as a result of increasing cancer survivorship. And, in a systematic review of cancer mobile apps, one of the authors' major tasks was excluding those apps identified in the search strategy, that were created for astrology!

Click for a link to the conference program

Dr Patrick in action as a newly qualified physician working in an obstetric unit in rural South Africa

Dr Kirsten Patrick is Deputy Editor at CMAJ

Last week I was fortunate enough to be invited to a great workshop, organized by the CMA’s Public Health division, aimed at developing a unified policy and advocacy platform for humanitarian medicine. As the background reading material pointed out, many Canadian physicians are interested in participating in humanitarian medicine initiatives and work or volunteer abroad at different stages of their life and career. The problem is that many such activities are ad hoc, not optimally planned, fragmented, and undertaken without due consideration of their impact. The CMA hopes to co-ordinate efforts in Canada to explore and delineate best practices, and to optimize the way that global health activities are coordinated among NGOs, physicians, residents and medical students.

I’ve had some experience with developing guidelines for best practice during short term experiences in global health. In 2010 I was part of a group led by Jeremy Sugarman, professor of bioethics and medicine at Johns Hopkins, and John Crump, a professor at Duke’s Global Health Institute, that produced the first Open Access guidelines on Ethics and best practice guidelines for training experiences in global health. The first decade of the new century saw an explosion of global health programs that would send students and graduates for short term experiences, usually from a developed country to a less developed country (without much traffic in the other direction). To quote Sugarman, we now have a “stunning  prevalence  of  initiatives covering  a  broad range  of  activities,  institutions,  and  countries”, offered by “Governmental, Non-­‐governmental, Religious, Humanitarian relief, Academic and Professional [organizations].”

In the early 1990s, as a medical student in Johannesburg, South Africa, I spent some clinical rotations in Baragwanath Hospital in Soweto. There I met many foreign medical students (mainly German and British) who came to get 'developing world experience' (mostly of performing surgery that they would not get to perform at home). If they were keen and hung around long enough sooner or later they’d get to do an appendectomy, or a circumcision, or excise a lipoma the size of a baseball. Ethically sound behavior? Mmmm. Not so much.

But it isn't just students. Trained physicians from wealthy countries also go to less well developed areas to offer their skills. Historically the pattern was for physicians to pack up their lives and go to live and work in an under-served area for many years. Yet in the last few decades the ease with which air travel and temporary accommodation can be arranged has changed this pattern. Now the opportunity exists for physicians to keep their ‘developed world lives’ relatively intact while taking a short trip to ‘do good’ somewhere else.

Do they do good? That's the million dollar question. While they may be motivated by good intentions there is no clear evidence that such activities are beneficial in an enduring way to the host countries. An oft-quoted paper points out that there IS benefit for physician who goes abroad for the brief stint, both for that physician personally and for his/her home country (because such people are more likely to work in under-served areas back home in their future careers). Trainers from leading humanitarian organizations acknowledge that one thing we DO know for sure is that there is always some harm that comes from even the most well-intentioned of humanitarian missions (see list of resources below).

Some of the ethical considerations and potential negative consequences of short term global health experiences were outlined in an influential 2008 JAMA article. The cynical term ‘voluntourism’ is perhaps a realistic descriptor of such activities, given their clear benefit for the traveler and much less clear benefit for the receiving community.

I think there is a particular difficulty for many who are fired up by the noble desire to ‘do good’ or ‘make a difference’ to stop and think about potential negative consequences of their well-intentioned behavior. Because how could giving up one’s time for the good of others be bad? Yet it is probably ‘placebo’ at best as some have argued “don’t go”. But realistically, without some Icelandic volcanic ash scenario in which all airplanes out of North America and Europe are grounded, physicians will continue to go abroad on global health ‘missions’. The only thing that we can do is increase awareness of ethical concerns, encourage physicians and students to think about scenarios ahead of time and endeavor to educate, educate, educate…. in the hope that the harm done by people going on global health experiences and humanitarian missions can be minimized.

The CMA meeting’s participants were top notch, representing all the main stakeholders leading the way in humanitarian activities and global health electives in Canada and some international players, perhaps with the notable exception of experts from countries who receive medical humanitarian missions and voluntourists. The CMA will produce an official report at the end of the process. In the mean time here are some educational and support tools that may be helpful to those who are thinking of going abroad to ‘do good’ in a medical way.

  • The Johns Hopkins Berman Institute of Bioethics collaborated with the Stanford Center for Innovation in Global Health to produce an excellent case based online course on Ethical Challenges in Short-Term Global Health Training. [This course is based on the guidelines on Ethics and best practice guidelines for training experiences in global health I mentioned earlier; it is widely understood that case studies are the best tools to teach applied ethics…best for pre-departure training, but also useful as an in-field resource and to assist debrief after return.]
  • HumEthNet, a website that developed out of empirical research on the ethical dilemmas faced by humanitarian healthcare professionals working in humanitarian crises, disasters or areas of extreme poverty.
  • The McGill Humanitarian Studies initiative, which offers the Canadian Disaster and Humanitarian Response Training Programs that range from an introductory course to an advanced program that includes simulation training.
  • The 53rd week, a non-profit organization that aims to maximize the benefits derived from short-term volunteer initiatives using innovation, education, and research.