TB screening prior to long term care admission: time to choose wisely

I recently had a patient who was accepted for admission into long-term care, and I completed the usual paperwork detailing their active problem list, past history, medications, vaccinations, and last chest x-ray (for TB screening purposes).

A few days later, I received a call from the long-term care home. The patient’s chest x-ray was not done recently enough. I checked the file. It was done 110 days ago. They wouldn’t accept my patient for admission unless they had a chest x-ray from the past 90 days (if under 65, they require a TB skin test if they have never had a previous positive test). “It’s in the provincial legislation” was the rationale. No room for any negotiation, it had to be done.

Every family doctor in Ontario has been in this exact same situation, likely multiple times a year, held hostage to order a test that intuitively seems of very little use. But I wanted to do a deeper dive on this issue to see where the genesis of this policy is, and to see whether changes should be made (spoiler alert: changes should definitely be made).

First, the legislation. Any health unit or long-term care home that makes reference to the legislation cites the same two pieces of legislation, the Long Term Care Homes Act from 2007 and the Retirement Homes Act from 2010. Here are the excerpts that make reference to tuberculosis:

The Long Term Care Homes Act 2007
(10) The licensee shall ensure that the following immunization and screening measures are in place:
1. Each resident admitted to the home must be screened for tuberculosis within 14 days of admission unless the resident has already been screened at some time in the 90 days prior to admission and the documented results of this screening are available to the licensee.
4. Staff is screened for tuberculosis and other infectious diseases in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices. O. Reg. 79/10, s. 229 (10)
Retirement Homes Act 2010
(8) The licensee of a retirement home shall ensure that,
(b) each resident is screened for tuberculosis within 14 days of commencing residency in the home, unless the resident has been screened not more than 90 days before commencing residency and the documented results of the screening are available to the licensee;
(c) each member of the staff has been screened for tuberculosis and all other infectious diseases that are appropriate in accordance with evidence-based practices or, if there are no such practices, in accordance with prevailing practices; and
(d) the screening for each of the infectious diseases described in clause (c) has been done using procedures that accord with evidence-based practices or, if there are no such practices, with prevailing practices. O. Reg. 166/11, s. 27 (8).

A couple of things to note. The legislation makes no specific mention of chest radiography, and does not explicitly state what form of “screening” is compulsory. Is screening for risk factors sufficient, or is it necessary to order a test of some sort?

What do the guidelines say? The Canadian Tuberculosis Standards were last updated in 2013 with the 7th edition, and chapter 15 is the relevant section for this topic (Prevention and Control of Tuberculosis Transmission in Health Care and Other Settings). Table 6 outlines the recommendations for TB screening in long-term care:

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“Baseline posterior-anterior and lateral chest radiography on admission for people >65 years old from identified populations.” Which populations? “People known to belong to an at-risk population group listed in the section ′′Identification of patients with active respiratory TB within hospitals′′. Here’s that list:

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So nearly all patients admitted to long-term care would meet at least one of these criteria, bring born prior to 1966. The rationale for the 1966 criteria is that the TB incidence rate in Canada prior to 1966 was similar to that in a high TB incidence country. The guidelines therefore state that these patients should have a baseline chest x-ray, but do not specify when this has to be done. There is absolutely no mention in the guidelines to any 90-day cutoff. According to the guidelines, for the TB skin test for those under 65 years old, a negative skin test in the past 12 months is sufficient.

What does clinical common sense dictate? One would think that a clinician should be able to look at the guidelines, look at the patient’s risk factors, and determine whether it is reasonable to repeat a chest x-ray given recent possible exposures. If a 90 year old patient had a chest x-ray during a hospitalization 4 months ago, and hasn’t left their home since, requiring them a repeat x-ray to rule out TB is lunacy. There is no reasonable explanation for why this can’t be left to clinical discretion. Keep in mind that a significant portion of admitted patients to long-term care homes have been hospitalized in the last year, likely receiving at least one chest x-ray, and have been waiting months for admission.

The selective insistence on overly prescriptive TB screening in long-term care homes has always struck me as odd. Yes, patients admitted to long-term care are higher risk for TB than their age-matched cohort. But we don’t insist on chest x-rays for high-risk individuals who are hospitalized for a non-respiratory cause. We don’t insist on chest x-rays for incarcerated individuals unless they will be in jail for over 1 year. We don’t insist on chest x-rays for all individuals spending time in a homeless shelter or drop-in centre. So why are we so militant with screening in long-term care, especially when most long-term care homes would be designated as low-risk according to the guidelines?

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The answer is clearly a desire for the ministry to avoid any medico-legal risks, but we need to base our decisions on more than just a fear of litigation. There has not been a single case of LTC-associated TB in London-Middlesex in at least the past two years (health unit is tracking down earlier data for me). Having spoken to local infectious disease experts, that is not necessarily a product of good screening, as they aren’t seeing any significant number of elderly patients with active TB detected through the screening process.

The logic of the “90-day chest x-ray” is also significantly flawed. I will grant that patients born in Canada prior to 1966 are higher risk for TB, and deserve a chest x-ray at some point prior to admission. But if they have been continually asymptomatic, why does this particular time point of admission deserve any further scrutiny? They have been asymptomatic for 50 years or more, and had a chest x-ray done at some point to rule out TB. Do we honestly think we are going to pick up TB that has magically decided to re-activate at the exact point the patient is admitted to long-term care? And what about if another patient has a normal chest x-ray at admission, but develops a non-productive, afebrile (likely viral) cough two months after admission? Is it not more likely that this symptomatic patient has TB than the patient who was asymptomatic at admission with a previous normal chest x-ray? The bottom line is that the hypothetical viral cough patient doesn’t need a chest x-ray, nor does the asymptomatic patient require a chest x-ray at admission if a previous chest x-ray was clear (with no other subsequent high-risk exposures since 1966). They’re both exceedingly low risk for TB.

With the way the legislation reads, I understand why Health Units and long-term care homes are interpreting it as they are, here, herehere, and everywhere. The long-term care homes are understandably fearful of inspections from the Ministry of Health that could find that they are not “compliant” with the legislation. The health units understandably want to be conservative in their recommendations, not leading any of their local long-term care homes to be “non-compliant”.

Without either 1) a change in legislation or 2) a public memo from the Ministry of Health clarifying the legislation and how it will be enforced, we’re not going to see any of the health units or the long term care (or retirement) homes make any changes in what is expected of physicians. Until we see a change from the ministry on this, we’re going to continue to be forced to order low-utility chest x-rays, wasting valuable health care dollars. One lifetime chest x-ray (with a physician review to rule out other subsequent high-risk features) should be sufficient for admission to long-term care in Ontario.

My Christmas wish-list for primary care in Ontario

It’s Christmas Eve, and I only have a few hours to articulate my demands (sorry, requests) to Santa for changes I want to see to our primary care system in Ontario. I won’t be going into a ton of detail on each point, because 1) family obligations are waiting, and 2) Santa needs time to put these into action before he arrives tonight.

Off we go…

  1. Increase the fee paid for consults in specialties across the board, and decrease the fees paid for follow-up visits by specialists (with the exception of time-based services, those will remain the same). OMA Economics can do the math to ensure this remains cost neutral. This will incentivize specialists to see new patients to help family doctors, reducing wait lists, while encouraging the discharging patients who can be easily and competently taken care of by their family doctor. Require that any consult billed is preceded by a new referral by another physician. Any diagnostic test performed by a physician requires a referral from another doc for that specific test (echocardiograms, holters, etc.). Any billed visit by a specialist for consult or follow-up must produce a note to be provided to the family doctor.
  2. Any walk-in clinic visit must produce a note to be provided to the family doctor. Yes, I realize a universal EMR would solve this problem with information going in both directions, but in the meantime, we need to improve communication.
  3. I’m still waiting for this wish to come true about transparency of office hours.
  4. Make second opinions by specialists for the same issue non-insurable by OHIP, and allow specialists to bill patients privately for those consultations. The logistics of this are challenging, but we first need consensus among physicians, the public, and the government, on the general premise of the idea, before moving forward with an implementation plan that will require significant electronic infrastructure (for checking consults by other physicians, etc).
  5. Make “physicals” non-insurable by OHIP, unless done for a pre-approved indication (cancer follow-up, weight loss, lymphadenopathy, etc). If a patient still requests a physical, they can be privately billed at OMA rates. Specify what tasks are exactly encompassed within a Periodic Health Examination, based on what methods of screening there is firm evidence for.
  6. Stop the practice of primary care physicians (paediatricians or family doctors) running large ambulatory clinics manned by nurse practitioners, where the physician bills OHIP and pays the NPs a wage or salary for their services. We don’t have the money in our system to pay doctors to be middle-men. A separate OHIP Schedule of Benefits strictly for delegated acts could be a possibility in under-serviced areas where non-MDs are necessary to maintain adequate patient care.
  7. Add shadow tracking codes for family physicians in FHOs or FHGs who correspond with patients via email or telephone (or any non-in-person visit). If they’re dealing with issues outside of a traditional visit, let’s give them credit for it.
  8. Fix the FHO out-of-basket service codes that are not a reflection of adequate access to primary care. An ER physician appropriately suturing a laceration for a patient who felt it was an emergency should not penalize their family physician.
  9. House calls performed by physicians outside of the group to whom the patient is rostered, should NOT be insurable through OHIP (exceptions being those with certification in palliative care). We should not be funding convenience visits for patients who saw an advertisement for “doctors who will come to your house!”

Alright Santa, there’s the list. Make it happen.

Making physician billings public? Here’s my proposal.

It’s an issue that predictably rears it head during any labour impasse between a government and physicians. Provincial governments calling for physicians to disclose their billings, in an attempt to characterize them as overpaid and greedy in the eyes of the public. The media often joins the action, looking for a juicy story. Members of the public will often chime in, asking where their health care dollars are being spent.

In Ontario, Minister of Health Eric Hoskins has raised the issue, offering to potentially exchange public disclosure of physician billings for the binding arbitration process that physicians are seeking. Putting aside the fact that physicians should be entitled to a fair dispute mechanism without having to make these concessions, I wondered whether there is a solution to be found (assuming that Dr. Hoskins is genuine in his offer).

Let me start by stating unequivocally that simply providing a list of total yearly billings sorted by physician should be a complete non-starter. That type of list, like the Blue Book provided in BC, gives us virtually no useful information. Doctor X made $250,000 in 2015. So what? That tells us nothing about what volume and type of service Doctor X provided. It’s a shaming exercise, and nothing more.

The argument often made in favour of disclosure of physicians billings is that it would provide a degree of accountability in the system that is currently lacking. However, providing only a total billing figure by physician does not provide enough detail to make any form of meaningful analysis.

Here’s what I would propose.

An online database where any citizen can search for any physician (search by name, specialty, billing number, or location), and view a itemized listing of what fee codes were billed by each physician by date. This database would not include any dollar amounts, either by code, date, or totals, again because these totals can be inflammatory without providing any value. The OHIP schedule of benefits is a separate document available to view for anyone, which lists the dollar amount for each fee code. The details in that document is where a debate can be had as to the relative appropriateness of each fee amount. The online database I am proposing should be solely focused on outlining what services physicians are claiming through OHIP, for full disclosure.

(An important exclusion to this disclosure would be fee codes involving abortion and medical aid in dying, in order to maintain the confidentiality and safety of the physicians involved).

I want to know how many patients Doctor X saw on Date Z, and what they were seen for. That is the information that we need to identify outliers. Was the volume and frequency of billing reasonable? How much the physician made should be of secondary importance, and can be debated fee code by fee code as a profession, but not by looking at a physician’s total billings. If an investigative journalist wants to data mine to determine what total amount each physician billed for a given time frame, they can certainly do so, but ethically they should be expected to describe the details of the thousands of services provided by the physicians to earn their billings.

I would also propose a database where patients can search, by their health card number, for what services were billed in their name, by fee code, date, and physician involved. There would need to be some additional security measures to ensure that only the patient themselves can access their billing history, as certain billing codes can easily disclose elements of their medical history. The current process for patients to access this information can take weeks, and is quite tedious, discouraging patients from inquiring about any questions about OHIP claims made in their name.

At this point, anyone proposing simply listing total yearly billings by physician is either doing for political gain, or through ignorance of the inadequacies of such a system. Many physicians are indeed open to system of disclosure of billings, but only under a carefully thought-out methodology that provides accountability without inappropriately vilifying hard-working physicians.

A few thoughts from last weekend’s OMA Council meeting…

With most of the Ontario medical community feverishly discussing the Auditor General’s report from Wednesday, I wanted to spend a bit of time reviewing what transpired at this past weekend’s OMA Fall Council meeting.

All of us in attendance knew that it would certainly be an eventful meeting, being the first Council meeting following the tPSA rejection, and with the backdrop of the Coalition of Ontario Doctors’ active petition to call for another General Members’ Meeting. I am always pleasantly surprised when the polarization and hyperbole of social media is replaced with generally cordial and thoughtful dialogue. I thought the meeting was productive, with a litany of provocative motions passed and the OMA board and executive seemingly committed to major changes.

However, reading many of the online posts and comments both during and after the meeting, it felt like I had attended a different meeting than a few of my fellow members. I understand that the primary goals of the Coalition remain the removal of the Executive and the voting of the President by membership (not Council), but painting the entire meeting with deceptive and misleading brushes does everyone a disservice, particularly engaged members who simply want to know the facts.

Failed motions that were posted on social media by members were chosen specifically to feed the narrative that the OMA is out of touch with membership. In many cases, the issue with the motion was simply a matter of word-smithing, and other motions with similar intent passed with near-unanimous support. The overwhelming tone of the meeting was in opposition to Bill 41, with many motions opposing Bill 41 in various iterations. However, when one motion about Bill 41 failed after a vigorous debate because of a concern about how it may be manipulated politically, it was posted online with the clear intent of misleading members into thinking that Council was somehow in favour of Bill 41. On one particular occasion, the original mover of the motion stepped into the social media discussion to point out that the dissenters actually gave a very good reason for opposing the motion. The debates around motions are so important to understanding the context of the issues, and members seeing only what motions were approved or defeated provides them virtually no meaningful information.

I am quite excited to have the Council meetings broadcast online in their entirety. If the events of Council are going to be manipulated by certain groups in how they are presented to members, then the benefits of transparency far outweigh any potential strategic advantage in keeping Council private from the eyes of the MOH. They need to be broadcast to remove the selective editorializing that is happening, because it is far too easy to disseminate misinformation and inflame existing tensions.

One of the more contentious debates was surrounding the Code of Conduct suggested by the Strategic Working Group. Many Council delegates raised concerns about whether inviting the CPSO to be further involved in the personal activities was wise, but the message that I heard from Dr. Athaide was that this was a policy in evolution. Members would be surveyed as to how a Code of Conduct should look (eg. should CPSO be involved, etc.), which was approved through a motion.

It was striking to me how different the overall tone was of this meeting compared to previous Council meetings I had attended. At previous meetings, I was a bit taken aback by how abrasively the Executive dealt with questions from members that they clearly disagreed with. It was very much a “We know best, please sit down” mentality. Now some may argue that they still saw some of that this past weekend, but I certainly felt that it was a marked change in overall tone. Much more conciliatory, much more willing to support motions rather than pick nits. I am still shocked that the Executive gave its support to the motion that called for “equal time and equal money” to opposition groups during any future general members’ votes. There were also a number of votes on motions where the recommendation of the Executive was ignored, which was also a  relatively new development. There is certainly no shortage of independent thinkers on Council, which is great for the strength of our organization.

Two new board members were elected, Dr. Silvana Bolano and Dr. Nadia Alam, both of whom have been sharp critics of the OMA and supporters of reform. Ousted were a current member of the Executive and a former member of the Negotiations Committee. Somehow that doesn’t count as “real change” in the eyes of some. We heard from the Strategic Working Group which provided 114 recommendations for how the OMA needs to move forward and learn from the disastrous events of this summer. We saw the report from Pricewaterhouse Coopers which detailed the chronology of the tPSA events, and a very clear signal from Council that many were hoping for more of an analysis rather than a simple chronology. We saw a motion approved that would see the “Moving Forward, Moving Together” document put together by Dr. Graham Slaughter’s grassroots group of physicians used to inform the work of a future Negotiations Committee. There was news that a governance map would be drawn up for the organization, to outline to members clearly how the labyrinth of the OMA is to be navigated. There were also promises for clearer instructions to members on who their reps are and how they can contact them. A motion passed that would have the OMA outline on their website the progress of all of the motions from Council, and another motion that would have the Board post their minutes on the OMA website.

Now of course these motions were mostly non-binding, but they show at least a general movement towards a more progressive organization. I’m optimistic.

The OMA still has a long way to go before re-establishing trust with many of its members. I hope that members who didn’t have a chance to attend Council continue to follow ongoing developments, and to ensure that the OMA follows through on their promises, but to do so by following sources that are committed to presenting objective information.

To quote an Ontario surgeon who was very active at Council: “I have seen the change firsthand over the past 18 months. It is slow and frustrating, and at times downright obnoxious, but is happening”.

2016: My year with the Cleveland Indians

I’m not sure the sting of losing in the 10th inning of Game 7 of the World Series will ever wear off. Getting so close to a championship and not closing the deal is excruciating, but over the past few days I’ve reminded myself of the importance of the journey rather than the destination. Even before the playoffs began, this had been the most memorable Indians season for me personally, and our playoff run was simply the cherry on top.

I want to remember the 2016 season vividly for the rest of my life, so it’s time for a diary of sorts. My own personal memories and interactions with the 2016 Cleveland Indians. (Warning: if you’re not a family member, or a really close friend, or an Indians fan, this post is going to bore the hell out of you. Even if you fall into those categories, you’ll probably still be bored. I’ll let you know when I write something more exciting.)

 

  • First decision to be made to start the season is about MLB.tv. Do I get the yearly subscription or the monthly subscription? Yearly ends up being cheaper over the course of the season, but if the Indians are out of contention by mid-season, it’s a huge waste. Verdict: I went for the yearly. I’m all in for 2016. I feel it, this is going to be the year.
  • May 31: Indians finish the day in 3rd in the AL Central, 2.5 games back of the Royals, after a 7-3 loss at home to the Rangers. Next night? Yan Gomes walk-off to beat the Rangers in 11 innings. Night after that? Come from behind victory 5-4 over the Royals. Momentum building just in time for me to arrive in Cleveland for the next 3 games against the Royals.
    •  Friday, Salazar is dominant, Cleveland wins. Oh, plus I got these cool sunglasses.

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    • Saturday, game starts with a 1-hour rain delay, during which I have my first interaction with Frankie Lindor. I’d heard plenty about how great he is with fans, and he didn’t disappoint. Oh, and the Indians win again with a stellar start from Tomlin. And a free retro Indians jersey. And Tyler Naquin’s first career home run!
    • Sunday we weren’t planning on going to the game since it looked like it would be rained out. We were having breakfast at Denny’s just outside of Cleveland, and as I was scanning the weather at around 12:30pm, the forecast looked clear for game time, so we decided to chance it. Let’s make it 3 for 3. Again, the Indians didn’t disappoint. Naquin, Santana, and Lindor all homer to right field in the 5th inning. The rain eventually did descend on Progressive Field for a lengthy delay, during which we started the drive back home. We listened to Tom Hamilton on WTAM for the end of another Indians victory.
  • In late June, I made the trek to St. Mary’s for the Canadian Baseball Hall of Fame inductions, where I had a chance to meet Dennis Martinez, hero of Game 6 of the 1995 ALCS for the Indians.

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  • July 1st: Canada Day. Jays vs. Indians in Toronto. We get some seats in the nosebleeds, literally sitting above the light standards. Before the game I had an interesting chat with Trevor Bauer about what he wanted to see happen after Roberto Perez returned from injury. He made a grimace that I will never forget (didn’t get a picture of it), since he had developed a close relationship with Chris Gimenez.

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Massive Canadian flag during the anthem, Edwin Encarnacion and John Gibbons ejected in the 1st inning, met up with an old med school buddy, our friends left in regulation, then the longest game in Blue Jays history, 19 innings. Pompey and Goins pitching for the Jays. Multiple chances to win for both teams. Bauer with 5 shutout innings, and a Santana homer to win it. 14th straight win. Elation.

  • Spent the next couple of days wandering around the Indians hotel looking for autographs. Yes, I realize I am an adult. But I’m a kid at heart. And hey, I have this neat souvenir now.

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  • The next two games in Toronto were awful, two losses, we blew through our bullpen, which eventually would lead to the releases of Chamberlain, Gorzelanny, and Hunter. I sat through a 17-1 Blue Jays win, which was probably karmic punishment for sneaking down to the expensive seats. Plus it was quite sunny, I didn’t wear sunscreen, and spent the whole game trying to hide in the shade created by the man sitting to my left. It certainly was not a Party at Napoli’s.
  • August 19th: Celebrating my wife Jess’s birthday a day early at our house. I was following the game against the Jays on my phone as she blew out her candles. Jose homers to tie the game in the 9th! Now we’re eating cake, but there’s no way I’m turning the TV on to watch the game. Phone loading….loading….Naquin inside-the-park home run to win the game. Um…pardon me? Indians fans would watch the highlights from this moment dozens more times this season. Incredible.
  • We were in Italy for the end of August as the Indians were heading towards the division title. With the time change, I was often up until 4am following the play by play on my phone. Everyone wondered why I was always napping so much in the car as we drove between cities…
  • September 26th: Indians clinch the AL Central! The next night my clinic finished a bit early so I drove down to Detroit to spend some time with what would be a hungover bunch. We lost 12-0, which meant the Indians had lost a combined 29-1 in the last two games I had attended. Eek.
  • Then the playoffs. Vanquished the Red Sox in 3 games. ALCS against the Jays. Watched all of game 1 on my phone at a friend’s wedding. Lindor with a 2-run blast to win it. Next day, Jess and I headed to Cleveland for Game 2 with some friends. Tomlin with a performance for the ages to put us up 2-0.
  • Game 5 in Toronto. I found some cheap tickets, and went to watch from the 500s with my brother-in-law. I was expecting the worst with Ryan Merritt on the hill. Instead, we’re leading 3-0 going into the late innings. We snuck down to the 100s for the last two innings (thanks for the heads up for the open seats to Kevin Hopper). Cody Allen in for the save and Santana with the catch in foul territory to end it. Pure elation. Dozens of Indians fans at the dugout celebrating the victory with our team. Being 10 feet away from Lindor seeing his tears of joy celebrating with family. Here I am after the victory.

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  • World Series Game 5. Chance to win the World Series on the road, but unsuccessful. Carved this pumpkin to let off some steam.

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And sure, the World Series didn’t end as planned, but I had one hell of a time with this team. They fought hard all season, dealt with injuries to multiple key players, and gave us moments to cherish for a life time.

Here’s hoping for a great 2017.

Spotting pseudoscience on social media

It sometimes feels like a tsunami. As social media becomes an integral part of our lives, scientific misinformation is being propagated at a faster rate than ever before. Videos, articles, memes, all cleverly designed to trick unsuspecting patients and consumers into thinking that their information has a grain of truth to them. Some are selling products directly, some are selling books or talks, and most are creating an environment of fear and mistrust of the medical system, which indirectly is used to sell various products and services.

So here are a few basic guidelines I want my patients to be aware of when trying to sift through what information is likely true and what is likely rubbish.

1) Look for the “store”

If you are reading something on a page that has a “store” button anywhere on it, it is likely that sales are driving the editorial policy of the website rather than any dedication to science. Supplements and herbal products are the usual products they sell, but these websites will sell just about anything that vulnerable patients will buy. They post information to create a disease or condition that needs treating from the products they sell, or just create a general mistrust of authority, which will result in higher long-term sales. Bottom line, if you see the “store”, it’s likely a terrible source of information.

2) Look for the buzzwords

Thankfully, most sites and sources with poor quality information give us a few obvious clues as to their motives. Many use the same marketing keywords that are designed to steer patients towards pseudoscientific treatments. In no particular order, these words are: natural, naturopathic, homeopathic, organic, toxins, detox, antioxidant, holistic, integrative, inflammation, functional, and wellness. There are hundreds more, but these are the main culprits. It is possible to be a reputable site and still use one or more of these words periodically, but when you see them, it should be a big red flag to be wary of the quality of information from that source.

3) Look at other information from the same source

Does every piece of information from the source follow the same basic narrative? Does the site that is telling you not to vaccinate your child also pushing 9/11 conspiracy theories? Does the chiropractor’s website telling you to go for routine adjustments also claim that doctors are maliciously hiding the cure for cancer? Sometimes it’s unfair to label all of an organization’s information as questionable based on one flawed belief or claim, but in many of these cases, if you do even a basic search, you will see that they have an agenda that goes well beyond that 2 minute Youtube video you just watched.

4) Look for citations

It’s too easy to make claims on the Internet without an ounce of solid evidence to back up those claims. If you encounter information that may change your beliefs on a certain topic, you need to spend ample time looking for whether proper studies have been done. A link to another questionable website or opinion piece does not count as reliable evidence. There is just too much of an incentive for quacks to spread misinformation that you cannot simply assume that all claims are equally deserving of your trust.

5) Ask a professional that you trust

There is nothing that I appreciate more than when a patient, friend, or family member, sends me a link to something that they want me to look over. Is it legitimate? Can it be trusted? In a time where ordinary citizens don’t have the time or expertise to sift through available reams of information, yet have tremendous access to both good and poor quality information, it is more important than ever to develop relationships with health professionals you trust. Professionals who can be looked to for critical analysis of any scientific topic, without bias or prejudice.

 

So go ahead, click on the link. Click on the video. But before you share it, or use it to guide you or your family’s health care journey, please apply these basic principles to decide whether it is likely accurate and trustworthy. We all need to play a role in ensuring that only high-quality information is propagated through our social network.

When World Series returns to Cleveland, time for game ops to show common sense

Year after year, every Cleveland Indians postseason appearance is predictably met with a few individuals who feel it is appropriate to show up to a game at Progressive Field wearing red face paint. These individuals are always shown prominently during the TV broadcast, and many of us with any sensibility squirm in our seats. The next morning’s sports shows inevitably re-litigate the appropriateness of the logo and nickname, and Cleveland fans are left trying to justify their team’s marketing strategy to friends and family, rather than basking in our team’s success.

I was optimistic after Game 1 and 2 of the ALDS in Cleveland, where it looked like the usual suspects had traded in their red face paint for white face paint in the design of a baseball. Sadly, I was at ALCS Game 2 in Cleveland, and was horrified to see multiple fans donning headdresses and wearing red face paint again. One particular individual wearing a headdress, walking up the aisle to his seat, thought it would be appropriate to put his hand to his mouth to make what he likely interpreted to be an “Indian war call”. The Jays fans next to me sat with their mouth agape as multiple fans joined the man in his mockery.

I understand the dilemma the team faces. Every time the topic of phasing out Chief Wahoo comes up, a large segment of the fan base threatens to “boycott” the team. And for a team that struggles at the turnstiles like the Indians, they have to be sensitive to any public relations issues with any fans.

But with the World Series returning to Cleveland next week for Game 6 and 7, I hope that the Indians game operations team can take a simple first step towards decency. If fans are seen at the entrance wearing any costume including red face paint, or a headdress, they can easily ensure that those materials aren’t allowed into the stadium. Is that somewhat hypocritical given that Wahoo’s face will still be everywhere? Sure, but baby steps.

Am I being too politically correct? Maybe. But I want the focus of the sports world to be on this terrific baseball team, not its logo, and I want to be able to enjoy our first championship since 1948 without spending every conversation discussing the nickname and logo. Let’s not bring any more negative attention to what should be the best week of our baseball lives.