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Background: Medical student investment in resource stewardship (RS) is essential as resource overuse continues among physicians, but it is unclear whether this is influenced by hidden curriculum. This study investigated medical student perceptions of Choosing Wisely Canada (CWC). Methods: Canadian Medical students completed a bilingual questionnaire. Chi-square and student’s T-tests were used to analyze Likert responses capturing student attitudes toward questions grouped by theme, including the importance of the CWC campaign, the amount of CWC represented in undergraduate medical curriculum, the application of CWC recommendations in medicine, and the barriers which exist to student advocacy for CWC in practice. Results: There were 3,239/11,754 (26.9%) respondents. While most students (n = 2,720/3,171; 85.8%) endorsed the importance of CWC, few students felt that their institution had sufficiently integrated CWC into pre-clerkship (47.0%) and clerkship (63.5%) curricula. Overall, 61.4% of students felt that it is reasonable to expect physicians to apply CWC recommendations given the workplace culture in medicine. Only 35.1% of students were comfortable addressing resource misuse with their preceptor. The most common barriers included the assumption that their preceptor was more knowledgeable (86.4%), concern over evaluations (66.0%), and concern for their reputation (31.2%).  Conclusions: Canadian medical students recognize the importance of CWC. However, many trainees feel that the workplace culture in medicine does not support the application of CWC recommendations. A power imbalance exists that prevents students from advocating for RS in practice.

Background This study sought to determine the impact of the pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease. Methods This is a population-based cohort study performed in the province of Nova Scotia (population 979,499), between Pre-COVID (March 1, 2017 – March 16, 2020) and in-COVID (March 17, 2020 – December 31, 2020) periods. Adult patients (≥18 years) with new onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest. Results In the first month of the in-COVID period, emergency department visits (n=51,750) for cardiac symptoms decreased by 20.8% (95% CI 14.0% - 27.0%, p<0.001). Cardiovascular hospitalizations (n=20 609) declined by 48.1% (95% CI 40.4% to 54.9%, p<0.001). In-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95%CI 10.1%-118%, p=0.013). A decline of 20.4% - 44.0% occurred in cardiovascular surgical/interventional procedures. Out-of-hospital cardiac arrests (n=5528) increased from a monthly mean of 115±15 to 136±14, beginning in May, 2020. Mortality for ambulatory patients awaiting cardiac intervention (n=14,083) increased from 0.16% (n=12501) to 2.49% (n=361) in the in-COVID period (p<0.0001). Conclusion This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during COVID-19, in an area with low burden of COVID-19 disease. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms and policy for delivery of cardiovascular care.

Background Melanoma is one of the most common cancers in Canada, 1 with the highest incidence in Nova Scotia (NS). Objectives To describe the demographics, lesion characteristics, and diagnostic accuracy of suspected melanomas excised at the largest center in NS. Methods The dermatopathology database was interrogated for cases of possible melanoma from 2015 through 2019. Age, gender, site of lesion, pathologic diagnosis, Breslow depth, and equivocal pathology were assessed. Results 984 lesions had a clinical diagnosis of possible melanoma, identifying 301 melanomas. Of these, 142 (47%) were melanoma in situ (MIS) which in females occurred mostly on the extremities, while in males the head predominated. For invasive melanoma (IM), the extremities remained predominant for women, while the back was most common in men. Lower extremity lesions were more likely to be invasive and female patients were more likely to present with them at a younger age compared to males. The pathology was challenging for 23.94% of MIS, and 16.18% of IM. A mean of 3.1 lesions were excised for every melanoma identified. Conclusions Early diagnosis of melanoma is challenging clinically and pathologically. Our melanoma detection rate was 31%, with an increasing trend in the proportion of MIS, and decreasing trend in the proportion of IM over the years. Almost 50% of melanomas were detected in early stages, supporting positive outcomes. Melanomas were more common on extremities in females and the back in males. Melanomas on the lower limbs were more likely to be invasive regardless of gender.

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