MUSA - Alberta Pharmacy Students' Association

UAHSJ 

www.uahsj.ualberta.ca 

ISSN 1712-4735 

3 

University of Alberta Summer 

Students’ Research Day 

8 

Clinical application and 

review of typical and atypical 

antipsychotics in the treatment 

of delusional parasitiosis 

13 

Stem cells in cardiac repair: 

A review of the chang ing 

landscape of cardiovascular 

medicine 

17 

Fine art in health sciences: 

Recognizing students who 

find time to make art 

University of Alberta 

Health Sciences Journal 

28 

A bite into the media’s image 

of nursing in an apocalyptic 

world 

30 

Albert Ross Tilley: The legacy 

of a Canadian plastic surgeon 

April 2012 • Volume 7 • Issue 1

UAHSJ www.uahsj.ualberta.ca 

University of Alberta Health 

Sciences Journal 

c/o Medical Students’ Association 

1-002 Katz Group Center for Pharmacy 

and Health Research 


Edmonton, AB 

T6G 2H7 

www.uahsj.ualberta.ca 

uahsj@ualberta.ca 

ISSN 1712-4735 

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Jennifer Chan 

Webmaster 

Jimmy Wang 


Health Sciences Journal 

April 2012 • Volume 7 • Issue 1 

Editors in Chief 

Andrew Taylor 

Sebastian Vrouwe 

Junior Editor 

Andrew Tang 

Editor of Musa 

Dr. Tamar Rubin 

Interim Faculty Advisor 

Dr. Fraser Brenneis 

Faulty Editor of Musa 

Dr. Pamela Brett-MacLean 

Editorial Board 

Matthew Benesch 

Alyssa Cruz 

Zachary Guenther 

Nathan Hoy 

David Lesniak 

Max Levine 

Jonathan Liu 

Babak Maghdoori 

Kevin Mowbrey 

Alim Nagji 

Andrew Tang 

Reji Thomas 

Publication Layout and Design 

Marketing and Communications 

Marketing Services 


Cover Image 

Katie Stringer 

Faculty Representatives 

Serena Westad 

(Pharmacy Undergraduate) 

Lisa Dollansky 

(Nursing Undergraduate) 

Coral Forrester 

(Nursing Graduate) 

Michelle Beveridge 

(Nutrition and Food Sciences) 

Liz Bolt (Medical Laboratory Sciences) 

Danielle Tingley 

(Dentistry and Dental Hygiene) 

Lauren Eastman 

(Medicine) 

Kayla Atkey 

(School of Public Health) 

Julia Esch 

(Rehabilitation Medicine) 

Mary-Pat Gibson 

(Summer Student Research)

Contents Editorial 

Commentary 

OSCE: The subjective experience of an objective exam 

Alim Nagji 2 

researCh 

Uncovering the role of topoisomerase II-beta binding 

protein 1 in DNA replication stress response 

Mark Assmus, Charles Leung, Mark Glover 3 

PAX3 expression in melanoma 

Zachary Tan and D. Alan Underhill 3 

Rosiglitazone decreases angiogenesis in the MCL after ACL 

rupture - A pilot study 

Christopher J. DeSutter, Daniel Miller, 

Catherine Leonard, Robert C. Bray 4 

review 

Clinical application and review of typical and atypical 

antipsychotics in the treatment of delusional parasitiosis 

Nathan Y. Hoy, Patricia T. Ting, Stewart Adams 8 

Stem cells in cardiac repair: A review of the changing 

landscape of cardiovascular medicine 

Nicholas A. Avdimiretz 13 

musa 

Fine art in health sciences: Recognizing students who find 

time to make art 

Sarah R. Stonehocker 17 

On the value of narrative reflective practice: A personal 

reflection 

Debbi Andrews 21 

It all began with a cup of tea: Introducing narrative reflective 

practice... 

Marie-Therese Cave, D. Jean Clandinin 23 

Enter stage right: An actor’s adventures in patient centred care 

Nadine L. Cross 27 

A bite into the media’s image of nursing in an apocalyptic 

world 

Sherrylynn Kerr 28 

Albert Ross Tilley: The legacy of a Canadian plastic surgeon 

Kevin S. Mowbrey 30 

The House of God still worth a read for today’s medical 

trainees 

Alby Richard 35 

As we enter the eighth year of the UAHSJ, we are excited to 

announce a number of changes. Two thousand and eleven was 

a transition year for the journal, with two major initiatives in 

the works. Emphasizing multidisciplinary involvement is an 

ongoing priority, and in the coming years we hope to continue 

this momentum by including other health sciences faculties 

and schools at the University of Alberta. We have reinstituted 

Faculty Representatives to aid in better distributing the journal 

and, most importantly, solicit even more submissions from 

the talented writers and researchers in our student body. On 

a similar note, we also look forward to working with other 

universities across Canada to widen both our readership and 

submissions base. 

There have been a number of content changes in the works at 

the UAHSJ. Beginning with this issue, we will focus on pieces 

geared towards a general health sciences reader: clinical and 

scientific reviews, summer student abstracts, book reviews, 

history of medicine pieces, medical education research, 

personal reflections, and letters. Our hope is that this will 

complement the push for more multidisciplinary involvement. 

Of course, none of this would be possible without the tireless 

efforts of the Journal’s contributors, our Editorial Board, and 

our new Junior Editor, Andrew Tang. We extend our thanks 

to the Faculty of Medicine and Dentistry for their generous 

financial support, and Dr. Fraser Brenneis, Vice-Dean of 

Education, who took the time to guide and advise us through 

the publication of this issue. Finally, we would like to warmly 

welcome Dr. Tamar Rubin, a PGY-1 resident in Pediatrics, who 

has assumed the role of Editor of Musa. Tamar has extensive 

experience in both literary writing and the medical humanities. 

Many thanks to Dr. Pamela Brett-MacLean, who originally 

conceived Musa and will now carry on as its Faculty Editor. 

Yours, 

Sebastian Vrouwe and Andrew Taylor 

Editors in Chief 

University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 1 

CONTENTS / EDITORIAL 

RESEARCH

COMMENTARY 

OSCE: The subjective experience of an objective exam 

Alim Nagji, BHSc 

Medical Student (2012), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

Correspondence to Alim Nagji, Email: anagji@ualberta.ca 

Abstract 

The Objective Structured Clinical Examination (OSCE) is the 

primary modality for testing clinical skills throughout medical 

school and in residency training. This article explores the difficulties 

of the exam via the subjective perspective of a student in the 

system, commenting on reticent standardized patients, the lack 

of consensus on what makes an ideal medical student and the 

absence of feedback. As the exam celebrates nearly four decades in 

use, it is important that we continue to evaluate its usefulness and 

brainstorm innovative approaches to advancing the state of clinical 

examinations. 

The Objective Structure Clinical Examination (OSCE) has rapidly 

become the leading clinical examination in North American Medical 

Schools. The unassailable champion of repetitive and reproducible 

evaluation, it has become the envy of all other tests. While multiple 

choice still holds a prominent position in most medical curricula, 

that is usually for the convenience of administering the test and the 

sheer volume of information one can sift through. As a learner, one 

has had ample time to exploit the system, mastering the nuances of 

the “all of the following EXCEPT” and “which answer is the BEST” 

questions. In reality, we have been asked this type of question since 

kindergarten and the PBS specials we grew up on sang “one of these 

things is not like the other one.” 1 

The OSCE is succinctly explained in the abstract of a 1975 BMJ article: 

“the examination is more objective and a marking strategy can be 

decided in advance.” 2 The veracity of the latter half of this requirement 

is evidenced by the rubric style approach of many modern OSCEs. 

However, the first part is where the interesting dilemma lies. Is the 

examination more objective? From the subjective experience of 

students, it would hardly seem so. 

The variability lies in the innate qualities of both the “standardized 

patient” and the examiner. Having worked as a standardized patient, 

the instructions one often receives is to be as guarded as possible 

about information, refraining from volunteering details unless 

specifically probed. This is in direct contrast to the guidance offered 

in basic history taking skills, where students are counselled to allow 

the patient to convey the narrative of their illness uninterrupted. For 

those that have participated in OSCEs, it is easy to recall those actors 

from whom information had to be stolen as if it were precious gems. 

From many a station I have walked out and, in conversation with 

my peers in different tracks, realized that another “standardized” 

patient had been much more forthcoming with a pivotal piece of the 

diagnostic puzzle. 

In Rowntree’s 17 proposals for better assessment, he notes that 

“there is an assumption rampant in talk of academic standards, 

that all qualified assessors feel, understand and judge in much the 

same way when confronted with the work of a particular student. 

It is presumed that they would notice and value the same skills and 

qualities and would broadly agree in their assessments. Abundant 

evidence attests to the falsity of such assumptions.” 3 In the same 

2 

way, examiners vary widely in their preferences of what they believe 

makes the ideal learner. One need only glance at the complicated 

medical admission system or the behemoth that is the Canadian 

Resident Matching Service (CaRMS) to realize that we cannot agree 

on the perfect model student, yet we continue to cling to antiquated 

standards so as to maintain a united front. Despite the broad 

accusations suggesting poor inter-rater reliability across a variety 

of domains, 4 OSCE examinations remain a mainstay of evaluation 

despite their artificial construction and potentially variable 

environment. 

In the same seminal article, the authors proclaim that the 

“examination results in improved feed-back to students and staff.” 2 

This may hold true for the teaching OSCEs, where 2 minutes of 

personalized commentary follows each station, but for the majority 

of exams in medicine, the results are protected and not released. So 

while occasionally one may receive a grade or score sheet, one is 

left waiting for the commentary that can enhance clinical skills or 

refine an approach. The majority of instructors emphasize the need 

to train physicians, not test takers, yet the very nature of receiving a 

pass or a fail undermines the learning process. Research has shown 

that overall, detailed, descriptive feedback was found to be most 

effective when given alone, unaccompanied by grades or praise, the 

direct opposite of what students usually receive. 5 The OSCE has 

significant advantages over multiple choice questions, providing a 

rich opportunity for students to simulate patient encounters and 

maintain some degree of standardization. However, it’s limitations 

and shortcomings should be discussed, rather than disputed. The 

modern OSCE, nearly 40 years after its rise to prominence, seems 

stagnant in the face of the rapid change in the medical community. 

Perhaps as we enter a new decade of medical education we can 

critique our instruments, as well as our students, and develop 

innovative models to evaluate competence in clinical skills. 

1. Cooney, J.G. (creator). Seasame Street [Television Series]. New York: 

PBS 1969. 

2. Harden, R. McG. Stevenson, M., Downie, W.W. & Wilson, G.M. 

Assessment of clinical competence using objective structured 

examinations. British Medical Journal 1975;I: 447. 

3. Rowntree, D. Assessing students: how shall we know them? 

London: Kogan Page 1977. As cited in: Harden, R., Gleeson, F.A. 

Assessment of clinical competence using an objective structured 

clinical examination (OSCE). Medical Education 1979;13(1):39-54. 

4. Thistlethwaite, JE. Developing an OSCE station to assess the 

ability of medical students to share information and decisions 

with patients: issues relating to interrater reliability and the use of 

simulated patients. Educ Health (Abingdon) 2002;15(2):170-9. 

5. Lipnevich, A.A., Smith, J.K. Response to assessment feedback: The 

effects of grades, praise and sources of information. Retrieved from 

ProQuest Digital Dissertations 2008; 3319438. 

University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

University of Alberta Summer Students’ Research Day 

In 2011, over 200 undergraduate students participated in the Faculty of Medicine & Dentistry Summer Student 

Research Program. On October 15, 175 students presented posters at the 44th Annual Summer Students’ Research 

Day. Listed below are the 14 finalists from the poster competition. We congratulate the finalists and all participants. 

From these 14 finalists, two students were selected to represent the 

University of Alberta at the annual National Students’ Research 

Forum in Galveston, Texas. Their abstracts are presented below. 

Uncovering the role of topoisomerase II-beta 

binding protein 1 in dna replication stress response 

Mark Assmus, Charles Leung, Mark Glover 

DNA replication stress can lead to genomic instability which has 

been shown to be one of the primary hallmarks of cancer. TopBP1 is a 

crucial mediator protein found within the replication stress response 

in mammalian cells. TopBP1 activates Ataxia telangiectasia mutated 

related (ATR) kinase which phosphorylates many of the downstream 

substrates to initiate this response. The replication stress response 

involves specific interactions between the nine BRCA1 C terminus 

(BRCT) domains of TopBP1 and various proteins. More specifically, 

TopBP1 has been shown to provide an essential role in interacting 

with both ATR-interacting protein (ATRIP), Rad9-Rad1-Hus1 (9-1-1) 

complex as well as Mediator of DNA damage checkpoint protein 1 

(MDC1) which are all essential components of the response pathway. 

The crystal structure of TopBP1 BRCT 4/5 in complex with MDC1 was 

previously solved in our lab. The structure shows a unique mode of 

TopBP1 binding to MDC1 that involves the dimerization of two BRCT 

4/5 molecules. In an effort to further examine this interaction, I used 

a fluorescence polarization (FP) binding assay involving an MDC1 

FITC labelled di-phospho-peptide. I was able to express and purify 

GST fusion proteins of TopBP1 BRCT 4/5 and TopBP1 BRCT 5, as well 

as TopBP1 BRCT 5 alone, which were used for further FP studies. 

The results of the FP assays indicated that it is the BRCT 5 binding 

pocket which is primarily responsible for the interaction with MDC1 

and that the dimerization induced by GST allows for tighter binding. 

Additionally, mutant constructs of the putative BRCT 5 binding 

pocket were designed, successfully over-expressed and purified. 

The FP assays showed decreases in binding affinity associated with 

mutation of key conserved residues in the binding pocket. FP was 

also used to confirm that the phosphorylation of the MDC1 peptide 

is essential for TopBP1 BRCT 4/5 recognition. Taken together, these 

FP results further support the unique dimerization-based binding 

mechanism suggested by the crystal structure. 

PaX3 expression in melanoma 

Zachary Tan and D. Alan Underhill 

The transcription factor PAX3 is critical for development of neural 

crest lineages including melanocytes. Prior to birth, PAX3 is 

required for the proliferation of melanocyte precursors and it is 

thought to maintain an ‘undifferentiated plastic state’ in epidermal 

melanocytes after birth, as well in melanocyte stem cells. In 

addition, PAX3 is expressed throughout melanoma progression, 

from nevi to metastatic disease. Nevertheless, little is known about 

how PAX3 carries out these diverse roles. PAX3 is reported to be 

phosphorylated by Glycogen Synthase Kinase 3ß (GSK3ß). In the 

present study, the potential role of this kinase in modulating PAX3 

activity in B16F10 melanoma cells was examined using chemical 

inhibitors. Fluorescence Activated Cell Sorting (FACS) was used 

to assess cell cycle distribution and PAX3 levels were monitored 

by immunoblotting. Treatment of cells with the GSK3ß inhibitors 

lithium chloride (LiCl) or BIO caused decreased cell proliferation 

(P=0.05) and G2/M accumulation (P=0.05), and was associated 

with increased PAX3 expression (P=0.05). In contrast, knockdown 

of PAX3 using siRNA resulted in G1 accumulation (P=0.05). 

Immunofluorescence techniques for exogenous BrdU incorporation 

and endogenous PS10H3 allowed for direct microscopic visualization 

and quantification of cells in S and G2/M phase respectively. Upon 

PAX3 knockdown, there was significantly less BrdU incorporation 

and PS10H3 staining (P=0.05). Lastly, cell motility assays were 

conducted using live-cell Differential Interference Contrast (DIC) 

microscopy and analyzed using T-Scratch software. Interestingly, 

inhibition of GSK3ß as well as PAX3 knockdown was associated 

with markedly decreased cellular motility and proliferation. These 

investigations identify GSK3ß and as an important modulator of 

PAX3 levels in melanoma cells, and also suggest broader roles for 

PAX3 in regulating the G1 to S-phase transition in melanoma. 

Student Poster Title Supervisor 

Mark Assmus Uncovering the role of topoisomerase II-beta 

binding protein 1 in DNA replication stress 

response 

Christopher 

Beavington 

Department/ 

Division 

Dr. Mark Glover Biochemistry 


Alanna 

Chomyn 

The structural studies of bacterial lactoferrin 

binding protein B from Neisseria meningitides 

Isolation of trkA expressing and IB4-binding 

sensory neurons through the use of saporin 

Nicholas Chua A model system for complex redox enzyme 

maturation 

Alexandru 

Cojocaru 

Michelina 

Kierzek 

Using inhibition of protein N-myristoylation 

towards the design of a synthetically lethal 

treatment of B-cell lymphomas 

Elucidating the molecular mechanisms 

of heart disease-linked mutations of 

phospholamban 

Stephanie Mah Capase 1 Inhibition in inflammatory bowel 

disease reduces epithelial cell extrusion 

Scott Meyer Investigating the quinone binding site of 

Escherichia coli fumarate reductase 

Robyn Millott The novel interaction between 

N-myristoyltransferase 1 and calnexin 

Kian Parseyan Proposed improvements for intraspinal 

microstimulation array fabrication and 

insertion 

Amit Persad Expression of ST8Sia family in developing 

chick retina and their role in AP2deltamediated 

axonal generation 

Raheem 

Suleman 

Does long life come from mom? Isolation of 

a longevity-conferring mitochondrial DNA 

mutation in Caenorhabditis elegans 

Dr. Joanne Lemieux Biochemistry 

Dr. Christine Webber Anatomy 

Dr. Joel H. Weiner Biochemistry 

Dr. Luc G. 

Berthiaume 

Cell Biology 

Dr. Howard S. Young Biochemistry 

Dr. Julia Liu Medicine/ 

Gastroenterology 

Dr. Joel H. Weiner Biochemistry 

Dr. Marek Michalak Biochemistry 

Dr. Vivian K. 

Mushahwar 

Cell Biology 

Dr. Roseline Godbout Oncology 

Dr. Bernard D. 

Lemire 

Biochemistry 

Zachary Tan PAX3 expression in melanoma Dr. Alan Underhill Oncology 

Terri Waller Partial deficiency of adipose trigylceride 

lipase (ATGL) does not protect against 

diabetes-induced cardiac dysfunction 

Dr. Jason R.B. Dyck Pediatrics 

RESEARCH

RESEARCH 

Rosiglitazone decreases angiogenesis in the 

MCL after ACL rupture - A pilot study 

Christopher J. DeSutter, BSc, 1 Daniel Miller, MD PhD, 2 Catherine Leonard, MSc, 2 Robert C. Bray, MD, MSc 2 

1Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

2McCaig Centre for Joint Injury and Arthritis Research, University of Calgary, Calgary, Canada 

Correspondence and reprint requests to Dr. R. Bray, Department of Surgery, University of Calgary, 3330 Hospital Dr. NW, 

Calgary, Alberta, Canada T2N 4N1, Ph: (403) 220-4244, Fax: (403) 270-0617, Email: rcbray@ucalgary.ca 

ABSTRACT 

In the anterior cruciate ligament (ACL) 

transected knee, the medial collateral 

ligament (MCL) incurs numerous 

physiological changes that include 

inflammation and increased angiogenic 

activity resulting in functional deficiency. 

Peroxisome proliferator activated receptor - 

γ(PPAR-γ) agonists show promising results 

for their possible use in osteoarthritis 

therapies, but there are limited studies 

looking at their effects in this area. The 

purpose of this study was to examine the 

effect the PPAR-γ agonist rosiglitazone 

has on the angiogenic response in the 

osteoarthritic rabbit model. Six rabbits were 

assigned to one of three groups: control 

(n=2); 4-week right leg ACL transected 

(ACL-X) (n=2); 4-week right leg ACL-X 

treated with 5 mg/kg per day of rosiglitazone 

(n=2). The two contralateral MCLs in 

the 4-week ACL-X rabbits treated with 

rosiglitazone were also used as the drug 

treated non-ACL transected leg control. In 

total 8 MCLs were analyzed. To measure 

the blood vessel volume and angiogenic 

response in the MCLs, the vascular 

endothelium (CD-31) and vascular smooth 

muscle (SMA) volumes of them were 

determined. In the ACL-X rosiglitazone 

treated MCL, CD-31 volume decreased 

3-fold down to control levels, in comparison 

to non-treated ACL-X MCLs. Rosiglitazone 

had a significant effect on SMA, causing 

decreased volume in comparison to non – 

treated MCLs. In summary, rosiglitazone 

has a significant effect on the angiogenic 

response in the ACL ruptured animal model. 

INTRODUCTION 

Joint injury and arthritis are major causes 

of morbidity in the United States. One 

of the most clinically important ligament 

injuries that occur is to the anterior cruciate 

ligament (ACL). Each year in the USA, there 

are 80,000 surgical ACL reconstructions 

performed. 1, 2 Patients possessing ACL 

ruptures often complain of recurring loss 

of joint stability that often leads to the 

4 

premature onset of osteoarthritis, the 

most common type of degenerative joint 

3, 4 disease. 

In the knee, ACL rupture results in anterior 

translation of the tibia in relationship 

to the femur resulting in joint laxity 

(Figure 1). This abnormal biomechanical 

environment in an ACL ruptured knee is 

not only detrimental to cartilage health, but 

induces a series of adaptive structural and 

physiological changes in secondary joint 

stabilizing structures. There is angiogenesis, 

hyperaemia, inflammation and increased 

cellularity in the ligaments, meniscus, 

capsule and synovium of the knee joint. 5-7 In 

the medial collateral ligament (MCL) there 

is increased blood flow, increased DNA and 

RNA synthesis and cellularity7-10 Due to 

the properties of the MCL being degraded, 

this leads to further cartilage degeneration 

and altered joint mechanics in the ACL 

ruptured knee. 11 

There is limited information available on 

how this physiological adaptation occurs. 

The modification of adaptive changes in 

osteoarthritic tissues has the potential to 

provide new information on underlying 

mechanisms, leading to new therapies for 

osteoarthritis. The peroxisome proliferator 

–activated receptors (PPAR) agonist drugs 

show great promise in this area as a 

potential therapeutic treatment. 

PPAR agonists are ligand activated 

transcription factors that are part of the 

nuclear hormone super family. 12 Three 

different isotypes have been identified: 

PPAR-α, PPAR-β and PPAR-γ. These 

PPAR endogenous ligands form a diverse 

group of fatty acids with their derivatives 

generated by lipid metabolism. 12 Recently, 

Figure 1. Anterior view of the knee detailing the major ligaments, bones, menisci and 

tendons. UpToDate (2011). Anterior knee anatomy adult. http://www.uptodate.com/contents/ 

image?imageKey=RHEUM%2F26531 (accessed August 7, 2011). 


it has been found that PPAR-γ agonists are 

involved in vascular biology, inflammatory 

responses, tissue repair, cell differentiation 

and proliferation. 12-15 In arthritic 

synoviocytes, PPAR-γ agonists greatly 

inhibit inflammatory cytokine expression. 16 

PPAR-γ agonists have also been expressed in 

human chondrocytes acting as a protective 

17, 18 

mechanism for cartilage. 

PPAR-γ agonists have therapeutic potential 

in a variety of clinical conditions. There is 

literature showing PPAR-γ agonists role in 

fat metabolism and their anti-inflammatory 

actions shown through their effect on 

inhibiting cytokine expression. 19, 20 There 

are limited published studies looking at the 

effect of PPAR-γ agonists in osteoarthritis 

models. One study by Kobayashi et al., 

using a partial medial menisectomy 

guinea pig model, found that the PPAR-γ 

agonist pioglitazone reduced cartilage 

lesion depth and area. 21 By studying the 

effect of the PPAR-γ agonist rosiglitazone 

on the adaptive physiological response 

in ACL ruptured knees (specifically the 

angiogenic activity), its potential as a new 

therapy to treat osteoarthritic patients can 

be determined. 

The purpose of this study is to examine the 

effect of the PPAR-γ agonist rosiglitazone on 

the physiological and angiogenic responses 

in the rabbit model of joint laxity and 

osteoarthritis. The rabbit model was chosen 

as we can compare the results obtained 

to our established database on adaptive 

physiology in rabbit ACL – ruptured joints. 

It is hypothesized that PPAR-γ agonists 

will decrease physiological degeneration 

of the MCL in the ACL ruptured knee. 

The blood vessel volume and degree of 

angiogenesis occurring in the MCL of the 

ACL ruptured knees will be measured using 

immunohistochemistry for specific markers 

for vascular endothelium (CD-31) and 

vascular smooth muscle (SMA) in the MCL. 

MATERIALS AND METHODS 

Subjects 

Six young skeletally mature 1-year-old New 

Zealand white rabbits (4.5 - 6.5kg; Riemans 

Fur Ranch, St. Agatha, Ontario) were 

assigned to one of three groups: control 

(n=2); 4-week right leg ACL transected 

(ACL-X) (n=2); 4-week right leg ACL-X 

treated with a low dose of 5 mg/kg /day of 

rosiglitazone (n=2). The two contralateral 

MCLs in the 4-week ACL-X rabbits treated 

with rosiglitazone were used as the drug 

treated non-ACL ruptured leg controls. This 

results in a total of 8 MCLs analyzed in this 

study. Rabbits were kept on a 12 – hour 

light/dark cycle and fed standard laboratory 

chow and tap water ad libitum. All animals 

were treated and maintained according 

to the Canadian Council on Animal Care 

guidelines and this study received approval 

by the University of Calgary Faculty of 

Medicine Animal Care Committee. 

aCL transection and 

Rosiglitazone injections 

Rabbits were given 0.18 mL of acepromazine 

maleate (Atravet ®) intravenously and 

anesthetized with halothane (2-5%, 1.0 L/ 

min O ). All ACL transection surgeries were 

2 

completed on the right leg of the rabbits. 

An anterior tibial draw test was performed 

on the right leg to ensure no prior ACL 

injury existed. The anterior tibial draw test 

was done by grasping the tibia with both 

hands below the joint line, thumbs placed 

on either side of the patella, with the tibia 

pulled anteriorly. 

An antero-lateral surgical approach was 

used. The ligament was exposed by lateral 

subluxation of the patella and reflection 

of the intra-articular fat pad. The ACL was 

isolated using a hooked probe and the 

ligament was transected at the middle with 

a #12 hooked blade. A second anterior 

tibial draw was performed to ensure the 

transection was complete. Following the 

unilateral surgery, rabbits were treated with 

standard antibiotics and allowed to resume 

normal cage activity for four weeks. 

Rosiglitazone treated animals were injected 

subcutaneously with a low dose of 5 mg/ 

kg of body weight per day for a total of four 

weeks. In the ACL-X rabbits, injections 

began on the day following the ACL 

transection surgery. Since the contralateral 

MCL was used as the non-operated leg 

rosiglitazone treated control, the 4-week 

drug treatment was simultaneous. At the 

beginning and end of the 4-week dosing 

period, anterior tibial draw tests were 

completed on the left leg to ensure no ACL 

injury existed. 

Immunohistochemistry 

MCLs were sectioned and labeled for CD-31 

and SMA according to the following doublelabel 

protocol. Rabbits were euthanized then 

the MCLs were harvested from control, ACL 

ruptured and rosiglitazone treated knees 

then cleaned of any extra tissue. Tissues were 

cryopreserved in serial sucrose solutions 

of 10%, 20% and 30% concentrations. 

Following cryoprotection, ligaments were 

frozen in isopentane at -80°C, embedded 

in OCT media then stored at -30°C for one 

month until processing. MCLs were cut into 

100 μm thick longitudinal serial sections and 

placed individually in 24 well plastic plates. 

Sections were washed in phosphate buffered 

saline (PBS) (3 x 10 minutes) then immersed 

in 10% normal donkey serum (Jackson 

Immunoresearch, West Grove, PA, USA)/ 

PBS 1% Triton X100 for 1 hour at room 

temperature. MCLs were then incubated 

with mouse anti-human CD-31 antibody 

(1:50 dilution; Dako, Carpinteria, CA, USA) 

for 24 hours at 4°C in a humidified chamber. 

Sections were washed in PBS (3 x 10 

minutes) and incubated with donkey antimouse 

Cy5 conjugated secondary antibody 

(1:300 dilution; Jackson Immunoresearch, 

West Grove, PA, USA) for 2 hours at room 

temperature. Sections were washed in 

PBS (3 x 10 minutes) then incubated with 

goat anti-human smooth muscle actin 

(SMA) antibody (1:400 dilution, Novus 

Biologicals, Littleton, CO, USA) for 24 hours 

at 4°C, followed by further PBS washes 

and incubation with donkey anti-goat Cy2 

conjugated antibody (1:400 dilution; Jackson 

Immunoresearch, West Grove, PA, USA) 

for 2 hours at room temperature. Sections 

were then washed for a final time, placed 

on slides with Fluorsave TM (Calbiochem, 

Mississauga, Ontario) and coverslipped. 

Slides were stored in a cardboard slide 

holder to protect fluorescence loss due 

to light. 

Confocal Microscopy 

MCL sections were analyzed using an 

Olympus Fluoview FV-1000 confocal 

microscope. They were visualized under a 

10x objective and imaged using 4-micron 

thick optical z-stack sections. Simultaneous 

dual channel scanning laser confocal 

analysis was performed using preconfigured 

Cy2 and Cy5 channel settings. Images were 

saved in the OIF file format. 

Statistical analysis 

The CD-31 and SMA volumes found in 

the MCL were determined using Image 

J software. The volumes of CD-31 and 

SMA in each image were put into an excel 

spreadsheet and then summed together to 

get a total volume converted into milliliters 

for each ligament. The volumes of CD-31 

and SMA for each MCL type had their 

averages calculated. Since there are only two 

subjects per group, the mean and the range 

of data was the chosen method of statistical 

analysis. If the subjects in each group had 

increased numbers, inferential analysis 

using a two – way ANOVA would have been 

preferred for comparative purposes. By using 

this method of analysis, one could then 

interpret if rosiglitazone has an effect on the 

angiogenic response in this pilot study. 


RESEARCH

RESEARCH 

RESULTS 

To quantify the blood vessel volume and 

the angiogenic response in the MCL of 

normal, ACL ruptured and rosiglitazone 

treated knees the CD-31 and SMA volumes 

were determined. Figure 2 shows that in 

control (non-drug treated) animals, MCL 

CD-31 volume ranged from 0.077 mL to 

0.118 mL with an average of 0.097 mL. CD- 

31 volume ranged from 0.291 mL to 0.307 

mL with an average of 0.299 mL in the 

MCL of ACL transected knees (Figure 2). 

In the rosiglitazone treated unoperated 

leg MCL, CD-31 volume ranged from 

0.077 mL to 0.131 mL with an average of 

0.104 mL (Figure 2). In the ACL transected 

rosiglitazone treated MCL, CD-31 volume 

averaged 0.119 mL and ranged from 0.099 

6 

mL to 0.139 mL (Figure 2). Thus, the 3-fold 

increase in CD-31 volume of the MCL in 

the ACL transected knees was mitigated by 

treatment with rosiglitazone. 

To further quantify the angiogenic response 

the volume of SMA was measured. Figure 3 

shows that in control (non-drug treated) 

animals, MCL SMA volume ranged from 

0.128 mL to 0.153 mL equating to an 

average of 0.141 mL. In the ACL transected 

knee the average SMA volume was 0.191 

mL and ranged from 0.162 mL to 0.221 

mL (Figure 3). In the rosiglitazone treated 

animals, unoperated leg MCL SMA volume 

average was 0.037 mL and ranged from 

0.029 mL to 0.045 mL (Figure 3). In the ACL 

transected rosiglitazone treated MCL, SMA 

volume average was 0.050 mL and ranged 

Figure 2. Mean vascular endothelium volume and range in the MCL. There is a 3-fold increase in vascular 

endothelium volume in the ACL transected non- drug treated knee MCLs as compared with control and 

rosiglitazone treated MCLs. 

Figure 3. Mean vascular smooth muscle volume and range in the MCL. In the ACL transected knee MCL 

and control knee MCL, there is a 4 and 3 fold increase respectively for vascular smooth muscle volume as 

compared to rosiglitazone treated MCLs. 

from 0.049 mL to 0.051 mL (Figure 3). This 

represents an approximate 4-fold increase 

in SMA volume in the ACL ruptured 

knee MCL over control and rosiglitazone 

treated MCLs. 

DISCUSSION 

ACL rupture causes numerous 

morphological and histological changes in 

human cartilage which includes osteophyte 

formation, increased surface roughening, 

increased tissue water content, increased 

cellularity, collagen fibril organization and 

biochemical alterations. 22-29 In addition 

to the detrimental changes to cartilage 

health, there are a number of structural 

and physiological adaptations found in 

secondary joint stabilizing structures in 

the knee. In the MCL, this has included 

increased DNA and RNA synthesis, 

increased blood flow, cellularity and scar 

like tissue formation. 7-10 All of these changes 

result in significant long-term consequences 

for the human patient that includes 

considerable pain, degenerative joint disease 

and osteoarthritis. 

Angiogenesis is a complex process, which 

involves the development of new vessels 

from existing ones. These new vessels 

grow in response to inflammation, injury, 

hypoxia and increased metabolic need. 30 

As the MCL of the ACL ruptured knee may 

experience all of these factors, angiogenesis 

may prove crucial to the viability of the 

tissue. Unfortunately, growth of new blood 

vessels in supporting connective tissues of 

an ACL ruptured joint may compromise its 

mechanical properties and lead to further 

tissue degradation and inflammation. These 

new angiogenic vessels are deficient in 

several ways compared with more mature 

vessels. Angiogenic vessels are considered 

chronically “leaky” and allow for greater 

tissue exudation and leukocyte diapedesis. 31 

Increased fluid exudation can increase the 

creep and decrease low-level stress – strain 

mechanics of the MCL. 32 This state is 

evident when qualitatively analyzing the 

images captured by the confocal microscope. 

In the ACL ruptured MCLs, the CD-31 and 

SMA labeling was denser in comparison to 

control MCLs. Further, increased leukocyte 

content may exacerbate the inflammatory 

conditions of the joint and prolong 

inflammation in the ACL ruptured knee. 30 

PPAR-γ agonists have been found to be 

involved in vascular biology, inflammatory 

responses, tissue repair, cell differentiation 

and proliferation. 12-15 In one study, a PPAR-γ 

agonist was found to be expressed in 

rheumatoid synovial, osteoarthritic, and 

normal cells. 16 In another, 15d-PGJ and 2 


trioglitazone greatly inhibited inflammatory 

cytokine expression, inhibited proteoglycan 

degradation, MMP-1, MMP-13 and 

17, 18 

interleukin-1β production. 

To look at the role of PPAR-γ agonists on 

the angiogenic response following ACL 

rupture and its effect on secondary joint 

stabilizing structures, rabbits were given a 

low dose of 5 mg/kg /day of rosiglitazone 

for four weeks then had their MCLs CD-31 

and SMA volumes measured. This dose was 

chosen to see if levels less than 30 mg/kg 

used in another in vivo osteoarthritic guinea 

pig model study would be an effective 

treatment. 21 No rabbit had any ACL injury 

prior to surgery or injections. Quantification 

of the vascularity in the MCLs showed 

a significant 3-fold increase in vascular 

volume as identified by the volumetric CD- 

31 antibody label in the ACL transected 

knees versus controls. When looking at 

the effects of the rosiglitazone treatment, 

the vascular volumes of the treated ACL 

transected MCL was reduced to near 

control MCL levels. Overall, rosiglitazone 

has the ability to limit excess vascular 

endothelium development in the MCL after 

ACL transection. 

Quantification of the SMA volumes in the 

MCLs by volumetric SMA antibody labelling 

was also performed. Rosiglitazone caused 

a reduction in SMA volume over untreated 

ACL ruptured knees. An unexpected finding 

in this study compared to other studies was 

the similarity between SMA volumes in ACL 

ruptured MCLs and non-operated control 

MCLs. Another unexpected finding was that 

the control MCLs had a much greater SMA 

volume than the rosiglitazone treated MCLs, 

while CD-31 volumes in these groups were 

similar. A possible reason for these findings 

could be that the rosiglitazone treatment 

may affect the production of MMP-13 and 

interleukin-1β differently. In one study, the 

PPAR-γ agonist pioglitazone was shown 

to decrease interleukin-1β and MMP-13. 33 

Interleukin-1β is an angiogenic initiator 

effecting endothelial cell production. MMP- 

13 is a factor released from endothelial 

cells, which plays a role in the degradation 

of fibrous collagens, facilitating vascular 

smooth muscle and adventitial cell 

migration and proliferation. If rosiglitazone 

affects MMP-13 more than interleukin-1β 

this will lead to decreased smooth muscle 

production. Decreased levels of smooth 

muscle may contribute to endothelial 

dysfunction and decreased responsiveness 

of MCL vasculature, which has been found 

in ACL ruptured osteoarthritis models. 34 

Future studies with increased subjects per 

group, varying dosages of rosiglitazone and 

measurement of markers for interleukin-1β 

and MMP-13 need to be conducted to gain 

a better understanding of the mechanisms 

that are occurring. 

This study has two inherent weaknesses, 

which can confound the results obtained. 

First, there are only two subjects per group, 

which is quite low compared to a number 

of other rabbit studies conducted. 10, 34 In 

those cases, there were usually minimums 

of 6 rabbits per group. The second limitation 

was the use of the contralateral MCL in the 

rosiglitazone treated rabbits. Due to the 

budgetary constraints of the study, the cost 

incurred to treat separate control rabbits 

with rosiglitazone and increased subjects per 

group would not have been feasible. 

Based on our results, it seems that the 

rosiglitazone treatment has a significant 

impact on decreasing angiogenic activity 

in the MCL of the ACL ruptured rabbit 

model. Due to the reduced angiogenic 

activity, the use of this PPAR-γ agonist could 

prove beneficial in reducing the negative 

effects angiogenesis has on the structural 

and physiological properties of the MCL 

in response to an ACL ruptured human 

knee. Rosiglitazone may prove beneficial in 

other secondary stabilizing structures and 

components in the knee. Further studies 

looking at the effects of rosiglitazone on 

these structures by using RT-PCR, cartilage 

and meniscal grading, blood flow imaging of 

the MCL and biomechanical testing of the 

MCL are thus warranted. 

Overall, quantification of the vasculature of 

the MCL of ACL ruptured and rosiglitazone 

treated knees by confocal microscopy has 

shown that rosiglitazone significantly 

decreased the angiogenic and physiological 

degeneration of the MCL. Vascular 

endothelium volumes returned to near 

control levels in rosiglitazone treated MCLs 

in ACL ruptured knees while vascular smooth 

muscle volume was lower in rosiglitazone 

treated versus non – treated MCLs. 

ACKNOWLEDGEMENTS 

The authors wish to thank the Canadian 

Institute for Health Research (CIHR) for 

providing the operating funds for this 

project. The authors also thank Tim Leonard 

from the Human Performance Laboratory 

at the University of Calgary for his 

technical support provided for the confocal 

microscope. 

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1 Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

2 Deparment of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, Canada 

3 Department of Dermatology, University of Calgary, Calgary, Canada 

Correspondence and reprint requests to: Nathan Hoy, #110 Beddington Co-op Mall, 8220 Centre St. N.E., 

Calgary, Alberta, Canada T3K 1J7, Ph: (780) 289-3383, Fax: (403) 275-1143, Email: nhoy@ualberta.ca 

ABSTRACT 

Background: Delusional parasitosis (DP) 

is a monosymptomatic hypochondrial 

psychosis characterized by a false belief 

that one is infected with parasites. 

Traditionally, treatment revolved around 

typical antipsychotics, especially pimozide. 

Pimozide’s adverse effect profile and the 

advent of atypical antipsychotics have made 

the latter the treatment of choice. Given the 

paucity of randomized control trials and 

relatively recent introduction of atypicals, 

little is known about their efficacy in the 

treatment of DP. 

Objective: The purpose of this study is to 

review the evidence for the efficacy and use 

of both typical and atypical antipsychotics 

as treatment modalities for DP, with a 

specific emphasis on the newer atypical 

pharmacologics. As well, we aim to provide 

suggestions on how best to implement 

treatment in a dermatological setting. 

Methods: Medline and EMBASE were 

searched for available literature for both 


types of antipsychotics used in the treatment 

of DP. A systematic review was not 

completed to allow for discussion of clinical 

application of treatment. 

Results: Risperidone and olanzapine are 

currently the most commonly used atypical 

antipsychotics in DP treatment and are 

as efficacious as pimozide (full or partial 

remission rates of 68% and 90% respectively 

vs. pimozide average of 79%), and have 

fewer side effects. Other atypicals such as 

quetiapine, aripiprazole and paliperidone 

as well as risperidone long acting injections 

have demonstrated promising remission 

rates > 75% in a limited number of patients, 

but still require further studies to be 

considered first-line therapies. 

Conclusion: Limited clinical studies 

with small study populations implicate 

risperidone and olanzapine as first line 

treatments, but more randomized control 

trials are needed. We also review methods 

of how dermatologists may best initiate 

treatment with atypical antipsychotics. 

Keywords: Delusional parasitosis, atypical 

antipsychotics, typical antipsychotics, 

treatment 

INTRODUCTION 

Delusional parasitosis is a 

monosymptomatic hypochondrial psychosis 

characterized by an unwavering false 

belief that one is infected with parasites. 1 

Thieberge first described this disorder in 

1894, and the name delusional parasitosis 

(DP) was introduced in 1946. 2 The 

prevalence of DP is not well established, 

but is considered rare. Overall, the femaleto-male 

ratio of affected individuals is 

approximately 2:1, with the mean age of 

diagnosis being slightly higher for females 

than males (mean age, 50 years to 40 years). 3 

The classification of DP is as either primary 

or secondary. Primary DP is characterized 

by a somatic delusion lasting for at least 

1 month, whereby patients do not meet 

criterion A for schizophrenia and there can 

be no underlying cause of the delusion. 4 

Secondary DP results from the use of a 

substance, organic causes, or other medical 

or psychiatric disorders with the most 

common causes being schizophrenia, 

diabetes, depression, cardiovascular 

events, and neurodegenerative disease. A 

comprehensive review of other secondary 

causes of DP is discussed by Huber et al. 

(2007). 5 

Given that DP is a somatic delusion, patients 

often initially present to dermatologists 

instead of psychiatrists with symptoms of 

pruritis, crawling sensations attributed to the 

presence of parasites under the skin leading 

to secondary excoriations, lichenification, 

prurigo nodularis and full thickness 

ulcers. 6, 7 Commonly, patients bring in 

samples of skin in small boxes as proof 

that the parasites exist; this stereotypical 

presentation is referred to as “the matchbox 

sign.” 8 Furthermore, patients may attempt 

to rid these “parasites” with anti-scabetic 

permethrin cream or even perform harmful 

skin cleansing rituals with disinfectants 

or pesticides. 9 

METHODS 

Treatment of DP requires the differentiation 

between the primary and secondary forms. 

Treatment of secondary DP relies on treating 

the underlying cause or cessation of the 

offending drug. 10 Treatment of primary DP 

has mostly revolved around typical and the 

newer atypical antipsychotics, which have 

differing mechanisms of action compared 

to typical antipsychotics. We conducted a 

literature search using combinations of the 

search terms: delusion*, parasitosis, typical, 

atypical, antipsychotics and treatment, in 

EMBASE and PubMed inclusive of studies 

published prior to May 1, 2010. For studies 

involving typical antipsychotics, only those 

with n≥20 (including placebo group) were 

reviewed, since these represent the most 

influential studies on which the basis of 

typical antipsychotic treatment is formed. 

Due to the relatively recent introduction 

of atypical antipsychotics in the treatment 

of DP, the n values for these studies were 

significantly smaller; thus sample size was 

not used as a definitive exclusion criterion. 

We included at least one study for each 

atypical. The criteria we considered included 

the size of the study, with preference being 

given to larger sample sizes; whether or 

not numerous atypicals were compared 

within the same study, to control for variable 

treatment practices; and how well the 

study represented the general treatment 

population with respect to disease severity, 

co-morbidities and age. 

RESULTS 

Typical antipsychotics 

The most common typical antipsychotic 

used in the treatment of DP is pimozide. 11 

Pimozide is an approved treatment for 

Gilles de la Tourette syndrome in the United 

States, but it has also been shown to have 

a therapeutic effect for numerous offlabel 

disorders, such as DP. 10-19 Pimozide’s 

primary mechanism of action is via central 

Dopamine-receptor D2 antagonism. 12 One 

advantage of pimozide over other typical 

antipsychotics is its weak noradrenergic 

receptor blockade effect which reduces 

adverse side effects such as orthostatic 

hypotension and dizziness. 14 

A number of case reports, case series, and 

double-blind crossover trials showing 

the effects of pimozide in DP have been 

conducted (summarized in Table 1) 15-19 . 

The first double-blind crossover study was 

performed by Hamann and Avnstorp (1982) 

which demonstrated that 10 out of 11 DP 

patients had a decrease in Brief Psychiatric 

Rating Scale points and improvement of 

delusion and itching following 6 weeks 

of treatment with pimozide, while only 

one patient from the placebo group 

experienced improvement in the 4 week 

evaluation period. 15 In 1986, another 

double-blind crossover study showed 

significant improvement in 10 DP patients 

administered 2-8 mg/day of pimozide for 

3 weeks followed by a relapse following 2 

weeks of placebo treatment and subsequent 

improvement when pimozide was restarted. 

Improvement was based on the authors’ 

own rating scale using symptoms of DP. 13 

Although these studies used a placebo 

control, the results are limited by the 

small sample size (i.e. n=11 and n=10 

13, 15 

respectively). 

The rates of partial and full remission are 

variable amongst studies with pimozide. 

Zomer et al. (1998) found a partial to full 

remission rate of 61% (11 out of 18 patients) 

in patients treated with pimozide compared 

to 20% (3 out of 15) in the non-treatment 

group. 16 A survey conducted by Lyell (1983) 

demonstrated 44 of 66 patients treated 

with pimozide demonstrated full or partial 

remission (combined remission rate of 

67%). 17 Partial and full remission of DP in 

patients treated with pimozide have been 

reported as high as 87% (n = 46)18 to 100% 

(n=10). 13 

The long-term efficacy of treatment with 

pimozide was demonstrated in a follow-up 

study by Lindskov and Baadsgaard (1985). 19 

Fourteen patients were followed up between 

19 and 48 months after termination of 

pimozide treatment. Seven patients had 

improved, while 4 had deterioration of 

their symptoms and 3 had relapses that 

responded well to intermittent pimozide 

treatment. 

A systematic review conducted by Lepping 

et al. (2007) found a total of 92 patients 

treated with typical antipsychotics for 

primary DP. Of those 92, 40 (43%) 

had partial remission, 45 (49%) had 

full remission and 7 (8%) showed no 

improvement or were lost to follow-up. 10 Of 

the 53 patients treated with pimozide, 50 

had either full or partial remission (94%), 


REVIEW

REVIEW 

Table 1: Efficacy of typical antipsychotics in treatment of DOP 

10 

Study 

Hamann and Avnstorp 

1982 15 

Ungvari and Vlader 

1986 13 

Sample 

Size Treatment Dose 

Duration of 

treatment or 

follow-up 

Number of 

patients with 

full or partial 

remission (%) 

Number of patients 

with no change in 

symptoms (%) 

n=11 Pimozide 1-5 mg/day 6 weeks 10 (91 1 (9) 0 


with deterioration 

of condition (%) Additional notes 

n=9 Placebo N/A 4 weeks 1 (9) 0 8 (73) Two lost to follow-up for 

senility (n=1) and extensive 

relapse (n=1) 

n=10 Pimozide 2-8 mg/day 3 weeks 10 (100) 0 0 

n=10 Placebo N/A 2 weeks 0 1 (10) 9 (90) 

Zomer et al. 1998 16 n=18 Pimozide 1-5 mg/day 3-4 weeks 11 (61) 0 7 (39) 

n=15 None N/A 3 (20) 12 (80) 0 

Lyell 1983 17 n=66 Pimozide 2-12 mg/day N/A 44 (67) 16 (24) 0 6 lost to follow-up 

Bhatia et al. 2000 18 n=46 Pimozide 4-8 mg/day N/A 40 (87) 0 6 (13) 

Lindskov and 

Baadsgaard 1985 19 

n=14 Pimozide Unknown 19-48 weeks 

after termination 

of treatment 

Table 2: Efficacy of atypical antipsychotics in treatment of DOP 

Atypical Antipsychotic 

Treatment 

Sample 

Size Dose 


with full or partial 

remission (%) 


with no change in 

symptoms (%) 

7 (50) 0 4 (29) Three patients with relapses 

but responded to intermittent 

treatment 


with deterioration of 

condition (%) 

Number of patients lost 

to follow up (%) 

Risperidone 24-28 41 0.25-5 mg/day 28 (68) 1 (2) 0 7 (29) lost to follow up; 

4 were switched to other 

drugs for varying reasons 

including requiring a different 

antipsychotic for co-morbid 

psychiatric disease, and 

intolerance of risperidone; 

1 took it once and refused to 

continue medication 

Olanzapine 25,26,28 10 2.5-20 mg/day 9 (90) 0 0 1 (10) 

Quetiapine 27, 28 2 100-150 mg/day 2 (100) 0 0 

Aripiprazole 30-32 4 10-15 mg/day 3(75) 0 0 1 (25) 

Paliperidone 33 1 3 mg/day 1 (100) 0 0 

RLAI 29 1 25-37.5 mg IM 1 (100) 0 0 

while 3 patients were non-compliant with 

treatment. 10 Of note, the sample sizes for the 

other typical antipsychotic treatments were 

relatively small. 

atypical antipsychotics 

Atypical antipsychotics differ from typical 

antipsychotics in their various mechanisms 

of action and are generally associated with 

less extrapyramidal symptoms. Meltzer et 

al. (1989) 20 proposed that a preference for 

5-HT2A receptor antagonism rather than 

DA D2 receptor antagonism distinguishes 

this class of drugs, although a number of 

other hypotheses question this. 21, 22 Atypical 

antipsychotics used in the treatment of 

DP that will be discussed are risperidone, 

olanzapine, quetiapine, aripiprazole, and 

paliperidone (Table 2). 

A number of case series have utilized 

risperidone as the main treatment modality 

for DP. Gallucci and Beard23 first established 

risperidone as a potential treatment of DP. 

Overall, of the 41 cases of DP treated with 

risperidone that we reviewed, 28 had a full 

or partial remission, one had no change in 

symptoms and 12 were lost to follow up or 

were switched to another drug during the 

treatment course – reasons for switching 

medications include co-morbidities that 

could be simultaneously treated with 

DP using another drug and unspecified 

intolerance of risperidone (Table 2). 24-28 

The most recent and largest retrospective 

case study followed 20 patients utilizing 

atypical antipsychotics for DP. 26 Fifteen 

patients were treated with risperidone as 

the main atypical antipsychotic and 10 of 

them had full or partial remission, while 5 

were lost to follow-up. Five patients were 

treated with olanzapine as the main atypical 


antipsychotic. Of these patients, 4 had full or 

partial remission, and 1 was lost to follow up. 

Another case series compared 4 patients 

treated with risperidone and one 

treated with quetiapine. 27 Three of the 4 

risperidone-treated patients experienced 

total resolution of delusions; one of these 

three patients was also on lithium, another 

was on sertraline and alprazolam as well, 

and another was also on sertraline and 

donepezil. The last risperidone treated 

patient had a decrease in delusions and was 

on no other medications. The patient treated 

with quetiapine showed partial remission 

and was also on venlafaxine, clonazepam, 

buspirone and bupropion. 

Shah and Pervez (2009) published only 

the second case report for the use of 

risperidone long-acting injections (RLAI). 29 

The patient refused to take oral risperidone, 

but accepted RLAI 25 mg IM every 2 weeks. 

This dosage was titrated up to 37.5 mg IM 

on discharge and she then switched to 5 

mg/day PO risperidone. Her symptoms 

improved, although complete remission was 

not achieved. 

There are also newer atypical antipsychotics 

whose efficacy in the treatment of DP 

has only been documented in a limited 

number of case studies. One example is 

aripiprazole. 30-32 Rocha and Hara (2007) 

documented the first case of aripiprazole 

treatment in an 85 year old DP patient 

and she underwent full remission. 30 In 

a subsequent study, 2 patients with DP 

were treated with aripiprazole and both 

had complete remission. 31 Paliperidone, an 

atypical antipsychotic approved by the FDA 

in 2006, has only been used in one DP case, 

where an 88 year old man treated with the 

drug underwent complete remission. 33 

DISCUSSION 

Our review of typical antipsychotics 

indicates that pimozide is an effective 

treatment option for DP. The rates of full 

or partial remission were similar to the 

numbers reported in a systematic review by 

Lepping et al. (2007). 10 There have been a 

number of smaller case reports and studies 

utilizing other typical antipsychotics such as 

haloperidol, trifluoperazine, flupenthixol and 

fluphenazine depot, all of which showed 

excellent rates of full or partial remission. 10 

Despite the past successes of pimozide, it is 

no longer considered first-line treatment of 

DP, due to the advent of the safer atypical 

antipsychotics. 34 

Furthermore, the long-term use of pimozide 

is associated with a number of adverse 

side effects. Extrapyramidal symptoms 

such as tardive dyskinesia, parkinsonism 

and akathisia occur in less than 10-15% 

of patients treated with pimozide for 

schizophrenia, and Gilles de la Tourette 

Syndrome. 11 It has also been associated 

with clinically significant QT interval 

c 

prolongation, including Torsades de Pointes, 

possibly due to the calcium channel 

blocking effects of the drug. 7, 14, 35 These side 

effects, especially its cardiac effects and 

drug interactions (drugs metabolized by 

cytochrome P450 isoenzyme 3A4), make 

pimozide a non-ideal DP therapy. 34 

Much less is known about atypical 

antipsychotics, because of their relatively 

recent introduction compared to typical 

antipsychotics. The largest review to date 

of atypical antipsychotic use in DP was 

conducted in 2008 by Freudenmann and 

Lepping, 34 which concluded that atypical 

antipsychotics should be the first line 

therapy for DP. 

The atypical antipsychotics with the largest 

sample sizes in our review were risperidone 

and olanzapine. Risperidone has been 

established as the most common atypical 

antipsychotic used in the treatment of DP. 

The particular effectiveness of this drug has 

been linked to its high affinity for 5-HT2 receptors, a receptor which has been linked 

to psychotic processes and perceptual 

differences. 12 Although risperidone’s 

side effect profile is superior to that of 

typical antipsychotics, there are instances 

where parkinsonism and akathisia have 

been produced by its use and it has been 

associated with a mild increase in metabolic 

syndrome. 32 An added benefit of risperidone 

is that it is the only atypical antipsychotic 

available as a long-acting depot. Long acting 

injections are particularly useful in patients 

who are demonstrating harmful behaviours 

and refusing to comply with oral treatment. 

The goal of such a treatment would be 

to help the patient accept their problem 

is psychological and thus comply with 

oral therapy. 

Olanzapine is the second most common 

atypical antipsychotic used in DP 

treatment. 34 Its side effect profile is also 

superior to that of pimozide and it rarely 

causes extrapyramidal syndrome. However, 

this medication is closely associated with 

metabolic syndrome and sedation. 32 Its use 

is still limited by a smaller body of evidence, 

but the fact that three patients treated with 

risperidone were switched to olanzapine 

due to intolerance suggests it may be a more 

tolerable drug. 25 

Quetiapine had an excellent remission rate, 

but with a small sample size (n=2), more 

studies must be done in order to assess its 

use in the treatment of DP. Freudenmann 

and Lepping (2008) found a full or partial 

remission rate of 88% after reviewing 8 

cases. 34 The side effect profile of quetiapine 

is generally limited to drowsiness, dizziness 

and postural hypotension, with minimal 

risk of extrapyramidal symptoms or adverse 

cardiac effects. 36 Quetiapine’s excellent 

side effect profile combined with its high 

remission rate makes it a potential treatment 

for DP. 

The results of aripiprazole treatment in DP 

have only been published for 4 patients to 

date with all 4 demonstrating full or partial 

remission. 23-25 There have not been any 

randomized control trials or placebo cross 

over studies performed with aripiprazole 

and DP, but the case study results are 

promising. Adverse effects of aripiprazole 

include nausea and akathisia, but it is nonsedating 

and less often associated with 

extrapyramidal symptoms and metabolic 

disturbances. 37 This excellent side effect 

profile may make it beneficial to DP patients 

who cannot tolerate the side effects of 

other antipsychotics. 

Paliperidone is the latest atypical 

antipsychotic used in the treatment of DP. 

Paliperidone is the main active metabolite 

of risperidone and it blocks 5-HT and D - 

2A 2 

receptors. It has a long half-life of 24 hours, 

which decreases the number of daily doses. 

As well, it decreases the risk of any potential 

adverse drug reactions, which is especially 

important because many DP patients have 

numerous co-morbidities being treated 

simultaneously. 33 The clinical efficacy of 

paliperidone as a treatment for DP needs 

to be confirmed by further case studies or 

randomized control trials. 

CLINICAL IMPLICATIONS 

Diagnosis of DP is definitely within the 

scope of a dermatology practice. However, 

the psychological basis of the disorder 

makes initiating therapy in a dermatologist 

office challenging. Patients often feel as 

if their symptoms are not being seriously 

considered when the dermatologist tries 

to explain that the disease is psychotic in 

nature. Referral to a psychiatrist is often 

met with anger and frustration, resulting 

in the patient either seeking the opinion 

of another dermatologist or resorting to 

self-treatment, which may be potentially 

harmful. 10 It may be prudent to ask the 

patient’s thoughts on you consulting an 

expert colleague who deals with similar 

conditions more frequently. This will open 

the door to discussing the management 

plan with a psychiatrist, while empowering 

the patient to be actively involved in the 

treatment decision. 


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In the event a patient demands a skin 

biopsy, it may be worthwhile to do one 

rather than risk losing rapport with the 

patient. Koo and Lee (2001) suggest making 

a verbal agreement beforehand, and that 

the patient be more flexible in his or her 

thinking if the biopsy returns negative; this 

may make it easier to convince the patient 

to take antipsychotic medications after 

the biopsy. 8 When antipsychotic therapy 

is initiated, it is advisable to offer the 

medication as an empirical therapy while 

emphasizing the potential for reduction 

in symptoms, like biting and crawling 

sensations. 8 Potential side effects of the 

antipsychotics should be discussed with 

the patient beforehand, to enhance patient 

compliance. Considering the patient’s comorbidities 

when selecting the particular 

antipsychotic to be used can help tailor 

the choice; for example, in a patient with 

diabetes, olanzapine should be avoided 

due to its potential for metabolic syndrome 

side effects. Depot injections (risperidone) 

should only be pursued as an option 

if the patient is willing to be regularly 

monitored by a psychiatric team. Working 

in conjunction with the patient’s family 

physician to monitor both the side effects of 

the antipsychotic medication and course of 

the DP will reduce the risks of complications 

from the therapy, especially if the patient 

refuses the involvement of psychiatry. 

CONCLUSION 

There has never been a randomized 

control trial directly comparing atypical 

antipsychotics to typical antipsychotics, 

which would be useful in establishing a 

clear treatment of choice for DP. 10 However, 

based on the efficacy of drugs in both 

classes as shown in Tables 1 and 2, it would 

appear that atypical antipsychotics have a 

lower side effect profile while achieving a 

partial to full remission rate similar to typical 

antipsychotics. The reduction in adverse 

iatrogenic events would improve patient 

compliance to treatment and help construct 

a therapeutic relationship between the 

patient and physician. 

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FA. A clinical paradigm of delusions 

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P,Schonfeldt-Lecuona C. Secondary 

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36. Milia A, Mascia MG, Pilia G, Paribello 

A, Murgia D, Cocco E, et al. Efficacy 

and safety of quetiapine treatment for 

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2008;31:310-2. 

Stem cells in cardiac repair: A review of the changing 

landscape of cardiovascular medicine 

Nicholas A. Avdimiretz, BSc 

Medical Student (2013), Faculty of Medicine and Dentistry University of Alberta, Edmonton, Canada 

Correspondence to Nicholas Avdimiretz: Email: naa1@ualberta.ca 

Abstract 

Cardiac disease is the leading cause of death 

for both men and women in developed 

countries. In Canada, the incidence of 

diabetes and hypertension has recently 

increased by 90% in middle income groups, 

resulting in substantially more cardiac 

disease. How can medical professionals 

keep up with these statistics? Imagine if 

physicians could regenerate the wounded 

heart post-myocardial infarction, or even 

bioengineer an entirely new organ. This 

is the future of cardiovascular medicine. 

Regenerating myocardium is hardly an easy 

undertaking; the heart contains about 20 

million cardiomyocytes per gram of tissue, 

meaning – in the left ventricle alone – there 

are approximately 4 billion cardiomyocytes 

at risk during a heart attack. Many cells are 

required to replace damaged tissue, making 

complete regeneration challenging. In light 

of the rich therapeutic potential seen in 

both adult and embryonic stem cells, it is no 

surprise that biomedical research on these 

cells has seen an intense amount of activity 

in the past decade. From fetal-derived 

cardiomyocytes and skeletal myoblasts, to 

bone marrow stromal cells and peripheral 

blood CD34 + cells, a myriad of cell lines 

have been tested to date. The last decade 

has seen an explosion of novel approaches 

using these cells to restore cardiac function 

post-infarction: from developing cell-based 

pacemakers and cardiac grafts, to building 

bioartifical hearts. This review will paint a 

picture of the rapidly changing landscape 

of cardiovascular medicine by elaborating 

on these new technologies. Limitations 

of these approaches will be discussed, as 

well as future developments. In the field of 

cell-based cardiac repair, the possibilities 

seem endless. 

Preamble 

Cardiac disease is the leading cause 

of death for both men and women in 

developed countries. In fact, cardiovascular 

disease – including coronary heart disease, 

hypertension, stroke, and congestive heart 

failure – has ranked as the number one 

cause of death in the US every year since 

1900, except during the 1918 influenza 

epidemic. 1 In 2007, heart disease accounted 

for 26% of all deaths in the US, resulting 

in an age-adjusted death rate of 211 per 

100,000 people. 2 Also shocking is the cost 

of medication, health care services, and lost 

productivity due to heart disease in the US: 

a projected $508 billion in 2010. 3 This cost 

is not expected to decrease any time soon. 

In Canada, the incidence of risk factors for 

cardiac disease has increased substantially 

over the past decade: both diabetes and 

hypertension have increased by 90% in 

middle income groups (roughly 50% of 

the population), 4 resulting in substantially 

more cardiovascular disease. What if there 

existed a therapeutic technique to treat that 

which physicians have for so long deemed 

incurable? What if one could regenerate the 

wounded heart after a myocardial infarction 

using stem cells? Imagine if one could 

bioengineer a new heart. This could be the 

future of cardiovascular medicine. 

Over the last decade, the utilization of 

stem cells to repair the damaged heart has 

seen an explosion of advancements. Novel 

therapeutic techniques will be addressed in 

detail: the methods used and the resulting 

applications of these innovations will be 

described. Limitations of these techniques 

and future developments will also be 

reviewed. 

37. Narayan V, Ashfaq M, Haddad PM. 

Aripiprazole in the treatment of primary 

delusional parasitosis. Br J Psychiatry. 

2008;193:258. 

Introduction to Cardiac Repair 

Cell therapy has experienced much 

growth over the last 25-30 years: from 

its first applications for reconstituting 

the immune system after a bone marrow 

transplant, to treating diabetes with 

pancreatic islet transplantation. 5 More recent 

treatments include those for liver cirrhosis, 

Huntington’s disease, and Parkinson’s 

disease. 6 As for heart disease, the majority 

of therapies have been centered on the 

treatment of heart damage post-myocardial 

infarction (MI). How can myocardial repair 

occur in an organ that is thought to be 

incapable of naturally self-repairing itself? 

The heart does not experience regeneration 

as the liver does; following MI, scar tissue 

forms over the infarcted area. Therefore, 

much of the research has been geared 

towards using cell-based approaches to 

regenerate myocardium directly from 

donor stem cells. Regenerating heart 

muscle following an MI is hardly an easy 

undertaking; the myocardium contains 

about 20 million cardiomyocytes per gram of 

tissue, so there are approximately 4 billion 

cardiomyocytes at risk in the left ventricle 

alone during a heart attack. Assuming 

that any repair therapy restores at least 

1/2 to 2/3 of the damaged myocardium, 

true regeneration would require 500 to 800 

million cells. 7 In light of the therapeutic 

potential seen in both adult and embryonic 

stem cells (coined ES cells by Martin in 

1981), 8 it is no surprise that biomedical 

research on these cells has seen an intense 

amount of activity in the past decade. 

Stem Cell Sources 

Stem cells not only have an unlimited 

capacity to self-renew, but they are also 

pluripotent; this means that stem cells 

can be induced to differentiate into cells 


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with specific functions. 9 Primarily two 

types of mammalian stem cells are used in 

myocardial regeneration: embryonic stem 

cells found in the blastocyst during early 

embryogenesis, and adult stem cells found 

in adult tissues acting as progenitor cells. 

ES cells are pluripotent and can potentially 

give rise to a number of cell types, they 

are vital to tissue regeneration therapy, 

regardless of the field of research. Skeletal 

myoblasts, on the other hand, are committed 

progenitor cells of skeletal muscle; they 

are resistant to ischemia and highly 

proliferative. 10 These myoblasts, harvested 

from neonatal and adult animals, have 

been shown to differentiate into skeletal 

myotubes and improve left ventricular 

function following an infarct. 10 These 

results have been obtained in autologous, 

syngeneic, allogenic, and xenogenic 

transplants – largely in mice and rats, but 

also in swine and canine subjects. 10 

Adult bone marrow derived stem cells have 

also been studied: there are hematopoietic 

stem cells, endothelial progenitor cells, 

and mesenchymal stem cells in adult bone 

marrow. Research has shown that treatment 

with mesenchymal stem cells (MSCs – 

precursors to muscle, bone, tendons, and 

ligaments) improves myocardial function 

by limiting ventricular remodeling. 11 It 

was known that intramyocardial injection 

of Akt-MSCs (mesenchymal stem cells 

overexpressing the survival gene Akt) 

restored cardiac function after only 72 

hours. 11 Gnecchi et al. hypothesized that, 

because such a rapid recovery could not 

be due to differentiation of the donor cells, 

regeneration was accomplished through the 

action of factors provided by the MSCs. 12 

It was thought that these factors acted in 

a paracrine fashion to rescue the damaged 

heart tissue. Gnecchi et al. found that it 

is possible, in an animal model, to use 

mesenchymal stem cells to alleviate acute 

MI by injecting a cell-free supernatant 

that had been recovered from cultures of 

mesenchymal stem cells. 12 

Adult CD34 + cells, easily obtained from 

peripheral blood, can trans-differentiate 

into cardiomyocytes in vivo at the site of 

injury in mice – yet this is still a work in 

progress. 13 Lastly, some sources suggest that 

there are small populations of “resident 

cardiac stem cells” endogenous to the heart 

that may serve a minor role in repair. 14 

While researchers clearly have many types 

of stem cells at their disposal for use in 

cardiovascular therapies, only ES-derived 

cardiomyocytes and skeletal myoblasts 

have been able to achieve a proper level 

of cell survival for complete myocardial 

regeneration. 7 

14 

Skeletal Myoblast 

Transplantation 

Studies on skeletal myoblasts began with 

work of Chiu et al., dating back to 1995. 

His team studied the ability to repair 

injured myocardium in the presence of 

skeletal muscle cells, called “satellite 

cells.” 15 Each skeletal muscle fiber contains 

a few myogenic satellite cells, which are 

normally undifferentiated and quiescent. 

Injury activates these cells, causing them to 

enter mitosis and restore the functionality 

of the fiber. 16 Chiu et al. hypothesized that 

satellite cells, when implanted into injured 

myocardium and influenced by the cardiac 

environment, would undergo “milieudependent 

differentiation.” 15 Chiu et al. 

conducted two experiments: one in which 

the histological outcome of implanting 

skeletal satellite cells into acutely damaged 

myocardium was observed, and the other 

in which the presence of satellite cells at 

the site of implantation was confirmed. 15 

Satellite cells were isolated from samples 

obtained from the tibialis anterior muscle of 

adult dogs, and then labeled with tritiated 

thymidine. Following which, the cells 

were grown in vitro for either 10 days or 3 

weeks and implanted into the cryoinjured 

myocardium of the same animal. A catheter 

was used to implant the cells into the 

injured left ventricular free wall, which was 

acutely damaged by liquid nitrogen. Implant 

sites were evaluated radiographically to 

Figure 1. Data comparing 

the change in slope of PRSW 

relationship at 3 weeks in 

cryoinjured myocardium (white) 

with that in which myoblast 

transplantation failed (grey) and 

was successful (black). Courtesy of 

Nat Med: Taylor, DA. 

Figure 2. Electron micrograph 

of the transplanted myoblasts. 

Intercalated discs (i) connect 

the myocytes that have been 

transplanted. Courtesy of Nat 

Med: Taylor, DA. 

detect the thymidine labels. The results 

showed successful transdifferentiation of 

myoblast satellite cells into cardiomyocytes: 

new muscle cells in the implant sites 

histologically mimicked cardiac muscle, 

including the presence of intercalated 

discs, which are unique to cardiac muscle 

fibers. 15 Chiu et al. concluded that the 

cardiac environment played a role in cell 

differentiation, possibly through growth 

factors or other signaling pathways. 

In 1998, Taylor’s group made use of the 

cryoinfarction and cell implantation 

techniques described by Chiu et al. to test 

whether skeletal myoblast transplantation 

actually improves myocardial performance. 17 

One week following myocardial injury, 

skeletal myoblasts from the rabbit hindlimb 

soleus muscle were transplanted into 

the damaged heart of the same rabbit. 

Following transplantation, 7 of the 12 

rabbits had an improvement in myocardial 

performance: PRSW slope (an indication of 

systolic function and contractility) increased 

34–400% compared to post-infarct values 

(Figure 1). 17 Electron microscopy of the 

implant sites did not show multinucleated 

skeletal fibers, but rather cells that 

resembled cardiomyocytes (Figure 2). 17 

For the first time in animals, myoblast 

transplantation into acutely injured 

hearts was reported to improve cardiac 

performance in vivo. 


Embryonic Stem Cell 

Transplantation 

Human ES cells served as another jumpingoff 

point for producing differentiated 

cardiomyocytes. Could ES cells normalize 

cardiac performance by being transplanted 

into injured myocardium? In 2002, Min’s 

team set out to answer this question using 

rat models. ES cells were transfected with 

green fluorescent protein (GFP) to identify 

cell survival, and transplanted into male 

rats after inducing MI by ligating the left 

anterior descending coronary artery. 18 

Hemodynamics and muscle contraction 

were evaluated both post-MI and after the 

transplantation. Survival of the transplant 

cells was confirmed by observing GFP 

expression. Cardiac α-myosin heavy chain 

and (α-MHC) and troponin I (cTnI) were 

identified using specific antibodies. Not 

only did these cells survive, but they also 

improved cardiac function. Cardiac muscle 

wall tension was measured to determine 

myocyte function at a given ventricular 

pressure and radius (according to LaPlace’s 

Law, wall tension (T) is proportional 

to intraventricular pressure (P) and 

ventricular radius (r): T ∝ P ∙ r). Wall tension 

increased ~2-fold in the rats that had 

undergone transplants. 18 

Cell-Based Pacemakers 

Thus far, efforts in stem cell transplantation 

have been discussed with the goal of 

repairing infarcted cardiac tissue. In 2004, 

Xue et al. approached cardiac therapy 

from a new angle: would it be possible to 

coordinate inactive cardiac muscle cells 

to beat synchronously with pacemakerlike 

donor cells? Human ES cells were 

transfected with GFP and transplanted 

subepicardially into guinea pigs in vivo. 19 

After allowing the stem cells differentiate, 

a beating outgrowth of cardiomyocytes was 

dissected and checked for GFP expression. 

The cells were then transplanted onto a 

layer of quiescent rat cardiomyocytes in 

vitro, resulting in synchronous contractions 

at ~49 bpm of GFP-expressing cells and rat 

cardiomyocytes. 19 Without direct contact 

between the two cell lines, there was no 

synchronous beating. It is important to 

note that, unlike cell-based pacemakers, 

electronic pacemakers are largely unable 

to adapt to fluctuating requirements. In 

addition, sensing and pacing leads may 

become dislodged or malpositioned, and the 

pocket in which the electronic pacemaker 

sits is prone to infection. 20 This research 

shows that bio-pacemakers are clinically 

attractive, and may overcome the limitations 

of the electronic pacemaker. 

Figure 3. Photograph of a heart at week 9 posttransplantation 

of the cellular construct. Note the 

presence of neovascularization into the implanted 

biograft (B). Courtesy of Circulation: Leor, J. 

Bioengineered Cardiac Grafts 

Because it is generally accepted that the 

myocardium cannot regenerate after injury, 

much research has gone into replacing 

damaged muscle. 21 For example, Leor et al. 

tested whether bioengineering cardiac tissue 

within three-dimensional (3D) scaffolds 

would enhance cardiac function after 

extensive MI. 21 This novel practice involves 

the use of 3D cross-linked biopolymer, 

which serves as a support structure upon 

which functional cells can grow. The 

structure biodegrades once the cells have 

formed their own matrix. Rat cardiac cells 

were isolated and cultured, and seeded in 

cylindrical scaffolds made of sodium alginate 

with 100 μm pores. 21 Biograft implantation 

was performed 7 days post-MI: in each 

rat, two scaffolds were attached to the scar 

tissue induced by left main coronary artery 

blockage. After 9 weeks, the rats were 

euthanized, and the hearts were examined. 

Under histology, the scaffolds showed that 

they had successfully merged with the 

infarcted area (Figure 3). 21 Control rats were 

subjected to heart failure as a result of left 

ventricular remodeling post-MI – but in the 

biografted rats, there was less ventricular 

remodeling and deterioration. 

Biotechnology Builds a Heart 

Over 1,000 Canadians are waiting for a 

donor heart. 22 Bioartificial hearts could 

potentially circumvent this issue, and 

prevent significant sequelae associated with 

allogeneic heart transplantation – including 

long-term immunosuppression, renal failure, 

and hypertension. 23 Ott et al. describes an 

attempt to fabricate the construct of an 

entire heart, complete with vasculature 

and inner architecture: it involves 

“decellularizing” whole adult rat hearts 

using detergents, and then repopulating 

them with neonatal cardiac cells (Figure 4). 23 

This ingenious technique utilizes “nature’s 

platform” of the heart, rather than 

attempting to engineer it from scratch. Not 

only does this bioartifical heart mimic the 

structure and cellular layout of a true heart – 

it also functions like one. When stimulating 

the constructs, acceptable measurements 

of cardiac function were obtained in 5 out 

of 8 hearts. 23 It is hypothesized that the 

bioengineered heart could be used as a full 

replacement organ in end-stage failure. 

However, this will only be possible with 

further organ maturation, reseeding of the 

heart’s vasculature with endothelial cells, 

and scaling up of the technology to work 

with human-sized hearts. 

Limitations 

Given the scarcity of donor hearts available 

to meet transplant needs, these approaches 

have immense advantages over heart 

transplants. However, a number of hurdles 

must be overcome before human ES cells 

can be used clinically. For instance, ethical 

issues related to accessing embryos limit 

scientists’ investigations. Also, human ES 

cells must go through rigorous testing 

before the cells can be used as a regenerative 

therapy. If transplanted regenerative cells are 

contaminated with undifferentiated ES cells, 

a tumor could form. 24 It has been suggested 

that differentiation of ES cells prior to 

implantation may prevent the formation 

of cancerous teratomas. 25 Also, in most cell 

transplant studies, many cells are lost before 

blood and nutrient supplies are established. 7 

Introducing exogenous genes into transplant 

cells could make them more robust or allow 

them to release growth factors. For example, 

induced pluripotent stem cells have been 

studied by obtaining fibroblasts after genetic 

reprogramming; however, these have been 

shown to form teratomas as well. 26 

It should also be noted that, in certain 

animal models, stem cells end up travelling 

from the heart to other nearby organs only 

a few hours post-transplant, and in some 

cases, the use of skeletal myoblasts has 

caused ventricular tachycardia. 27 Cell-based 

pacemakers could also lead to arrhythmias 

if the graft undergoes changes in ion 

channel expression. 19 Innovative methods 

have been studied in an attempt to prevent 

arrhythmias. A recent clinical, the CAuSMIC 

study, used a novel minimally-invasive 

catheter system to deliver autologous 

myoblasts to 23 human subjects with NYHA 

class II to IV heart failure. 28 This technique 

resulted in significantly improved heart 


REVIEW

REVIEW 

Figure 4. Mounted cadaveric rat hearts. Note that the heart becomes more translucent as cellular material is 

washed out of the right ventricle, then the atria, and finally the left ventricle. Courtesy of Nat Med: Ott, HC. 

failure symptoms, with no difference in the 

incidence of arrhythmias between treatment 

and control. 28 Still, more extensive clinical 

trials are required to overcome the many 

limitations of stem cell therapy. 

Future developments 

Transplant cell engineering, cell 

differentiation prior to implantation, and 

minimally-invasive methods may help 

improve the next generation of techniques. 

The possibilities seem endless in the field 

of cell-based cardiac repair. Judging by the 

current explosion of research, it may be 

possible to transplant tissue engineered 

16 

valves in the near future. For instance, 

trileaflet heart valves – fabricated from 

scaffolds and seeded with autologous 

stem cells – have been implanted in sheep 

using a minimally-invasive technique, 

resulting in functional valves. 29 Yet, why stop 

there? Complete organogenesis is within 

sight. “Organ printing”, the assembly of 

3D vascularized soft organs, is a feasible 

technology. With the help of computerized 

technology, sheets of single cells can be 

placed one on top of another using a cell 

printer, almost like printing paper. 30 

Stem cells hold the key to rebuilding 

damaged tissues. One decade ago, this was a 

radical idea; now it is a popular experimental 

concept with early clinical trials being 

conducted around the world. Research 

into this area offers promise to a variety of 

medical fields. However, rigorous testing 

is still required before moving from bench 

to bedside. 

References 

1. American Heart Association. Heart 

Disease and Stroke Statistics: 2010. Dallas: 

American Heart Association; 2010. 

2. Centers for Disease Control and 

Prevention. Deaths: Leading Causes for 

2006. National Vital Statistics Reports 

2010;58(14). 

3. Lloyd-Jones D, Adams RJ, Brown TM, 

Carnethon M, Dai S, De Simone G, et 

al. Heart disease and stroke statistics: 2010 

Update. Circulation 2010;121:e46–e215. 

4. Lee DS, Chiu M, Manuel DG, Tu K, 

Wang X, Austin PC, et al. Trends in risk 

factors for cardiovascular disease in 

Canada: temporal, socio-demographic 

and geographic factors. Can Med Assoc J 

2009;181:3-4. 

5. Pileggi A, Ricordi C, Kenyon NS, Froud T, 

Baidal DA, Kahn A, et al. Twenty years of 

clinical islet transplantation at the Diabetes 

Research Institute-University of Miami. 

Clinical Transplants 2004;177-204. 

6. Teo AK, Vallier L. Emerging use of stem 

cells in regenerative medicine. Biochemical 

Journal 2010;428:11-23. 

7. Dinsmore JH, Dib N. Stem Cells and 

Cardiac Repair: A Critical Analysis. J of 

Cardiovasc Trans Res 2008;1:41-54. 

8. Martin G. Isolation of a pluripotent cell 

line from early mouse embryos cultured in 

medium conditioned by teratocarcinoma 

stem cells. Proc Natl Acad Sci USA 

1981;78(12):7634-8. 

9. Stem Cell Basics: Introduction [Internet]. 

Bethesda (MD): National Institutes of 

Health (US); c2006-2008 [updated 2006 

Apr 28; cited 2008 Nov 1]. Available from 

http://stemcells.nih.gov/info/basics/basics1. 

asp 

10. Dowell JD, Rubart M, Pasumarthi KB, 

Soonpaa MH, Field LJ. Myocyte and 

myogenic stem cell transplantation in the 

heart. Cardiovasc Res 2003;58:336-350. 

11. Mangi AA, Noiseux N, Kong D, He 

H, Rezvani M, Ingwall JS, et al. 

Mesenchymal stem cells modified with 

Akt prevent remodeling and restore 

performance of infarcted hearts. Nat Med 

2003;9:1195-1201. 

12. Gnecchi M, He H, Liang OD, Melo LG, 

Morello F, Mu H, et al. Paracrine action 

accounts for marked protection of ischemic 

heart by akt-modified mesenchymal stem 

cells. Natural Medicines 2005;11(4):367- 

368. 


13. Yeh ET, Zhang S, Wu HD, Korbling M, 

Willerson JT, Estrov Z. Transdifferentiation 

of human peripheral blood CD34 + - 

enriched cell population into 

cardiomyocytes, endothelial cells, and 

smooth muscle cells in vivo. Circulation 

2003;108:2070-2073. 

14. Boyle AJ, Schulman SP, Hare JM. Is stem 

cell therapy ready for patients? Stem cell 

therapy for cardiac repair. Circulation 

2006;114:339-352. 

15. Chiu RC-J, Zibaitis A, Kao RL. Cellular 

cardiomyoplasty: myocardial regeneration 

with satellite cell implantation. Ann Thorac 

Surg 1995;60:12-18. 

16. Campion DR. The muscle satellite cell: a 

review. Int Rev Cytol 1984;87: 225-251. 

17. Taylor DA, Atkins BZ, Hungspreugs 

P, Jones TR, Reedy MC, Hutcheson KA, et 

al. Regenerating functional myocardium: 

improved performance after skeletal 

myoblast transplantation. Nat Med 

1998;4:929-933. 

18. Min JY, Yang Y, Converso KL, Liu L, Huang 

Q, Morgan JP, et al. Transplantation of 

embryonic stem cells improves cardiac 

function in postinfarcted rats. J Appl 

Physiol 2002;92:288-296. 

19. Xue T, Cho HC, Akar FG, Tsang SY, Jones 

SP, Marbán E, et al. Functional integration 

of electrically-active cardiac derivatives 

from genetically-engineered human 

embryonic stem cells with quiescent 

recipient ventricular cardiomyocytes: 

Insights into the development of cell-based 

pacemakers. Circulation 2005;111(1):11-20. 

20. De Bakker J, Zaza A. Special issue on 

biopacemaking: clinically attractive, 

scientifically a challenge. Med Biol Eng 

Comput 2007;45(2):115-118. 

21. Leor J, Aboulafia-Etzion S, Dar 

A, Shapiro L, Barbash IM, Battler A, 

et al. Bioengineered Cardiac Grafts: A 

New Approach to Repair the Infarcted 

Myocardium? Circulation 2000;102(19 

Suppl 3):III56-61. 

22. Canadian Institute for Health Information. 

Canadian Organ Replacement Register 

Annual Report – Treatment of End-Stage 

Organ Failure in Canada, 2000 to 2009 

[Internet]. Ottawa: CIHI; 2011 [cited 2011 

Jul 10]. Available from: http://secure.cihi. 

ca/cihiweb/products/2011_CORR_Annual_ 

Report_final_e.pdf. 

23. Ott HC, Matthiesen TS, Goh SK, Black 

LD, Kren SM, Netoff TI, et al. Perfusiondecellularized 

matrix: using nature’s 

platform to engineer a bioartificial heart. 

Nat Med 2008;14(2):213-21. 

24. Rosenstrauch D, Poglajen G, Zidar N, 

Gregoric ID. Stem cell therapy for ischemic 

heart failure. Tex Heart Ist J 2005;32:339- 

347. 

25. Collins JM, Russell B. Stem Cell Therapy 

for Cardiac Repair. J Cardiovasc Nurs 

2009;24(2):93-97. 

Fine art in health sciences: Recognizing 

students who find time to make art 

Sarah R. Stonehocker 

Medical Student (2014), Arts and Humanities in Medicine Class Representative, 

Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

Correspondence to Sarah Stonehocker: Email: sarah.stonehocker@ualberta.ca 

Making time for art is not always easy, 

especially for medical and dental students. 

Keeping up with lectures, readings, 

assignments and clinical skills leaves little 

room for photography, painting, sketching 

and other artistic projects. 1 The arts can be 

easily pushed to the backburner, forgotten, 

or crowded out by the demands of these 

intensive programs. For Katie Stringer, 

a second year medical student at the 

University of Alberta, keeping photography 

a part of her life has become increasingly 

difficult: “In some ways it makes me sad 

to talk about my art these days. While it 

has brought me a lot of joy over the years, 

I now find myself wishing I had more time 

to explore my craft.” 2 This sentiment is not 

unique. As students in health sciences, we 

can safely expect an emphasis on science 

and medicine in our studies. However, it’s 

not only Katie who recognizes the added 

value of engaging in art. As demonstrated 

by twenty five undergraduate medical 

and dental students, artistic expression 

through visual arts can play a powerful and 

multifaceted role in processing, enjoying and 

improving our educational experience. 

“The sciences and arts were once, not 

so very long ago, considered to be very 

26. Mosna F, Annunziato F, Pizzolo G, 

Krampera M. Cell therapy for cardiac 

regeneration after myocardial infarct: 

which cell is the best? Cardiovasc Hematol 

Agents Med Chem 2010;8(4):227-243. 

27. Dib N, McCarthy P, Campbell A, Yeager 

M, Pagani FD, Wright S, et al. Feasibility 

and safety of autologous myoblast 

transplantation in patients with ischemic 

cardiomyopathy. Cell Transplant 

2005;14:11-19. 

28. Dib N, Dinsmore J, Lababidi Z, White B, 

Moravec S, Campbell A, et al. One-year 

follow-up of feasibility and safety of the 

first U.S., randomized, controlled study 

using 3-dimentional guided catheter-based 

delivery of autologous skeletal myoblasts 

for ischemic cardiomyopathy (CAuSMIC 

study). JACC Cardiovasc Interv 2009;2(1):9- 

16. 

29. Schmidt D, Dijkman PE, Driessen-Mol 

A, Stenger R, Mariani C, Puolakka A,et 

al. Minimally-invasive implantation of 

living tissue engineered heart valves: a 

comprehensive approach from autologous 

vascular cells to stem cells. J Am Coll 

Cardiol 2010;56(6):510-520. 

30. Mironov V, Boland T, Trusk T, Forgacs G, 

Markwald RR. Organ printing: computeraided 

jet-based 3D tissue engineering. 

Trends Biotechnol 2003;21(4):157-61. 

similar, certainly complementary, and 

sometimes even overlapping ways of 

understanding the world. No longer. Today 

we accept such generalizations as that 

the sciences are objective, analytical, and 

rational whereas the arts are subjective, 

emotional, and based on intuition.” 3 This 

generally accepted division between art 

and science was challenged by the students 

who showcased their work last April at the 

launch of the University of Alberta Medical 

& Dental Student Art Show. The idea for the 

event was sparked when medical student 

Continued on page 20 


MUSA

MUSA 

Fine art in health sciences: 

Recognizing students who find time to make art 

18 

Square Tree | by Katie Stringer 

Media: Stitched Photographs | SIZE: 36X34 IN 

Mice and Men | by Danny Purdy | Media: Pencil Crayon | SIZE: 8.5X11 IN 


Give Me Hope | by Vina Nguyen | Media: Acrylic and Crayon | SIZE: 20X16 IN 




Continued from page 17 

Asha Olmstead noticed the artistic talent 

of a few of her classmates and suggested 

a class art show. As plans progressed, 

it became clear that there was interest 

throughout the faculty, and the show was 

expanded to include students from all four 

years. The event allowed any medical or 

dentistry student to showcase their artwork 

for classmates, colleagues, instructors and 

friends, while also supporting a local nonprofit 

organization. “I thought the opening 

night event was a great opportunity to 

model the different ways of giving to a 

community,” says Roxanne Felix, a research 

consultant and assistant adjunct professor 

at the University of Alberta School of 

Public Health. 4 

I was really impressed with the 

energy and commitment brought 

by the students and faculty to 

this event. I think the University 

needs to foster these kinds of 

cross-sector and innovative events. 

There is obviously a lot of interest 

and passion for looking at how 

health sciences and the arts interact 

– now we just need to tap into 

that potential! 4 

Hosting the show within the context of the 

Faculty of Medicine and Dentistry created 

a space where the realms of fine art and 

health education could merge. Science and 

technology are already strongly emphasized 

in health education, but students who 

integrate the arts into their busy schedules 

must be self-motivated. 5 The Art Show 

was a way to recognize this effort and 

celebrate the results. In total, forty works of 

visual art were displayed, including acrylic 

painting, photography, sketches, sculpture, 

collage, and a short film. Proceeds were 

donated to the Multicultural Health Brokers 

Cooperative to establish an “engagement 

fund” which helps newcomers to Canada 

access early learning programs and healthrelated 

services for their young children. 6 

The weeklong exhibit was displayed in the 

John W. Scott Health Sciences Library at the 

University of Alberta, where the pieces could 

be viewed by students and faculty from 

across campus. 

The opening night event was a 

great example of the “determinants 

of health” in two ways. Firstly, 

the event modelled that “giving” 

doesn’t have to just be within the 

realm of our professional skills. By 

sharing our talents and our gifts, 

you can generate many things 

for the community – including 

20 

fundraising as that event did. 

Secondly, the event generated 

a sense of social support and 

community in general among the 

medical and dentistry students. 

This kind of social connectedness 

and gathering for a cause is so 

important for all communities – 

including students. It provides 

a type of resiliency that is really 

necessary. 4 

My hope is that those students who struggle 

to find space for art will continue to create. 

In an environment where the function of 

fine art can be questioned, it becomes even 

more important to continue to support 

and encourage this effort. “The linkages 

between arts and the sciences have been 

proven in research for years, but how to 

‘live’ this can be a bit challenging in the way 

that our social structures seem to be built,” 

explains Felix. 4 The structure of medical and 

dentistry school are especially challenging 

in this regard. For Katie, the struggle to 

find space for art as a medical student has 

been difficult; “The only consolation I find 

is knowing that [photography] will always 

be there, waiting, for me to tend to the 

process again.” 2 

As a community it is critical that we 

continue to affirm the insights and 

perspectives expressed through art. “With 

art, it is possible to transcend the limitations 

of traditional scientific inquiry and to explore 

a more human and holistic perspective,” 

writes Jessie Breton, resident physician 

and contributing artist at the event. 7 Those 

working and studying in health sciences 

possess a rich and valuable diversity of 

talent and perceptiveness that unfortunately 

often goes unrecognized and untapped. 8 

“Arts can contribute a lot to how we 

practice and achieve success in the health 

sciences – how we strive to create healthy 

conditions and achieve health with our 

clients.” 4 For students themselves, making 

art can be a powerful form of self-care; the 

process can be a way of relieving stress, 

learning concepts, processing emotions 

and experiences, and maintaining balance. 

Taking that next step of sharing our artwork 

allows us to draw strength and inspiration 

from one another. 

Art, literature, drama and music, 

in all their many forms, are 

expressions of human creativity; 

they reflect human joy and sorrow, 

and human celebration and 

reflection... They do not merely 

have usefulness in contributing 

to the development of ends other 

than themselves: they also have an 

intrinsic value in their own right. 9 

With the support of the Arts & Humanities 

in Health & Medicine (AHHM) Program at 

the University of Alberta, 10 the Medical & 

Dental Student Art Show will run again in 

April, 2012. I invite you to attend this special 

event and be a part of celebrating students 

who find the time to make art. 

The following excerpts are by students who 

were featured at this year’s Art Show: 

Square Tree 

Katie Stringer is a medical student in the 

class of 2014 at the University of Alberta. 

Media: Stitched Photographs 

Size: 36x34in 

Artist’s Statement: 

Our society has traditionally believed in 

the photograph’s ability to record the truth 

in a moment past. If this can still be the 

case, then my unadulterated photographs 

represent the history of my personal struggle 

to gain control in life. For many of us there 

are events in our lives that never surface to 

the public or even to our closest friends. We 

smile and tidy things up but somewhere in 

there is a piece of chaos that goes unspoken. 

On the whole, we look put-together but 

on closer inspection we’re people who deal 

with stress, difficult relationships, illness, 

trauma and death. These trees touch upon 

the power of human control, or a lack 

thereof. They are my attempt to wield and 

instrument against the natural and unruly 

world. The imperfections in the piece are the 

traces of humanity that reveal the truth in all 

this: control over life is an illusion. 

Mice and Men 

Danny Purdy is a medical student in the 


Media: Pencil Crayon 

Size: 8.5x11in 


Keeping up with one’s hobbies during 

medical school is sometimes perceived as a 

compromise, but is a genuinely constructive 

activity that tends to produce a greater level 

of satisfaction and enjoyment throughout 

one’s career. The importance of ‘balance’ 

is emphasized so heavily during medical 

training that, at times, it seems clichéd. 

However, after only one year of medical 

school I recognize the importance of having 

a life outside of Medicine. In my case, 

drawing has been a refreshing reprise from 

schoolwork on many occasions. Studying so 

hard without any physical manifestation of 

the hours you’ve put in can be frustrating, 

and studying the same subject for days 

becomes tedious. Drawing allows one to be 


creative, and actually produce something 

tangible. Furthermore, I find that finishing 

a piece of art into which I’ve put a lot of 

thought and effort is an extremely fulfilling 

activity. 

Give Me Hope 

Vina Nguyen is a medical student in the 


Media: Acrylic and Crayon 

Size: 20x16in 


In medicine, we can become caregivers 

holding the last source of hope for our 

patients. Unfortunately, sometimes we 

do not realize that what we say or do can 

greatly impact a patient’s quality of life, 

their perception of their illness, and their 

perseverance to survive and endure difficult 

times in their life. In these situations I 

find that art can help ground and open 

my perception of the world. Art also helps 

me realize my biases and misconceptions 

before I act upon them, so that I can become 

a more connected healer. As healers we 

are exposed to a multitude of experiences, 

from loss and grief, to anxiety and joy. Art 

can help us internalize all these emotional 

experiences so that we may learn and grow 

from them. In this way, I believe that art 

not only nurtures the heart and soul, but it 

may also nurture the mind by encouraging 

creative, open thinking. Art for me is an 

important part of medicine: it satiates my 

need for creativity, ensures there is balance 

in my life, and exercises my mind to stay 

open and understanding. 

References 

1. Lee, J. & Graham, A. (2001). Students 

perception of medical school stress and 

their evaluation of a wellness elective, 

Medical Education, 35 (7): 652–659. 

2. Stringer, K. Personal Interview. 10 August 

2011. 

3. Root-Bernstein, RS. (1996). The sciences 

and arts share a common creative 

aesthetic. The Elusive Synthesis: Aesthetics 

and Science. Dordrecht: Kluwer Academic 

Publishers: 49–82. 

4. Felix, R. Personal Interview. 12 August 

2011. 

5. Brett-MacLean, P. (2007) Use of the Arts in 

Medical an Health Professional Education. 

University of Alberta Health Sciences 

Journal, 4 (1): 26-29. 

6. Multicultural Health Brokers Co-operative, 

www.mchb.org 

7. Breton, J. (2011). Birth marks: An artistic 

exploration into the medical, personal, 

societal, and historical dimensions of 

postpartum depression (PPD) through 

a collection of sketches, collages, and 

journalling. University of Alberta Health 

Sciences Journal, 6 (1): 13-14. 

8. Brett-MacLean, P., Casavant, M., & 

Kennedy, D.Y. (2010). Artists Among 

Us: Happiness as an element in health 

professionals’ artist statements. Atrium: 

The Report of the Northwestern Medical 

Humanities and Bioethics Program, 8: 18- 

20. 

9. Macnaughton, J. (2000). The humanities 

in medical education: context, outcomes 

and structures. J Med Ethics: Medical 

Humanities, 26: 23–30. 

10. Art & Humanities in Health & Medicine 

(AHHM), www.med.ualberta.ca/Home/ 

Education/ ArtsHumanities 

On the value of narrative reflective practice: A personal reflection 

Debbi Andrews, MD 

Divisional Director and Associate Professor, Division of Developmental Pediatrics, 

Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

Correspondence to Dr. Debbi Andrews: Email: andrewsd@ualberta.ca 

In December 2010, I attended a workshop 

on Narrative Reflective Practice (NRP) 

hosted by the Health Sciences Education and 

Research Commons (HSERC) and Centre 

for Teaching and Learning (CTL) at the 

University of Alberta. The workshop facilitator, 

Dr. Hedy Wald from Brown University, 

asked participants to prepare and share short 

descriptions of their own experiences using 

narrative writing exercises with students. 

As I started to work on the customary 3-5 

Powerpoint slides, I realised that there was very 

little reflection involved in what I was proposing 

to present, just a bone-dry list of what was done. 

This didn’t capture the experience of facilitating 

an NRP session, and I doubted it would spark 

any reflection in the workshop group. I deleted 

the slides and took out a pen. The following 

is my own narrative reflection that I read to 

the group. 

I am no orator, but I am a writer. I choose 

today to talk about my own experience in 

teaching and facilitating narrative practice in 

the form of a read narrative. 

For the past two years I have facilitated 

small group narrative reflective practice 

sessions for first year medical students as 

part of their Patient-Centred Care course. 1 

These sessions are part of an initiative to 

insert exercises in reflection at key points 

during medical school and residency at the 

University of Alberta. The themes presented 

in the first year include professional identity, 

professionalism and biomedical ethics. Later 

the students have opportunities to reflect on 

their encounters with patients and staff in 

clinics and on the hospital wards. I confess 

that I was initially drawn to participating 

in these sessions for somewhat selfish 

reasons—I am a writer and wanted a way to 

integrate my own writing background with 

teaching. Now, because of two very different 

experiences in facilitating these groups 

from last year to this one, I am even more 

committed to the importance of reflective 

writing in medical training. I have a better 

understanding of what the act of writing can 

mean for achieving understanding. Let me 

explain what I mean. 

The students’ assignment was to write, then 

share aloud, a one page narrative on the 

topic of medical identity—what it means 

to become a doctor, both as a general 

process and how this might apply to them 

as individuals. For each session the writing 

prompt was a film that was viewed by the 

entire first year medical class, followed by 

a faculty panel who reflected on some of 

the issues from the film and an interactive 

question and answer session. Afterwards, 

the students wrote their own brief reflective 

responses to the film, and then, two days 

later they shared those reflections in 

facilitated small groups. 




As often happens for busy clinician teachers, 

my schedule precluded my facilitating at the 

same point in the course two years in a row, 

so the material discussed differed from one 

year to the next. Last year I had facilitated 

a small group after they watched the movie 

The Doctor (1991) starring William Hurt 

as a callous surgeon who discovers he has 

cancer and must become a patient. 2 The 

experience changes the way he views his 

patients, his family and his life. Although the 

film was fictional, it was based on a real-life 

physician’s memoir. This year I facilitated a 

group discussion of The Doctors’ Diaries, a 

condensed version of the Nova documentary 

series which followed eight Harvard medical 

students for fifteen years, from the first year 

of medical school, through residency, and 

into practice. 3 

Facilitating the two groups was very 

different. With last year’s group, the 

narratives contained significant insights 

about the film The Doctor. Topics presented 

in the students’ reflections included personal 

experiences of illness, family support, worklife 

balance, spirituality, and the concept 

of duty assumed upon entering a caring 

profession. The students read descriptions 

of their own doctors, and also the kinds of 

doctors they wanted to be. Their writing 

styles and abilities were varied, but they 

honoured each others’ stories, and the 

discussion was very rich. 

Not so with this year’s group. At first, I 

thought it was because of the material 

used for this particular session—because 

it was a documentary, not a story, or 

perhaps because it was about a prestigious 

ivy-league school, and not “here”. Yet 

it was clear from the kinds of questions 

and comments made during the panel 

discussion that the students had been 

emotionally engaged with these real people, 

and threatened by the very real stresses the 

Harvard medical students experienced as 

depicted in the film. There was something 

else going on in my group’s session. I 

should have noted it then and put a stop 

to it because what was done was not what 

was intended, but I didn’t figure it out until 

I myself reflected on the process for today’s 

workshop. 

This is what happened. The first student 

took out what I thought was his written 

narrative, and instead of reading it 

aloud, he presented his ideas in a casual 

conversational style as in any other group 

discussion. When I glanced at his paper, I 

saw it contained some thoughts scrawled 

across the page in point format, like 

speaker’s notes. Not a narrative. The next 

student, who had written a full narrative, 

22 

started to read but when she got to a 

sentence that was similar in its theme to 

the first student’s, she followed his lead and 

apologetically abandoned her text to wing 

it—“Oh, yeah, I sorta felt the same way,” 

and “I’ll skip that because it was the same as 

he said,” and so on, essentially stripping her 

response of her individual writing style and 

all the personal narrative details—especially 

the careful selection of WHAT TO SAY. 

Those two students set the tone of the 

session, and the other students followed 

suit. No one read more than a few 

sentences. Yes, there was a good discussion 

overall, but the responses became muddled 

together, and at the end I could not 

identify one distinctive story. Why had this 

happened? The groups were the same size 

and equally varied in their backgrounds 

and experiences, we’d started with the same 

introductions process and the students 

seemed comfortable with each other. 

The session left me unsatisfied. I felt I had 

somehow not done my job as facilitator 

although I wasn’t able to figure out what I 

had done wrong. I recalled the individual 

student voices from the year before in 

their carefully chosen words and phrasing 

and compared that to the bland “Me, 

too”-ing of this year’s group. Even one 

young woman who’d admitted during 

the introductions to having participated 

in a poetry—yes, POETRY—group as an 

undergraduate, became self-conscious of 

her written attempts to create a voice and 

left off reading her text for the comfortable, 

conforming anonymity of chat. 

Perhaps you now can see why I have 

chosen to read this narrative script instead 

of casually discussing my experiences 

with reflective writing. Writing and oral 

language are not the same. Oral language, 

by its speed and spontaneity, is inaccurate. 

We speak off the cuff and in the moment, 

trying to communicate with someone who 

is physically present. This works because 

we have instantaneous feedback from our 

communicative partners—in their body 

language, their attentiveness to the message, 

the quality of their response. If we’re not 

making sense, we know it—the listener asks 

questions to clarify the message, and based 

on these questions, we change what we are 

saying—repeating, perhaps paraphrasing, 

altering word choice, even backtracking 

or simplifying to arrive at understanding. 

Speech language pathologists with whom 

I work call this process “narrative repair.” 

People who are good communicators don’t 

wait for the questions from the listener 

to begin this process. They’re in there at 

the first frown or lifted eyebrow, when the 

internal “uh-oh” tells then they’d better 

go back and fix things, or they’ll lose their 

audience. They are already starting to pick 

up the pace before the increasing frequency 

of yawns tells them that they are being 

boring. This does not happen with written 

text. 

In writing, the repair is in the edits and 

must be done before the “speaker” ever 

“speaks” his piece, because any clarifying 

feedback will be removed in time and space. 

This forced clarification creates a powerful 

communication tool. Spontaneous oral 

language is ephemeral, unless recorded or 

written down. We as listeners are left with 

an impression of someone else’s truth. In 

writing we aim to achieve our own truth. 

Writing should stand alone. 

In John Sandars’ 2009 article in Medical 

Teacher he states that reflection is a 

metacognitive process. 4 I would add that 

editing is also a metacognitive process—it 

requires us to think about language, to 

deliberate and become deliberate in our 

approach to a communicative task. The 

act of writing slows us down. We carefully 

consider the ways we use words to avoid 

the possibilities for ambiguity that can 

ambush the sought-after clarity and ultimate 

presentation of our personal truth. When 

we submit our final written draft, we are no 

longer figuring out what we want to say. We 

know. We say, “THIS is what I think. THIS 

is what I feel. THIS is what I believe.” NOT 

“I’ll say this about that”, but “THIS is what I 

WANT to say about THAT”. 

This is the lesson of narrative reflective 

practice, and should be our focus when 

we teach this to others: the deliberate 

consideration of what we think and feel and 

believe, and the value of communicating 

these thoughts and feelings and beliefs 

through the deliberate consideration of the 

written word. The narrative reflective 

process was not as effective in my small 

group this year, at least partially because 

I let the discussion stray from the written 

word. Despite the students’ emotional 

engagement in The Doctor Diaries, the 

superficial conversations did not capture 

their individual reflections or link the 

experience of viewing the film with their 

own stories. The discussion never reached 

down to the very deep issues that had arisen 

from the film. 

Next year I know what to do. If any of the 

students wander away from their requested 

narrative reflection, I am going to stop 

them and say, “Please read what you wrote, 

because the words are important.” 


References 

1. Brett-MacLean PJ, Cave MT, Yiu V, Kelner 

D, Ross D. Film as a means to introduce 

narrative reflective practice in medicine 

and dentistry: A beginning story presented 

in three parts. Reflective Practice. 

2010;11(4):499-516. 

2. Haines R. The Doctor [Motion Picture]. 

Burbank (CA): Touchstone Pictures; 1991. 

It all began with a cup of tea: Introducing narrative 

reflective practice into undergraduate and postgraduate 

medical education at the University of Alberta 

3. Barnes M. Doctors’ Diaries [Documentary]. 

Boston (MA): WGBH-TV; 2009. 

4. Sandars, J. The use of reflection in medical 

education: AMEE Guide No. 44, Medical 

Teacher. 2009;31(8):685-695. 

Marie-Therese Cave, MSc, P.G Dip Couns. Cert. Ed. 

Assistant Professor, Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

D. Jean Clandinin, PhD 

Professor and Director, Centre for Research for Teacher Education and Development, University of Alberta, Edmonton, Canada 

Correspondence to Marie-Therese Cave: Email: marie.cave@ualberta.ca 

Abstract 

Marie Cave and Jean Clandinin describe 

their experience of bringing narrative 

reflective practice into medical education 

at the University of Alberta. In this account 

they discuss their experiences with the 

process of curriculum change, as well 

as some of the unique characteristics 

of narrative reflective practice in 

medical education. 

Marie-Thérèse Cave: 

There are certain moments that turn out 

to have important consequences. Except 

for flashes of intuitive prescience, rarely 

is one able to predict which events will 

turn out to be the momentous ones. 

Only in retrospect can one appreciate the 

significance of the beginning points, turning 

points, and contingencies that characterize 

the introduction of a curricular innovation 

in medicine. This is the way it was for the 

individuals in the story that follows. 

I suppose I should be the person to begin 

the story. However, for me, it didn’t begin 

with the cup of tea. It began weeks before, 

one morning, when I walked into my office 

in the Department of Family Medicine to 

find a journal on my desk. 

The journal was the latest edition of 

Reflective Practice: International and 

Multidisciplinary Perspectives. The title 

itself was enough: This was the first 

journal to address the work in which 

I had been involved for more than ten 

years. My own education in how to be a 

reflective practitioner, and how to facilitate 

reflection, began in Liverpool, during my 

undergraduate work in education. At the 

time I was also personally engaged in 

exploratory learning through the work 

of John Dewey, and his accounts of how 

learning takes place. My self-education 

included Donald Schon’s writings and also 

that of more local reflective practitioners, 

like Hawkins and Shohet, in nearby Bath. 

My education continued later, in Bristol, in 

my second career as a counselor and then 

as a supervisor of counselors and therapists. 

My clinical work began with educating and 

supervising the practice of counselors and 

therapists in Bristol, England. My practice 

then expanded to involve physicians, mostly 

family doctors, who were seeking a way 

to reflect upon the challenge of delivering 

optimal care to patients and patients’ 

families, and themselves. As a practitioner, 

my interest grew from trying to understand 

how students learn to understand, to how 

I, and my peers, made meaning of our 

experiences with clients. 

When I came to the University of Alberta I 

was able to continue some of this work, as 

the College of Family Physicians of Canada 

had recently announced their expectation 

that residency programs develop curricula 

in behavioural medicine. This was to be a 

curriculum that included “opportunities 

for reflective practice with skilled and 

sensitive teachers of family medicine.” As 

the Behavioural Medicine coordinator within 

the family medicine residency program, 

I incorporated a “reflective practice” 

pedagogy into the curriculum. 

In the 15 years that followed, I continued 

listening to physician stories, trying to help 

resident physicians make meaning of their 

experiences. Some of the medical educators I 

met shared my interest in reflective practice, 

but much of the work in which we were 

involved together focused on developing 

curricula in communication skills and the 

practice of patient-centered care. 

I opened the new journal eagerly. I was 

keen to discover if it was a place in which 

I could share my interest in reflective 

practice, and read of others in the midst of 

similar work in medicine. An immediate 

scan revealed interesting work being done 

in several of the “helping professions” – in 

nursing, education, and also, surprisingly, in 

business – but none of the articles focused 

on medicine. I then read the list of those on 

the international editorial board, and I was 

surprised to see the name of a professor 

at the University of Alberta, in the Faculty 

of Education. Instinctively I picked up the 

university directory and made a call. “Dr. 

Jean Clandinin is in Taiwan,” responded her 

secretary, and then she added “you can leave 

a message if you like.” So I did. 

d. Jean Clandinin 

The message from Marie Cave came in 

the fall of 2003 while I was in the midst 

of planning what eventually became the 

Handbook of Narrative Inquiry: Mapping 

a Methodology. 1 The handbook was to be 

interdisciplinary and inter-professional, and 

I had a lot to learn. While I knew editing 

a research methodology handbook for 

a major international publishing house 




was going to be a lot of work, I also knew 

the handbook mattered to me. I have 

spent all my academic life on developing 

a conceptualization of professional 

knowledge; what we termed “personal 

practical knowledge.” We conceptualized 

this way of thinking about professional 

knowledge as embodied narrative 

knowledge: knowledge shaped by personal, 

institutional, cultural, familial, social and 

linguistic narratives. I knew that professional 

knowledge was shaped by, enacted, 

and lived out in multiple personal and 

professional contexts. 

My scholarly work is undertaken from a 

Deweyan conceptualization of experience. 2 

Because of our shared interest in Dewey’s 

work, I came to meet Donald Schon and had 

the opportunity to share ideas on reflective 

practice and on educating reflective 

practitioners. While Donald Schon did not 

work from a narrative conceptualization of 

reflective practice or from narrative notions 

of practitioner knowledge, we shared a deep 

commitment to the work of Dewey and to 

how Dewey’s works might help us move 

forward in professional education. 

My long interest in working with 

practitioners in reflective ways led to the 

invitation to join the editorial board of 

Reflective Practice. When I returned from 

Taiwan, I received the message that Marie 

Cave wanted to talk about reflective practice. 

I agreed to meet her for tea. I had no idea, 

beyond her interest in my work on the board 

of Reflective Practice, what the meeting would 

be about. I was intrigued, however, with 

learning more about medical education. My 

daughter-in-law is a physician and my son 

had accepted a position in a well-known 

faculty of medicine. 

This phone call from Marie Cave had 

serendipitously coincided with my being 

reminded of Rita Charon during my editorial 

work for the Handbook. I first met Rita 

Charon when I was a beginning faculty 

member at the University of Calgary. Rita 

was a member of an NIH taskforce who had 

come to the university to learn more about 

the possibilities of engaging in qualitative 

research into the experiences of geriatric 

caregivers. Their 1987 visit occurred just as 

my colleague, Michael Connelly, and I were 

completing our book Teachers as Curriculum 

Planners: Narratives of experience. 3 I was not 

expecting Rita’s interest in stories but, as we 

talked over those three days, Rita spoke of 

physicians’ stories. She was intrigued by how 

Michael and I were suggesting a split page 

method of keeping research field notes: on 

one side of the page, field notes were written 

which documented events and dialogue 

24 

and so on; on the other side of the page, we 

wrote our researcher reflections on what was 

happening to and for us. We had not been 

in contact for many years but I remembered 

her well because of our shared interests in 

the stories professionals told. 

And so it all began with a cup of tea. 

Conversation over Tea 

Marie-Thérèse Cave and 

D. Jean Clandinin 

We agreed to meet over tea in the teahouse 

in the university hospital at the end of a 

long and busy day for each of us. Raised on 

two different continents, we learned we had 

much in common. Born in the same month 

in the same year, we had both begun our 

professional careers in elementary education 

and we had both become counselors. We 

both married soon after graduating and 

we both had sons the same age who were 

now married. 

We shared stories of our lives, as our 

life compositions had taken us on 

different paths: Jean’s into academia and 

Marie’s into delivering training courses 

and supervising therapists and health 

professionals. We connected around the 

work of Donald Schon and his ideas on 

reflective practice. 4 As we talked over tea, 

we were telling and listening to stories and, 

because there seemed promise here for a 

working relationship, we were interested 

in possible ways of working together. Here 

in the hospital’s teahouse we were finding 

resonance between our stories and we were 

also beginning to imagine how we might 

compose a new story, together. We were 

both interested in the processes of becoming 

a physician and both wondered about the 

learning experiences that shaped physicians 

along the way. 

As we composed a story of what we might 

do together, we decided to explore the 

possibility of doing some narrative work 

together. Jean had recently read Susan Florio 

Ruane’s work about an autobiographical 

book study with beginning teachers. 5 

We wondered what would happen if we 

gathered a group of beginning physicians to 

read autobiographies and memoirs written 

by physicians. We imagined this study could 

be a starting point for further collaborative 

inquiries into the world of clinical practice. 

The time was right, not only in medical 

school, but in the larger field of research 

and professional education, where the ideas 

of narrative inquiry and narrative reflective 

practice were taking hold. There was a 

narrative turn occurring across disciplines. 

As we tentatively planned the small 

study that would bring us together as 

co-researchers, we arranged to meet 

the Associate Dean for Undergraduate 

Education. We proposed a small qualitative 

study in which the participants would 

read a series of physician-authored 

autobiographical books that would serve 

as triggers for narrative reflections on their 

own practices. The study would involve 

undergraduate students beginning their 

clerkships, residents, and beginning family 

physicians. While this was not a narrative 

inquiry, we wanted to think narratively 

about the interwoven ideas of knowledge, 

context, and identity in professional practice. 

We both saw this as a way to learn about 

each other as researchers, as well as to learn 

about narrative reflective practice as a way 

to think about medical education. We were 

curious to learn about what happens to 

physician learners as they progress through 

the medical curriculum into practice. 

There was also room to explore different 

pedagogical approaches to learning around 

professionalism and ethics. The Associate 

Dean for Undergraduate Education, along 

with postgraduate program directors, was 

particularly interested in these areas of 

the curriculum and the possible impact of 

reflection on narratives of practice. 

The First Study: Beginning 

the Journey to narrative 

Reflective Practice. 

In our study, participants read one book 

a month and then shared their responses 

to the stories of the physician authors. We 

planned five sessions over a six-month 

period. The books were selected to serve as 

triggers for the participants’ own stories. 

As the research progressed, Jean continued 

to edit the Handbook of Narrative Inquiry. As 

part of her reading, she read Rita Charon’s 

edited book (with Martha Montello) on 

narrative in medical ethics. 6 Marie located a 

web-based video demonstration of a parallel 

chart group, facilitated by Rita Charon. In 

this demonstration, medical student clerks 

completing their internal medicine clerkship 

rotation at Columbia Medical School are 

seen coming together to read aloud their 

written reflections on a patient encounter. 

As we worked together on the analysis 

and interpretation of data from our first 

study, we decided to design another study, 

this time with family medicine residents. 

This study would draw on Jean’s previous 

work on narrative inquiry, as well as on 

Rita Charon’s work with parallel charts. We 

decided to invite Dr. Charon to come to the 

university as a visiting scholar to further 

explore the use of clinician narratives as an 

aid to reflection on practice. 


The arts and Humanities in 

Medicine Program 

Synchronistically, the Faculty of Medicine 

& Dentistry was launching a new Arts & 

Humanities in Health & Medicine (AHHM) 

program. Both of us were serving on the 

planning committee for the launch of the 

program. When Verna Yiu heard that we 

had invited Dr. Rita Charon to visit with us 

to discuss our shared interest in narrative 

reflective practice, she suggested we 

combine our purposes. A renewed invitation 

was extended to Dr. Charon as a visiting 

professor and also as a keynote speaker for 

the AHHM program launch. 

We were very excited to learn what Dr. 

Charon might bring to the faculty and to 

our research. At around this time, Alan 

Thomson, a well-known gastroenterologist, 

spoke with Jean and asked for assistance 

with some curriculum design work. On the 

day of the launch, Jean agreed to meet with 

Alan to share some resources she thought 

might be helpful to him. Jean was carrying a 

copy of Narrative Medicine, Charon’s book. 7 

As Alan and Jean discussed what Jean 

brought for him, he noticed Charon’s book 

and asked about it and about the work in 

narrative Jean and Marie were doing in 

Family Medicine. Before Jean left Alan’s 

office, she had promised to send him some 

articles and chapters on narrative inquiry 

and some of her work with Marie as well as 

a chapter from Charon’s book. 

The launch was well received, and the days 

following Charon’s visit led to an expansion 

of interest in narrative medicine and 

narrative reflective practice and a promise 

to consider the possibility of visiting Dr. 

Charon in New York and attending her 

workshop at Columbia. 

The Forward Looking 

Story Unfolds 

While Alan Thomson had not been involved 

in Dr. Charon’s visit, he had been reading 

the literature Jean had sent him. He asked 

if he could host a dinner one evening to 

discuss narrative research possibilities 

for medical education. Those present at 

this dinner were Alan Thomson, Andrew 

Cave (the two physicians in the group), 

Marie and Jean. Naming our conceptual 

framework ‘Narrative Reflective Practice’, we 

began to imagine how narrative reflective 

practice could become part of the medical 

curriculum. We also began to imagine 

research possibilities that would accompany 

the curriculum change. The main purpose of 

the research was to establish the difference, 

if any, narrative reflective practice played in 

the professional development of physicians 

and in medical education for physiciansin-training. 

This represented a continuation 

of Jean’s work using narrative inquiry 

methodology to explore the process of the 

professional formation of teachers and 

administrators. That evening over dinner we 

began work on a research agenda focused 

on narrative inquiry and narrative reflective 

practice in medical education. We were 

continuing a narrative turn in the Faculty of 

Medicine & Dentistry. 

Marie was stunned by the alacrity with 

which the small group began planning. 

All present were keen to discuss narrative 

research possibilities for a narrative reflective 

practice curriculum in the medical school 

and for the faculty. It was decided that in 

residency education we would begin by 

approaching three disciplines: internal 

medicine, family medicine and pediatrics. 

Our small research group already had 

physician involvement in family medicine 

and internal medicine. We decided to invite 

Verna Yiu as the pediatrician member of our 

research team, because of her leadership at 

the time in the Arts & Humanities in Health 

& Medicine program and her involvement 

in supporting Dr. Rita Charon’s visit to the 

University of Alberta. 

The following day we sent an email to the 

then Dean, Tom Marrie, and were surprised 

to receive an immediate response. He 

requested that we lead the delivery of a 

curriculum in narrative reflective practice 

in all four years of the undergraduate 

medical curriculum. Jean and Marie met, 

again over tea, and further sketched out 

a developmental curriculum in narrative 

reflective practice. A subsequent meeting 

of our small group with the dean allowed 

us to more fully inform him of our plans. 

We communicated the need for faculty 

development and gained funding for some 

of us to visit Columbia Medical School in 

New York and attend Dr. Charon’s two-day 

narrative medicine workshop. Funding 

also came from the Department of Family 

Medicine which had already supported 

some of our early research projects 

Other academic physicians were learning 

about, and expressing interest in, narrative 

reflective practice. We invited several of 

them to become champions of narrative 

reflective practice and to become involved 

with the recently formulated curriculum 

plan. In these early days, those involved 

were developing individual understandings 

of narrative medicine and narrative 

reflection on practice. Some had an interest 

in promoting an aesthetic and humanistic 

appreciation of the reading, writing, 

and listening to stories of patients’ and 

physicians’ lives. Others were primarily 

interested in researching the possibilities 

of narrative reflective practice as a tool, 

or pedagogical approach in physician 

formation. Still others saw the value of 

narrative inquiry as a research methodology 

in the acquisition of a deeper knowledge of 

patients’ and physicians’ experiences, and 

by so doing, increasing the evidence basis 

for clinical decision making. None of these 

understandings were mutually exclusive, 

but it was becoming increasingly evident 

that we needed a common language, so 

that we could better articulate our purposes, 

especially if we were to achieve our goal 

of engaging students and physicians in a 

cohesive developmental narrative reflective 

practice curriculum within the medical 

school. Faculty development was a priority. 

Faculty development 

We began faculty development with a 

residential course over three weekends 

spread out over several months. The setting 

was a retreat located outside of the city. 

Each weekend started with a review of 

pre-assigned key theoretical resources. 

These included work by John Dewey, 

Mark Johnson, Alasdair MacIntyre, Robert 

Coles, Mary Catherine Bateson, and David 

Carr. The rest of each weekend was spent 

in experiential learning about narrative 

reflective practice. Given that narrative 

reflective practice is about stories lived 

and told, 8 we invited participants to access 

their tacit knowledge of practice through 

the telling and re-telling of their stories 

of experience. 

Working within the three dimensional 

narrative inquiry space, they learned to 

attend to the past, present and future 

directions of their stories (temporality); to 

attend to their inner emotions and moral 

judgments as well as to unfolding events 

(sociality); and to the place or places where 

events were occurring. 8 They learned the 

importance of “wondering questions,” as an 

aid to the facilitation of the inquiry. Further 

faculty development courses were planned 

and delivered and, after consultation with 

various curriculum committees, Narrative 

Reflective Practice pedagogies were 

eventually launched, by the champions, in 

the first three years of the undergraduate 

medical curriculum. 

In their first year, students have little 

clinical experience. To assist in meeting the 

objectives related to communication in the 

Patient Centred Care course, we introduced 

films (visual narratives) as a means of 

facilitating the narrative reflection of each 




physician learner. Following full-length 

film screenings, a panel of faculty members 

modeled narrative reflection by sharing 

their reflections on the visual narrative with 

the students. Two days later, the students 

shared their written narrative reflections 

on the film in facilitated small groups. A 

series of wondering questions, arising from 

the visual narrative and based around the 

three dimensions of narrative inquiry (place, 

temporality, sociality) assisted in the process 

of narrative reflective practice. Student 

feedback helped to inform the ongoing 

evolution of the Narrative Reflective Practice 

(NRP) module in our first year Patient 

Centred Care course. 9 

In second year, Gilbert Scholars, physicians 

who work with second year students, were 

trained by Jean, Marie, and Alan Thomson 

to facilitate narrative reflective practice 

around listening to and inquiring into their 

experiences of “the patient’s story.” In the 

Gilbert Scholars’ course, students learn how 

to take a medical history, and learn how to 

perform a physical exam. A comparative 

research study was undertaken that involved 

having some small groups within the class 

meet for a second time with a patient and, 

in conversation, explore the patients’ stories 

of their illness experience. Each student 

then wrote, and shared with peers in their 

small group, a narrative reflection on the 

patients’ stories of their illness. The stories 

the second year students wrote showed how 

much they learned from attending closely 

to the stories that patients told of what 

was happening to them. We are hoping 

to repeat this study in the near future in 

order to establish conclusively if there is a 

difference in history-taking competencies 

between those students who participate in 

the narrative reflective practice intervention 

and those who do not. In the meantime, we 

recently introduced additional sessions of 

our film-based NRP module into the second 

year Patient Centred Care course. 

In third year, when students begin their 

clinical practice, we found that narrative 

reflective practice begins to impact the 

learner physicians’ professional identity 

formation. 10 Students in family medicine 

and surgery clerkship rotations now 

participate in narrative reflective practice 

activities. In surgery, clerks write a 

narrative reflection on a surgery clerkship 

experience. 11 In family medicine, student 

clerks write parallel charts of a clinical 

encounter in practice. 10 As described by Rita 

Charon, the parallel chart is the place where 

the physician learner writes those things 

that don’t belong in the chart “but need 

to be written somewhere”. 7 This exercise 

affords the learner opportunities for both 

26 

reflection and reflexive thinking around 

their responses to the clinical encounter. 

In their family medicine rotation, students 

share their written reflections in facilitated 

small groups, using the three dimensional 

narrative inquiry dimensions to inquire 

into their stories of experiences as written 

in their parallel charts. In addition, some 

residents have been involved in facilitating 

the small groups we introduced in our 

first and second year Patient Centred Care 

course. 

Pilot studies have been completed in family 

medicine and internal medicine residency 

programs. 12,13,14,15,16 At this point, NRP has 

now been introduced in family medicine and 

surgery residency programs, and recently a 

Narrative Reflective Practice journal club has 

begun as a means of supporting continuing 

professional learning for academic and 

clinical faculty. In addition to the Narrative 

Reflective Practice initiatives described 

above, we are aware that preceptors who 

teach and guide learners in undergraduate 

and postgraduate programs are exploring 

various approaches to reflection, some of 

it narrative reflective practice. This new 

initiative marks the achievement of the goal 

of our original developmental curriculum 

plan—to become involved in all stages of 

medical education. 

To date there have been nine publications 

in peer reviewed journals, as well as invited 

contributions to a chapter On Longitudinal 

Integrated Clerkships, editors Poncelet A 

& Hirsch D in the forthcoming edition 

of “Alliance for Clinical Education’s (ACE) 

Guidebook for Clerkship Directors.” Ed. Bruce 

Morgenstern. There have been workshops 

and peer-reviewed presentations at medical 

education conferences, and also invited 

workshops and presentations. Our group 

of researchers and educators are now part 

of a global network of pioneers in narrative 

reflective practice within medical education 

– and the research is ongoing. 

Narrative reflective practice and narrative 

inquiry are relational. True to form, our 

journey into Narrative Reflective Practice 

medical education research began through a 

relationship – with a cup of tea. We believe 

this experiential and relational approach to 

learning is providing medical learners, at all 

stages of their journeys as physicians, with 

a sense of being engaged in a community of 

learning, as we each learn from one another, 

and also experience the unique opportunity 

to learn from the self, by making tacit 

knowledge explicit. 

In a packed curriculum and with busy 

clinical agendas, Bolton reminds us of 

the importance of noticing moments for 

structured reflection. 17 She references the 

observer and poet William Wordsworth who 

wrote, “there are in our existence spots of 

time…whence...our minds are nourished 

and invisibly repaired. Such moments 

are scattered everywhere.” 18 This reflects 

well the impulse and motivation that has 

compelled us forward, as we continue 

to explore the potential of NRP in our 

curriculum and collaborate together in 

contributing to new ideas and visions that 

might inform future directions for medical 

education. 

Acknowledgements 

Our thanks to the Faculty of Medicine and 

Dentistry and the Department of Family 

Medicine’s Scott McLeod Fund for funding 

the visit of Dr. Charon to the University of 

Alberta. 

We would also like to thank Dr. Richard 

Spooner, Chair of the Department of Family 

Medicine, for his support of our narrative 

medicine initiatives, and again acknowledge 

the Scott McLeod fund for grants towards 

our research into narrative reflective practice. 

We acknowledge former Associate Chairs of 

Undergraduate Medical Education Dr. Chris 

Cheesman and Dr. David Raynor, without 

whom a narrative medicine curriculum in 

undergraduate medical education could 

never have begun. 

Our final thanks goes to our colleagues in 

the Faculty of Medicine and Dentistry, Dr. 

Alan Thomson, Dr. Verna Yui, Dr. Andrew 

Cave, Dr. Pam Brett-Maclean and Dr. 

Michelle Levy who contributed to earlier 

drafts of this paper. Thanks to Drs. Jonathan 

White, David Ross, Amy Tan, Stephen 

Aaron, David Kelner, Jasneet Parmar and Jill 

Konkin who joined with us in pioneering 

these narrative reflective practice pedagogies 

within the undergraduate medicine and 

dentistry curriculum. 

References 

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narrative inquiry: Mapping a methodology. 

Thousand Oaks, CA: Sage. 

2. Dewey, J. (1938). Experience and 

Education. Collier Books, New York: 1963. 

3. Clandinin, D.J., & Connelly, F.M. (1988). 

Teachers as Curriculum Planners: 

Narratives of experience. Teachers College 

Press: New York. 

4. Schön, D. (1983) The Reflective 

Practitioner: How Professionals Think in 

Action. Harper Collins Publishers: 

5. Ruane, S.F. (1994). The Future Teachers’ 

Autobiography Club: Preparing Education 

to Support Literacy Learning in Culturally 


Diverse Classrooms. English Education. 

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ethics. New York: Routledge. 

7. Charon, R. (2006). Narrative medicine: 

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qualitative research. San Francisco, CA: 

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9. Brett-MacLean, P.J., Cave, M-T., Yiu, V., 

Kelner, D., & Ross, D. (2010). Film as a 

means to introduce narrative reflective 

practice: A beginning story presented in 

three parts. Reflective Practice, 11, 499-516. 

10. Tan, A. Levy, M., Cave M.T., Ross, S. 

(2010). Family Medicine Clerkship: 

Implementation & Outcomes of a New 

Academic and Narrative Reflective Practice 

Curriculum. Family Medicine Forum poster 

presentation. 

11. White, J. (2008). The use of reflective 

writing in exploring student experiences 

in surgery. Journal of Surgical Education, 65, 

518-20. 

12. Cave, M-T., & Clandinin, D.J. (2007). 

Learning to live with being a physician. 

Reflective Practice, 8, 75-91. 

13. Cave, M-T., & Clandinin, D.J. (2007). 

Revisiting the journal club. Medical Teacher, 

29, 365-370. 

14. Clandinin, D.J., & Cave, M-T. (2008). 

Creating pedagogical spaces for developing 

doctor professional identity. Medical 

Education, 42, 765-770. 

15. Clandinin, D.J., Cave, M-T., Cave, A., 

Thomson, A., & Bach, H. (2010). Learning 

narratively: Resident physician’ experiences 

of a parallel chart process. The Internet 

Journal of Medical Education, 1 (1), May. 

16. Clandinin D.J., Cave, M-T., & Cave, 

A. (2010). Narrative reflective practice 

in medical education for residents: 

Composing shifting identities. Advances in 

Medical Education and Practice, 1, 1-7. 

17. Bolton, G. (2006). Narrative writing: 

Reflective enquiry into professional 

practice. Educational Action Research, 14, 

203-218. 

18. Wordsworth, W. (1888) in Bolton, G. 

(1999). The therapeutic potential of creative 

writing: Writing myself. Jessica Kingsley 

Pub.: London, p. 67. 

Enter stage right: An actor’s adventures in patient centred care 

Nadine L. Cross, RN, BScN, MHSc 

Research Associate, University Health Network Nursing Academy, York University, Toronto, Canada 

Correspondence to Nadine Cross: Email: nadine.cross@uhn.ca 

Abstract 

Through the use of drama and the art 

of storytelling, Robert Hawke has been 

sharing his journey of cancer diagnosis and 

treatment in a live, one-man comedic play 

entitled NormVsCancer. In the first person 

account below, Hawke describes how his 

play, when brought to patients, families and 

health professionals, was able to provide 

insight into his experience as a patient, 

and enrich patient centred care (PCC). This 

account also address how Rob’s play and 

his presence within the healthcare context 

has invigorated and drawn attention to the 

practice of PCC at the University Health 

Network, in Toronto, Canada. 

What if your nightmare was not a 

nightmare? What if your dreams were 

illuminating the possibilities of your life and 

the only thing to fear is how to live within 

those possibilities? This is my story such as 

it is. 

Five years ago I had thyroid cancer. It took 

me completely by surprise and I must say 

I was utterly unprepared for it. Diagnosis, 

surgery and recovery were tough, but what 

was most surprising to me was that this 

disease was so challenging in virtually every 

area of my life as it is with so many of us 

who deal with having cancer. 

I have worked as an actor and writer in 

comedy for years and shortly after surgery, 

I began writing and improvising the show 

that would become NormVsCancer. It wasn’t 

as clean cut as that of course - I didn’t wake 

up in the morning and say “and now I will 

write a significant piece about my experience 

that will hopefully resonate with others”. It 

was a lot more ragged than that. Alone in 

my apartment, I would become upset or sad 

and would just start acting out conversations 

between myself, and imaginary characters. 

Medical professionals might call this an 

interesting way of coping with a troubled 

psyche; my neighbours might have called 

it “batshit crazy”; I called it “theater”. I 

actually began to write this stuff down and 

form a structure around my ramblings that 

made some kind of sense. I managed to get 

the show partly written and knew I needed 

some help at that point to get any kind of 

finished piece. 

With the help of my friend Michael Cohen, 

we were able to co-create the first version 

of NormVsCancer and take it to the Prague 

Fringe Festival three and half months after I 

had surgery. I don’t recommend this. I pride 

myself on being prepared and professional; 

however, under the circumstances, we were 

under a very tight deadline and I just didn’t 

possess my usual levels of stamina, creativity 

and skill. Michael, as a consummate 

professional and director of the play, wanted 

to make the piece as good as it could be 

in the time we had. This made for a tense 

rehearsal period with me breaking down 

in tears on occasion and even throwing a 

chair across the room at one point. Now, 

please understand, I don’t believe that this is 

acceptable behavior at all. In fact, I think that 

any actor (or plumber or accountant) who 

engages in this kind of conduct deserves to 

be fired. My psyche was running amok at 

that point and I had all the coping skills of a 

rhino on acid. 

“Why did you do this?” you might ask. 

“Why not wait a couple of years for the dust 

to settle?” Well, it comes down to what I 

believe is a very basic human need, and 

that is the need to tell our stories. I HAD to 

talk about what had happened to me. Even 

dealing with my disease in a fictionalized 

way helped me to make some sense of it 

and process it. This was not obvious to me 

at the time. I thought I was just co-writing a 

funny show with some dramatic bits. 

Although this process was difficult and at 

times heart-wrenching, it was also a thrill 

to make something and share it with other 

people. It has been remarkably gratifying to 




find that folks in a similar situation could 

find resonance with their own experience, 

and by sharing the specifics of this one story 

we could find common ground and build 

community. 

I was quite nervous showing this piece 

to people who had been through cancer, 

thinking that I would be judged. After all, 

who was I to talk about this? These fears 

were put to rest after a performance for a 

small audience when a man in his fifties just 

came up to me without a word, hugged me 

and walked away. 

Throughout this theatrical process it has 

been my pleasure to talk with many cancer 

survivors and their families and time and 

time again I am struck by how folks who 

have been through something of this nature 

want to share their experience in order to 

process it in some way. More and more, we 

see patients coping with their traumatic 

experiences by expressing it in artistic ways. 

People paint, draw, act, sing, talk or choose 

any number of ways to communicate their 

experience. There is clearly value in this for 

patients. I don’t know how to measure it, 

quantify it or put it in a bottle, but it has 

28 

been my experience that many of us find it 

very useful. 

My wife works in healthcare, and through 

her, I was fortunate to meet some innovative 

and creative people at the University 

Health Network (UHN), Canada’s largest 

teaching, research and academic hospital. 

They identified a need for my show to be 

experienced by other patients and healthcare 

professionals alike. 

At UHN, Patient-Centred Care (PCC) 

is not just a set of words that hang on a 

plaque by the elevator on a ward; PCC is 

part of their guiding philosophy to practice. 

The philosophy encompasses the values 

of Respect, Human Dignity and Personas-Leader. 

The staff, which I have come to 

know and work with in light of our play, 

saw NormVsCancer as a wonderful vehicle 

to make clear the values of PCC. From my 

understanding, the staff at UHN has been 

engaged in iterations of PCC education 

over the past eight years. They have reached 

a crossroads, where the staff is not just 

hearing second-hand individual patient 

stories; they are yearning to hear from the 

patients themselves. 

Through NormVsCancer, I have been able to 

understand how to connect with my own 

healthcare team in way I never imagined. 

We have been able to stimulate lively and 

profound discussions with regard to PCC 

and how it is lived in practice. After each 

performance, patients and professionals 

are encouraged to tell their own stories 

and talk about what it was like for them in 

their own experience. You can practically 

hear the professional silos crumble and 

personal barriers fall, as folks share on a very 

human level what was for them a significant 

experience. It is an honour to be part of 

this process, to share with other patients 

of similar yet different experience and to 

be working with such dedicated health 

professionals who wish to advance PCC 

from the patient’s perspective. 

As a patient, these experiences have given 

me a tremendous amount of hope that we 

have the ability to make our healthcare 

system more effective, more caring and 

more human. How was I to know that 

my cancer diagnosis nightmare would 

awaken me to possibilities – to a life now 

illuminated? 

A bite into the media’s image of nursing in an apocalyptic world 

Sherrylynn Kerr, BA 

Nursing Student (2012), Faculty of Nursing, University of Alberta, Edmonton, Canada 

Correspondence to Sherrylynn Kerr Email: skerr@ualberta.ca 

Abstract 

In this article, the portrayal of the nurse in 

popular media is compared and contrasted 

with that found in professional nursing 

publications. The current stereotypical 

image and role of the nurse in contemporary 

film is described based on the film Dawn 

of the Dead (2004). 1 Critical thinking 

skills; professional ethics and values; the 

autonomous role of nursing; and the 

image of nursing within specific contexts 

are all investigated and compared. The 

often inaccurate portrayal of nurses within 

popular media still continues to pose 

challenges to the nursing profession. 

However, concurrently, there is a trend 

towards increasing positive images of the 

nurse, and evidence of this is certainly seen 

in Dawn of the Dead. 

The image and role of the professional 

nurse are commonly portrayed in popular 

media. These representations impact public 

perception of the nursing profession. 2 

Unfortunately, there are significant 

differences between these fictitious 

portrayals of the nurse, and the realistic 

expectations of the profession outlined in 

nursing publications. According to Stanley, 

the current media trend is to represent 

the nurse in a more positive manner. 3 In 

analyzing the representation of nursing in 

the contemporary film, Dawn of the Dead, 

I have found evidence of such a trend. 

Through comparing the nurse in the film 

with professional nurses, I was able to 

identify some challenges affecting the 

creation of a positive nursing image. 

The movie Dawn of the Dead depicts a 

North American geographical area that 

has been overrun by zombies, who do not 

possess higher order thinking. The zombies 

in the film are preoccupied with attacking 

individuals who have not yet become 

zombies. The lead character in the film is 

a nurse named Ana Clark. Ana and a few 

other survivors flee to the nearby Cross 

Roads Mall. Increasing numbers of zombies 

begin to conglomerate outside the mall, 

attempting to enter the building and feed on 

the survivors. 

Critical Thinking Skills 

Throughout the film, there are casualties 

among the survivors in the mall. Some of 

these survivors incur bites from the zombies. 

Ana resourcefully sets up a triage center 

and begins to assess, treat, and comfort the 

newcomers. As would be expected from a 

professional nurse, she treats the patients 

with respect, compassion, and competence. 1 

Ana uses critical thinking skills to determine 

the mechanism of transmission of the 

zombie infection. Critical thinking can 


e defined as making judgments about a 

situation using reflection, and integrating 

analysis, evaluation, and inference with 

knowledge. According to Profetto-McGrath, 

critical thinking is a necessary component 

for the professional nurse to exercise 

evidence-based practice. 1 Due to the threat 

of zombies and the characters’ isolation in 

the mall, it is not possible for Ana to employ 

evidence-based practice by consulting with 

experts. Furthermore, there is insufficient 

time for properly researched evidence to be 

generated and examined. 5 In the literature 

reviewing critical thinking skills and 

evidence based-practice, the professional 

nurse would ideally have opportunity to 

access such resources. Nevertheless, in the 

film, Ana uses the best evidence she has 

available to her in the given situation to 

guide her practice. 

In her triage center, Ana finds that one of 

her patient’s conditions is deteriorating 

quickly. She observes and astutely 

comments that the patient is cold, and that 

she has never seen such a bad infection 

without an accompanying fever. Within a 

couple of minutes, the patient dies. Ana 

assesses the patient for a pulse, checks 

the patient’s breathing, and determines 

that the patient is dead. Ana’s knowledge, 

assessment skills, and observations in this 

scene compare to those of a professional 

nurse. A few moments later, the deceased 

patient rises and begins to attack Ana. After 

Ana defends herself and kills her former 

patient (now a zombie), Ana evaluates the 

information available, uses inference and 

previous knowledge of her interactions with 

the zombies, and determines the mechanism 

of the zombie infection. She determines 

that the zombie infection is spread through 

bites. The critical thinking skills employed by 

the main character are comparable to those 

expected of a professional nurse, and are 

outlined in peer-reviewed nursing literature. 

Thus, this film portrays the role of the nurse 

positively, as comparable to roles outlined in 

professional literature. 

Professional nursing Values and 

Ethics 

The film takes place during a 

communicable-disease outbreak spread 

by zombie bites. The Canadian Nursing 

Association (CNA) states that: “During a 

natural or human-made disaster, including 

a communicable disease outbreak, 

nurses have a duty to provide care using 

appropriate safety precautions.” 4 Throughout 

the film, Ana abides by these regulations, 

using the resources she has available to her. 

Her actions in this respect are comparable 

to those expected of a professional nurse 

according to the CNA. 4 

After discovering the mechanism of 

transmission of the zombie infection in her 

triage center, Ana tells the group that Frank, 

one of her fellow survivors, has been bitten 

and should be quarantined immediately. 

Another character tells the group he thinks 

it is too dangerous to keep Frank alive. 

Our heroine immediately identifies and 

challenges the ethics of this situation: “What 

are we talking about here? Are we talking 

about killing him?” 1 Though this situation 

is not taking place within a formal nursing 

environment or practice, it addresses a 

number of nursing values and ethical 

responsibilities. 

Upon review of the Code of Ethics for 

Registered Nurses, I believe that Ana 

is encountering an ethical dilemma. 

Throughout the career of a professional 

nurse, ethical dilemmas and questions 

are encountered where the nurse has a 

difficult choice to make between two equally 

compelling courses of action. Ana is faced 

with this situation in the film. If Frank is 

killed, it will be demoralizing and traumatic, 

especially for his daughter, who is with 

him. However, if Frank is not killed, he will 

most likely become a zombie and attack the 

remaining survivors. 

Ana’s character is humanizing for the 

audience because she reminds us of this 

ethical dilemma. A professional nurse 

has specific nursing values and ethical 

responsibilities to uphold. Of the eight 

values outlined in the Code of Ethics 

for Registered Nurses, Ana maintains 

four values that pertain specifically to 

this situation: 1) Safe, Compassionate, 

Competent Ethical Care, 2) Informed 

Decision Making, 3) Preserving Dignity and 

4) Promoting Justice. 4 She provides safe, 

compassionate, competent and ethical care 

for all of the survivors—to the best of her 

ability—within her limited environment. 

She discusses the ethical dilemma regarding 

Frank’s zombie bite with Frank and the 

group, thereby recognizing, respecting and 

promoting Frank’s right to be informed 

and to make a decision. She recognizes 

and respects Frank’s intrinsic worth by 

reminding the group that he has a daughter 

who cares for him. And lastly, Ana upholds 

principles of justice by safeguarding human 

rights as much as possible within the given 

situation, and promotes the public good for 

the group of survivors. 

autonomous Role of the nurse 

At the very beginning of the film, the 

audience is able to see what life is like for 

Ana before the chaotic zombie infection 

spreads. Ana interacts with a physician, 

another health care professional, in the 

emergency department. The physician 

dismisses Ana’s statement that it is the end 

of her shift and asks her to find a patient 

who has been admitted to the hospital. 

Here, the audience briefly witnesses the 

heroine in a subservient role in relation to 

the physician. 

This situation relates to the autonomy of the 

nursing profession. In this particular scene 

in the film, Ana does not embody the role 

of an autonomous professional. However, 

in clinical settings, nurses do not report to 

physicians, as the film portrays. 1 Nurses 

report to their supervisor who is usually a 

nurse, not a doctor. This misperception is 

an ongoing challenge within popular media 

sources. As previously discussed, nurses 

have their own code of ethics as outlined by 

the CNA. 4 Nursing is a distinct autonomous 

profession that is regulated and governed 

by experienced nurses, many of whom hold 

graduate level degrees. 6 

In order to address the discrepancy between 

the media perception of the autonomy of 

nursing and the truly autonomous nature 

of the profession, nurses must advocate for 

their profession and effectively communicate 

with members of the media to demonstrate 

accurate representations, and for pride in 

the profession of nursing. 2 The image and 

role of the nurse will continue to evolve 

in a positive direction when practicing 

professional nurses are actively involved 

in a relationship with the media. McNally 

suggests that these efforts should begin at 

an undergraduate level. 6 

As the film progresses, the audience begins 

to see that Ana is capable of practicing 

autonomously, and that she is most certainly 

not subservient to other characters. Rather, 

Ana carries a leadership role in many 

instances throughout the film, such as 

independently setting up a triage center 

for those who are injured and encouraging 

group cohesion to battle attacking zombies. 

Ana’s autonomous role begins in the film 

once the zombie catastrophe begins. 

Context of the Film 

Overall, the film Dawn of the Dead presents 

a positive image of the nurse. I do, however, 

question the context in which this positive 

image is portrayed. This popular media 

portrayal of the nurse differs from what is 

found in the professional nursing literature, 

as the nurse in this film is acting within 

a fictional world overrun by zombies. Is 

the opportunity for the public to view 




the profession of nursing limited to the 

constraints of an apocalyptic setting? 

This catastrophic zombie world is 

comparable to the media representation 

of nurses during wartime, which presents 

nurses as “pure, brave, maternal, and free 

of the corruptive taint of war.” 2 Stanley 

examines how nurses are portrayed in 

feature films and identifies many themes 

in his data. In analyzing presentations 

of nursing throughout history, Stanley 

identifies themes such as: romance; heroism; 

self-sacrifice; intelligence; nurses as sex 

objects; nurses as strong women; nurses 

as victims; and the dark nurse. 3 Certain 

qualities, such as self-sacrifice, heroism, 

and the intelligent nurse, are predominant 

during difficult times in history, such as war 

and depression. 

In an earlier study, Kalisch and Kalisch 

examined English-language films released 

between 1930 and 1979. 7 Positive images 

and stereotypes of the nurse role are 

identified during World War I, the Great 

Depression, and World War II. In Dawn of 

30 

the Dead, the nurse is also a strong, positive 

character who demonstrates professional 

nursing during a similar global chaotic 

event. Interestingly, Kalisch and Kalisch note 

that once war is over, the representation 

of the nurse in the media reverts to that of 

a woman in her “rightful” place. That is, 

according to Kalisch and Kalisch, the nurse 

returns to “tending to children in their 

happy homes in the suburbs.” 7 

Despite the positive depiction of the nursing 

role in Dawn of the Dead, it is possible that 

nursing roles are only presented positively 

in the media when the nurse is working 

in the context of widespread disaster. The 

film Dawn of the Dead takes place in a 

chaotic environment, creating a challenge 

for the audience to view the value of the 

role of the professional nurse within a 

conventional world. 

References 

1. Snyder Z. Dawn of the Dead [Motion 

Picture]. Universal City (CA): Universal 

Pictures; 2004. 

2. Ku E. Nursing image: Reality versus media 

portrayal. Hong Kong Nursing Journal. 

2005; 41(3):7-12. 

3. Stanley DJ. Celluloid angels: A research 

study of nurses in feature films 1900-2007. 

Journal of Advanced Nursing. 2008;64(1): 

84-95. 

4. Code of ethics for registered nurses 

[Internet]. Ontario: Canadian Nurses 

Association [updated 2010 Jun 8; cited 

2011 Oct 27]. Available from: http://www. 

cna-aiic.ca/CNA/practice/ethics/code/ 

default_e.aspx. 

5. Profetto-McGrath, J. Critical thinking 

and evidence-based practice. Journal of 

Professional Nursing. 2005;21(6):364-371. 

6. McNally G. Combatting negative images 

of nursing. Kai Tiaki Nursing New Zealand. 

2009;15(10):19-21. 

7. Kalisch PA, Kalisch BJ. The image of the 

nurse in motion pictures. American Journal 

of Nursing. 1982;82(4):605-611. 

Albert Ross Tilley: The legacy of a Canadian plastic surgeon 

Kevin S. Mowbrey 

Medical Student (2014), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada 

Correspondence to Kevin Mowbrey: Email: kmowbrey@ualberta.ca 

ABSTRACT 

This article chronicles the career of one 

of the most important Canadian plastic 

surgeons of the twentieth century, Albert 

Ross Tilley. Tilley is best known for his 

innovations in burn management during 

World War II (WWII), and his treatment of a 

group of burn patients known affectionately 

as the Guinea Pig Club. In addition to the 

superb surgical skills he applied to the 

physical wounds of his patients, Tilley was 

also a pioneer of caring for the emotional 

and psychological afflictions suffered 

by many airmen of WWII. As one of the 

founding fathers of the Canadian Society 

of Plastic Surgeons, Tilley’s work was 

instrumental in establishing the specialty, 

and ensured its prominence for years to 

come. Serving in the capacity of leader, 

educator, and innovator, Tilley remains one 

of Canada’s most decorated physicians, 

and his contributions to the medical field 

continue to benefit patient care to this day. 

Key Words: Plastic Surgery, Burn 

Management, Ross Tilley, WWII, The Guinea 

Pig Club, East Grinstead 

INTRODUCTION 

As one of the first plastic surgeons in 

Canada, Dr. Albert Ross Tilley helped shape 

the discipline’s foundation (Figure 1). Tilley 

influenced the trajectory of a burgeoning 

specialty, as well as a generation of young 

practitioners who aspired to become part 

of the profession. Tilley was an innovator of 

burn management in the wake of a war that 

threatened to incinerate all those engaged 

in battle, and the healer of an affliction that 

society was ill-equipped to handle. The 

medicine Tilley dispensed indelibly altered 

the landscape of patient care forever. 

Tilley’s Background 

Albert Ross Tilley was born in Bowmanville, 

Ontario, on November 24, 1904. 1 Tilley’s 

interest in medicine was piqued at an early 

age, as he had the privilege of accompanying 

his father, a general practitioner, while he 

rounded on patients. Tilley graduated from 

the University of Toronto medical school in 

1929 as a silver medalist. 2 Following medical 

school, he traveled extensively for five years, 

studying surgery at the Toronto Western 

Hospital in Ontario, the Roosevelt and 

Bellevue Hospitals in New York, The Royal 

Infirmary of Edinburgh in Scotland, and 

with the renowned pathologist Sternberg in 

Vienna. 2 By 1935, Tilley was ready to open a 

private practice working at the Wellesley and 

Toronto Western Hospitals. 

In the same year, Tilley joined the No. 400 

City of Toronto Squadron of the Royal 

Canadian Air Force (RCAF) as a medical 

officer, and began what would turn out to be 

the most important training of his career. 2 

Dr. E. Fulton Risdon, a protégée of Sir 

Harold Gillies, and widely regarded as the 

father of modern plastic surgery in Canada, 

would guide Tilley’s focused training in 

plastic surgery. At the time, Dr. Risdon was 


Figure 1. Dr. Albert Ross Tilley. 

one of only three other plastic surgeons 

in Canada, and Tilley became the fourth 

upon the completion of his training just 

prior to the outbreak of World War II. 3 Tilley 

was called up to active service in 1939, and 

by 1940 he found himself a commanding 

officer and C Surgeon at Trenton Memorial 

Hospital. 3 A year later, he was appointed 

principal medical officer at the RCAF 

headquarters in London, England. 

Shortly after arriving in London, Tilley 

received a life-altering invitation, the 

acceptance of which would set into motion 

a chain of events that literally changed 

the faces of hundreds of airmen burned in 

WWII. Equipped with his newly honed skills 

in plastic surgery, Dr. Tilley traveled to the 

Queen Victoria Hospital in East Grinstead, 

Sussex in January of 1942. 1 There he was 

charged with the task of treating the most 

difficult burn injuries wrought from the pyre 

of war. 

Fates Worse Than death: Burn 

Casualties Of WWII 

History has frequently demonstrated that 

factors of circumstance set the stage for 

greatness, and one particular confluence of 

events allowed Tilley to produce outstanding 

innovations in the field of plastic surgery. 

One such event that would push Tilley’s 

skills to their very limit was the nature of the 

burn casualties of WWII. It is reasonable to 

assume that being caught in the crosshairs 

of a Nazi pilot was the worst nightmare of 

every Allied airman, but this was not the 

case. The entity that struck unadulterated 

fear into the hearts of the RCAF airmen 

was fire. Referred to by nicknames like 

“orange death”, the threat of burning alive 

was an unrelenting terror, and many pilots 

openly admitted that gravity or a bullet was 

a welcome alternative. 4 On Allied aircraft, 

whether Spitfire or Hurricane, the vector 

carrying the combustible arch nemesis of 

airmen was the fuel tank. 5 

During the interwar period, the Royal Air 

Force (RAF) conceived of new and ambitious 

strategies for air warfare of the future. 

Unfortunately, the demands of this strategy 

pitted fuel tank safety against parameters 

of performance. In order to produce planes 

that could out-fly and out-shoot the 

competition, drastic changes in aeronautical 

design were necessary, including upgrading 

the 87-octane fuel used in the Great War, 

to the more combustible 100-octane fuel. 7 

Furthermore, to achieve the highly soughtafter 

rapid rate of ascent, fuel tanks now 

had to be positioned directly below and in 

front of the cockpit. In essence, the pilot 

would find himself sitting on about 85 

gallons of fuel in the Spitfire, and 30 gallons 

of fuel in the Hurricane. 5 The problem 

with implementing previously used tank 

protection systems of rubber and metal 

encasements was that the materials added 

nearly 50 kg to the plane’s weight. This 

burden cut the maximum range of fighter 

planes by nearly 20%, and was a sacrifice 

in performance that top officials of the 

RAF were unwilling to accept. 4 Ultimately, 

strategy took priority over safety, and 

pilots were left to rely on their tactical skill 

rather than novel engineering to avoid the 

potential inferno sloshing around below 

them. To the dismay of hundreds of airmen, 

this performance requirement, though 

highly refined, would not prove enough, 

and many sustained burns rendering 

them unrecognizable. 

It is estimated that between 1940-1945, 

22,000 soldiers burned to death, and 4,500 

burn victims were recovered from crashes, 

with 60-80% of those rescued sustaining 

burns to their hands and face. 8 This scale 

of burn casualties had never before been 

witnessed, and was not predicted by 

Allied strategists. A certain pattern of burn 

injury presented so frequently to hospitals 

that it was given its own designation. 

“Airman’s Burn” was described in numerous 

wartime medical texts as ‘a burn of almost 

unwavering characteristics due to the 

sudden exposure of unprotected parts of the 

body to intense dry heat or flame, as though 

the patient were thrust into a furnace for a 

few seconds and withdrawn.’ The product of 

this process was ‘deep, searing burns, usually 

of third degree to areas of tremendous 

functional importance -- the hands and 

eyelids in particular.’ 9 The position of the 

fuel tank often resulted in its contents 

exploding in the face of the pilot, which 

accounts for the characteristic facial burns 

sustained. In addition to the hands and face, 

airmen commonly suffered burns to their 

wrists, neck, thighs, and scalp. 10 

The motivation of the RAF and RCAF to 

commit whatever resources necessary to 

ensure the best treatment possible for its 

burned airmen was two-fold. Firstly, these 

young men had volunteered to fight in the 

service of protecting their country, and the 

indebted nation demanded they receive care 

of the highest quality. Secondly, pilots were 

an invaluable resource in the war campaign, 

especially during the Battle of Britain. 

During the autumn of 1940, experienced 

pilots proved a commodity more critical to 

victory than steel or oil. 6 Burn injuries served 

to remove airmen from combat for weeks 

to months at a time, and therefore, the RAF 

needed to rehabilitate its most valuable 

resource as quickly as possible under the 

threat of an air campaign failure. Luckily for 

the multitude of victims, there were men 

like Tilley who were willing and able to 

set themselves to the task of rehabilitating 

these heroes. 

Tough as Leather: Burn 

Management Before WWII 

Shortly after arriving at East Grinstead, it 

became apparent to Tilley that the increasing 




Figure 2. Queen Victoria Hospital at East Grinstead (Left above). Schematic 

of Queen Victoria Hospital (Left below). Image from article of unknown source 

about the opening of the new Canadian wing at Queen Victoria Hospital (Right). 

number of Canadian burn casualties 

flooding the hospital would need their own 

ward. Under Tilley’s planning and leadership 

as the newly appointed chief surgeon 

and commanding officer, Royal Canadian 

Engineers prepared to erect a 50-bed wing 

that would cost $80,000 and take a year to 

build. 2-4 Upon its completion in 1944, the 

Canadian wing had a staff of over 50 people 

including orderlies, specialist nurses, and 

clerks (Figure 2). 

For decades before WWII, patients with 

severe burns were deemed terminal and the 

standard of care consisted of administering 

minute amounts of saline, a gargantuan 

dose of morphine, and orders for the 

patient to return home so they could be 

surrounded by their loved ones as death 

swiftly followed. 11 Burn patients were 

scarcely encountered in teaching hospitals 

because their case was viewed as hopeless 

and admission rarely occurred. The reason 

that major burns rapidly killed nearly 

everyone sustaining them was shock, and 

the inability of the medical profession to 

administer effective treatment to halt its 

progression. 8 Severe burns would initiate 

a chain reaction of events beginning with 

massive fluid loss from the wound, followed 

by shock and the successive failure of 

multiple organ systems until the patient was 

32 

no longer able to cling to life. If by some 

divine intervention the patient persevered 

through the shock, the next hurdle to their 

recovery was infection. With odds stacked so 

highly against recovery from severe burns, 

the treatments that developed were largely 

chemical interventions geared towards 

minor burns, with surgical involvement a 

rare occurrence. 10 Breakthroughs in treating 

shock changed everything. 

The 1920s saw physicians tinkering with the 

idea of fluid resuscitation, but out of fear of 

unknown adverse effects, they never dared 

to give fluid in the amounts necessary to 

stem the tide of shock. 8 It was not until the 

1930s that saline and plasma transfusions 

were gradually being administered in 

ever-increasing volumes. Eventually, the 

treatment of shock had evolved to such 

an extent that the majority of severe burns 

historically viewed as death sentences no 

longer produced corpses for coffins, but 

extremely complicated patients requiring 

specialized, multifaceted care. 4 The advances 

in shock therapy inadvertently created a new 

patient population that needed treatment 

desperately. The physicians of the day did all 

they could using the tools available to them. 

The results, however, proved unacceptable 

to physicians like Tilley. 

When the first wave of severely burned 

airmen presented to hospital, the major 

treatment method centered around 

coagulation. A coagulating agent would 

be applied to the burn, which caused a 

tough hide of scab-like tissue to encase 

the wound. 10 This functioned as a physical 

dressing of sorts, and was thought 

advantageous by many physicians in its 

ability to protect the wound, prevent lifethreatening 

fluid loss, and guard against 

sepsis. 8 The coagulant that was administered 

nearly universally was tannic acid, 12 the 

very same substance used in the leather 

industry to stiffen hides. Metal tubes of 

tannic acid were so widely distributed, that 

at the outset of the war, they could be found 

in almost every ER, medic bag, and first-aid 

kit in Allied territory. In theory, coagulation 

therapy served both as immediate firstaid, 

as well as a long-term treatment 

that remained in place until new tissue 

had grown underneath, after which the 

coagulum could be removed. 13 

The reality of treating airmen’s burns with 

tannic acid turned out to be so disastrous 

that it prompted one of Tilley’s mentors at 

the Queen Victoria Hospital, the great Sir 

Archibald McIndoe, to undertake a crusade 

against its continued use. The problems with 

treating airmen’s burn with coagulation 


therapy were numerous. Tannic acid applied 

to burns of the hands resulted in stiffness 

to the point of complete immobility. 14 

In addition to stiffness, the thick hide of 

coagulated tissue exacerbated edema, and 

constricted an already diminished circulation. 

This compression of blood flow in the hands 

frequently resulted in ischemia, necrosis, 

and the loss of fingers. 14 The black eschar 

produced also made it very difficult for the 

medical staff to detect infections, which often 

went unrecognized until the indicative aroma 

wafted into the nostrils of patient and staff. 

With the goal of avoiding septicemia, the 

coagulum was then ripped from the wound 

so antiseptic agents could be administered, 

but this commonly proved ineffective and 

agonizingly painful for the patient. 10 

Results of coagulants applied to burns of the 

face were equally distressing. Gentian violet 

was used for facial burns due to the belief 

that it was more ‘delicate’ than tannic acid. 15 

Despite its purported virtue, gentian violet 

left facial tissue rigid, and eyelids so taut that 

the patient often suffered corneal scratches 

or ulceration from being unable to blink. 15 If 

lucky enough to avoid irrevocable blindness 

during the gentian treatments, the patient 

then had to worry about the subsequent 

scarring that often everted the eyelids. 

Setting aside their immediate harm, the 

long-term hindrance posed by coagulation 

therapy was that it completely obliterated 

viable grafting surfaces. Once the coagulum 

was removed, its place was taken by thick 

spindles of keloid scarring, the likes of 

which vaporized hope for any degree of 

reconstruction. 15 

Fortunately for the hundreds of patients 

who suffered burns of the hands and 

face, McIndoe was able to persuade the 

majority of his colleagues, and the scientific 

community at large, that the heinous results 

of tannic acid justified the banishment of its 

use across Europe. 16 

Figure 3. Saline bath at Queen Victoria Hospital. 

Pulled From The Furnace: Tilley’s 

approach To Burn Management 

With coagulation therapy for third-degree 

burns of the hands and face effectively 

banned by the late 1940s, thanks to the 

advocacy of McIndoe and Tilley, the 

challenge of implementing an efficacious 

treatment regimen for severe burns loomed 

over the wards of East Grinstead. The 

approach cultivated by McIndoe and Tilley 

at the Queen Victoria Hospital, which served 

as the prototype for burn management and 

was duplicated at centers across Europe, 

consisted of three vital components. 4 In 

order to preserve surfaces viable for grafting, 

atraumatic dressings were essential. The 

form of dressing most commonly used 

consisted of a single layer of Tulle Gras, a 

non-adhesive bandage composed of fabric 

with variable proportions of paraffin and oil 

impregnating the material, placed directly 

on the surface of the wound, followed by 

a sterile saline compress over top. 14 The 

benefits of this method became apparent 

anytime staff needed to remove the 

dressings to clean the wound, or examine 

it for signs of infection; the Tulle Gras could 

be changed easily without inciting any 

additional trauma at the burn site. 

The second pillar of burn management 

Tilley utilized was the saline bath (Figure 3). 

Ablution was viewed as a critical method in 

maintaining clean, healthy wounds as well 

as being instrumental in the granulation 

process. 14 In addition to fostering a viable 

grafting surface, saline baths also allowed 

patients to keep their wounds flexible. This 

was especially important for burned hands, 

which were much more mobile under water 

and proved quite favorable for circulation 

and the salvaging of the greatest proportion 

of digits possible. 16 Patients under Tilley’s 

care would soak for an hour in tubs of 

saline, two to three times daily, during which 

Figure 4. Surgery at the Queen 

Victoria Hospital. 

time, dressings would seamlessly float off 

the burn site and save the patient from the 

potential agony of removing them under 

dry conditions. 10 

To achieve a truly successful treatment 

regimen, Tilley’s management of burns also 

had to neutralize infections. “Sulphanamide 

dusting” was one strategy employed, in 

which a powder form of sulphanamide, an 

antibiotic, was gently sprinkled over the 

surfaces of burns. 14 For burns of the hand, 

plastic bags filled with powder encasing the 

injured limb were used. 14 Tilley also noticed 

that the wool blankets used in hospitals 

harbored and transmitted infections to 

scores of patients across Europe, therefore, 

he had them exchanged with layered linens. 

One of the more ‘radical innovations’ 

employed at Queen Victoria Hospital was 

to ensure physical separation of the burn 

unit from other wards of the hospital, which 

broke with the convention of burn patients 

interspersed throughout various wards. 4 This 

served to cut the rampant infection rates 

produced by cross-contamination between 

patient groups that had plagued hospitals in 

the past. Patients at highest risk were those 

with burn wounds and jaw injuries, and they 

were housed in special isolation units. 

With the sulphanamide-tulle gras-saline 

sequence producing patients whose 

burns remained conducive to subsequent 

reconstructive therapy, Tilley now set himself 

to the task of restoring the hands and faces 

his patients had lost (Figure 4). One of 

Tilley’s first objectives was to reconstruct 

the ears of his patients: “without them” he 

asked, “how could a man hold his glasses 

on?” 3 Most men would need between 

between ten and fifty operations, requiring 

them to be in and out of the hospital for at 

least three years. It was customary to plan 

eight surgeries per year, alternating three 




to four weeks in hospital, with two to three 

week breaks outside. 10 

Generally, acromiothoracic flaps were 

utilized for deep unilateral burns, but in 

cases where adequate free grafts could be 

produced, patients were treated in this 

way entirely. 8 During his tenure at Queen 

Victoria hospital, Tilley would replace 

countless noses, reform a multitude of ears 

and eyelids, and re-establish facial features 

for hundreds of men; all of this with the 

objective of giving his patients the chance 

to return to a normal state of existence. But 

Tilley’s operative virtuosity was not all he 

offered his patients…. 

a Scalpel, a Guinea Pig, and a 

Tender Hand: Tilley’s approach 

To The Patient Relationship 

By 1944, the Canadian wing at Queen 

Victoria Hospital opened, and Tilley was 

promoted to the rank of Group Captain. 

In June of the same year, Tilley found 

himself standing in front of King George 

VI at Buckingham Palace with the Order of 

the British Empire being bestowed upon 

him. 1 This prestigious award was fitting 

recognition of Tilley’s success in Britain; 

along with the work of McIndoe and the 

hospital staff, they had become “the most 

formidable and effective response to burn 

injuries, anywhere in the world.” 4 

The work at Queen Victoria hospital was so 

groundbreaking that it brought one patient 

to remark in jest, “we’re nothing but a 

bunch of damn guinea pigs!” Subsequently, 

the Guinea Pig Club was formed in 1941, 

by a group of airmen who had suffered 

burn injuries in the war and were treated 

at the Queen Victoria Hospital. Consisting 

of nearly 650 members of a dozen different 

nationalities, the club was one of the first 

support groups in medical history. 17 The 

Figure 5. Tilley poses for a photo symbolizing the 

care he gave to his real patients, the Guinea Pigs. 

34 

camaraderie and sense of belonging fostered 

by the club has been acknowledged by 

many historians as instrumental in the 

therapeutic success ultimately achieved 

at East Grinstead. 4 The Guinea Pig Club 

helped shield patients from suffering their 

disfigurement in isolation, and gave its 

members the strength to venture out into 

the world, and walk the streets wearing their 

wounds as testaments of their sacrifice. Tilley 

served as president of the Canadian branch 

of the Guinea Pig Club, and continued to 

operate on over two hundred of its members 

for the next forty years (Figure 5). 3 

Tilley dedicated a tremendous amount of 

personal attention to the emotional and 

psychological condition of his patients. After 

operating all day and into the evening, Tilley 

would rest briefly in his living quarters only 

to make his way back to the hospital at 23:00 

h to check how his patients were faring 

after their surgeries. 4 In a medical landscape 

dominated by rampant paternalism, 

Tilley was a trailblazing pioneer of patient 

empowerment who went to great lengths 

to educate his patients about every aspect 

of their care, every nuance of their surgeries, 

and the intricate details of what they could 

expect during recovery. 18 Where many 

surgeons of the day saw their involvement 

in patient care beginning and ending in the 

operating room, Tilley was a fierce proponent 

of the importance of a patient’s psychological 

wellbeing in their overall rehabilitation. In his 

care of the Guinea Pigs, Tilley transcended 

the customary duties of a physician and rose 

to become a shining light that illuminated a 

comprehensive path to recovery. 18 

For decades after the war, Guinea Pigs 

from across the world would come together 

for an annual celebration where one of 

their toasts was always to the care they 

received from Tilley. Out of gratitude for 

Tilley’s commitment to them, the Guinea 

Pig Club funded a bronze bust of their 

beloved physician, which was installed in 

the Canadian wing of the Queen Victoria 

Hospital. The sculpture commemorates the 

man whose tender hand pulled them from 

the furnace, and allowed them to transcend 

what had once been thought of as a fate 

worse than death. 2 

no Sign Of Slowing down: 

Tilley’s Life after The War 

Upon his return from Britain in 1945, Tilley 

became a consulting physician at Christie 

Street Hospital and Toronto Wellesley 

Hospital. For several years between 1949- 

1965, Tilley also spent three days every 

month in Kingston where he worked as a 

staff physician at the Hotel Dieu, Kingston 

General, and Kingston Military Hospitals. 2 

As one of only ten other plastic surgeons 

practicing in Canada after the war ended, 

Tilley was extremely busy laying the 

framework for the future of his specialty. 

His colleagues viewed Tilley as a physician 

capable of breaking new ground. In July of 

1942, he led the first all-Canadian plastic 

surgery operation, and a few years later as 

an assistant professor at Queens University, 

he became the first to offer formal accredited 

courses in the specialty. 2 Tilley also invented 

several surgical instruments, such as an 

ingenious hand splint, and was the first to 

19, 20 

design the tube pedicle flap. 

Tilley was one of the twelve founding 

fathers of the Canadian Society of Plastic 

Surgeons in 1947. At its second annual 

meeting on June 2, 1948, the society’s 

members empowered Tilley to draft a fee 

schedule for the operations performed most 

commonly by plastic surgeons. 20 Appointed 

vice-president in 1953, and then president 

in 1954, Tilley’s leadership of The Canadian 

Society of Plastic Surgeons helped establish 

the profession in Canada and paved the way 

for the exponential growth and prosperity it 

would experience in subsequent years. 20 

As his specialty flourished across the 

country, Tilley continued to infuse his 

discipline with respect and integrity as 

he campaigned for years to develop burn 

treatment facilities in Ontario. In 1984, his 

vision came to fruition and the Ross Tilley 

Burn Centre opened at Wellesley Hospital. 21 

Only three years after becoming the first 

plastic surgeon to be appointed a member 

of the Order of Canada, Tilley also assumed 

the role of Founder and Director of the first 

19, 21 

adult burn centre in Canada. 

Even after retiring from practice at Wellesley 

and Sunnybrook hospitals in 1981, 

Tilley continue to be recognized for his 

outstanding career. An elementary school in 

his hometown of Bowmanville was named 

in his honour, and he was inducted into 

Canada’s Aviation Hall of Fame in 2006. 1,3 

After dedicating much of his 84 years of life 

to his patients, Albert Ross Tilley passed 

away on April 19, 1988. 21 

CONCLUSION 

The distinguished and illustrious career 

of Albert Ross Tilley exemplifies many of 

the qualities sought after by physicians 

today. As a surgeon, he is remembered 

for his meticulous technical skill, sound 

judgment, and tireless work ethic. He was 

a leader, innovator, and educator whose 

efforts sculpted an immature specialty into 

a refined profession. As a man, Tilley’s virtue 

and character stood beyond reproach, and 


he was acknowledged with Canada and 

Britain’s highest honours. 

The most valuable lesson that Tilley’s legacy 

offers this generation of medical students 

and physicians, can be gleaned from his 

first encounters at East Grinstead. Standing 

at the bedside of his patient and assessing 

the medicines he had at his disposal, Tilley 

shook his head and resolved to do better; 

he refused to surrender to the limitations 

dictated by existing medical practice. 

Tilley tossed aside the contemporaneous 

treatment of coagulation therapy, the merits 

of which were being espoused by experts 

in the field. With a steadfast conviction 

that his patients deserved a higher level 

of treatment, Tilley worked tirelessly with 

McIndoe and hospital staff to produce 

a revolutionary regimen that ultimately 

saved the hands, faces, and livelihoods of 

hundreds of men. Tilley’s actions at Queen 

Victoria Hospital serve as a reminder 

to modern day practitioners of their 

responsibility to address deficient aspects 

of patient care, and to innovate, when 

necessary, in order to provide patients with 

the best possible medicine. 

Acknowledgments: I would like to thank 

Dr. Gordon Wilkes of the University of 

Alberta, and Dr. Steven Morris of Dalhousie 

University for their generous guidance in the 

production of this article. 

References: 

1. Albert Ross Tilley. Alberta: Canada’s 

Aviation Hall of Fame; c2011 [cited 2011 

Jun 10]. Available from http://www.cahf. 

ca/members/T_members.php#A.%20 

Ross%20Tilley 

2. Gray C. Profile of A. Ross Tilley. Can Med 

Assoc J. 1983;129:154. 

3. Wilton P. WW II “guinea pigs” played 

crucial role in refining plastic surgery in 

Canada. CMAJ. 1998;159(9):1158-9. 

4. Mayhew ER. The Reconstruction of 

Warriors: Archibald McIndoe, the Royal 

Air Force, and the Guinea Pig Club. 1st ed. 

London: Greenhill Books; 2004. 

5. Downing T, Johnston A. The Spitfire 

Legend. History Today. 2000; 50(9):19-25. 

6. Keegan J. The Second World War. 1st ed. 

New York: Penguin Books; 1989. 

7. Bailey G. The Narrow Margin of Criticality: 

The Question of the Supply of 100-Octane 

Fuel in the Battle of Britain. English 

Historical Review. 2008;123(501):395-411. 

8. Jackson DM. Burns: McIndoe’s 

contribution and subsequent advances. 

Annals of the Royal College of Surgeons of 

England. 1979;61:335-40. 

9. McIndoe AH. Total reconstruction of the 

burned face. Br J Plast Surg. 1983;36:410- 

20. 

10. Geomelas M, Ghods M, Ring A, Ottomann 

C. “The Maestro”: A Pioneering Plastic 

Surgeon—Sir Archibald McIndoe and His 

Innovating Work on Patients With Burn 

Injury During World War II. J Burn Care 

Res. 2011;32(3):363-68. 

11. Alger EM. On Cutaneous Burns. Medical 

Record. 1898;53(22):766-68. 

12. Mitchiner PH. Treatment of burns and 

scalds with special reference to the use of 

tannic acid. The Lancet. 1933;233-39. 

13. Gordon RM. Treatment of burns by tannic 

acid. The Lancet. 1928;336-37. 

14. Hunter JB, Gillies H, McIndoe AH, Hudson 

RV, Colebrook L, Kilner TP. Treatment of 

Burns. The Lancet. 1940;621-622. 

15. McIndoe AH. The Misuse of Tannic Acid. 

The Lancet. 1940;627-28. 

16. McIndoe AH. Burns of the Hands and 

Face. The Lancet. 1940;655. 

17. Andrew DR. The Guinea Pig Club. Aviat 

Space Environ Med. 1994;65(5):428-33. 

18. Feasby WR. The Official History of 

the Canadian Medical Services, 1939- 

1945. Department of National Defense, 

Directorate of History and Heritage. 

1956;363-366. 

19. Cheng H. Firsts in Canadian Plastic 

and Reconstructive Surgery. University 

of Toronto, Division of Plastic and 

Reconstructive Surgery website. 2010 

[cited 2011 Jun 1]. Available from http:// 

www.uoftplasticsurgery.ca/main. 

php?p=1154&s=1 

20. Douglas LG. History of the Canadian 

Society of Plastic Surgeons. 1st ed. Quebec: 

Canadian Society of Plastic Surgeons; 1983. 

21. Taylor JR. Canadian Society of Plastic 

Surgeons: Tribute to our founders. Can J 

Plast Surg. 1997;5(1):22-32. 

The House of God still worth a read for today’s medical trainees 

Alby Richard, BSc 

Medical Student (2013), Faculty of Medicine, University of Calgary, Calgary, Canada, 

PhD Candidate (Neuroscience), Montreal Neurological Institute, McGill University, Montreal, Canada 

Correspondence to Alby Richard: Email: alby.richard@mcgill.ca 

THE HOUSE OF GOD 

By Samuel Shem 

New York, NY, Dell, 2003 (first published: 

New York, NY, Richard Marek, 1978). 

ISBN 978-0385337380 

Medical training has changed a great deal 

over the past thirty years, along with the 

way medicine is practiced in general. This 

is interesting to consider in the context 

of the American medical system, which 

has the dubious honor of boasting the 

most sophisticated yet unevenly accessible 

medical system. In light of this, it is perhaps 

not surprising that at some point along 

the way voices of dissent would emerge, 

even from within the ranks of the medical 

establishment itself. 

Samuel Shem’s (the pen name of Dr. 

Stephen Bergman) House of God was 

first published in 1978, as a semiautobiographical 

account of Dr. Roy Basch’s 

internship year in the eponymous hospital. 

With the ripples of the civil rights movement 

still being felt, and the Watergate scandal 

showcasing the moral ambiguity of the 

nation’s highest offices, Shem’s honest 

and at times disturbing portrayal of one 

of America’s most prestigious teaching 

hospitals was a timely contribution to the 

changing social and political landscape. 

Now, over three decades later, even a 

sophomore medical student on the brink 

of entering clerkship may be struck by Dr. 

Bergman’s candid observations concerning 

the challenges of medical education. This 

book offers a compelling caricature of some 




general themes that many facing a career in 

a medical discipline are likely to encounter: 

from management of chronically ill patients, 

to acrimonious relationships (both personal 

and professional) with fellow colleagues. 

If you have not yet read the House of God, 

your first thought may be whether this 

fictionalized account from the 1970s has 

any relevance to the plight of today’s 

medical trainee. The short answer, which 

becomes obvious even after the first few 

chapters describing Roy’s arrival to the 

House, is a resounding yes. There are of 

course elements of the book that will be 

difficult to reconcile with the reality of 

resident life thirty years later: The text is 

littered with outdated medical references, 

and is punctuated throughout with a 

tone of arcane paternalism that would be 

unacceptable by today’s standards. These 

anachronisms, however, beyond reminding 

us that the book is situated in another era 

altogether, are also important for another 

reason. They allow today’s reader to 

appreciate those egregious aspects of the 

American healthcare system of the 1970’s 

for their comic relief, and serve to reinforce 

many of the book’s themes. Furthermore, 

the fact that many of its themes still apply 

today only reinforces Bergman’s talent and 

perspicacity. 

By introducing us to the morbid humour 

and unsavory behaviour which Roy and 

his colleagues would often invoke to make 

sense of the difficult situations in which 

they found themselves, Bergman reveals the 

importance of having a stress outlet. We see 

this evinced through different characters 

in the book. The narcissistic Pinkus 

comes to mind, with his utter emotional 

detachment from his ICU patients, coupled 

with his nearly monastic devotion to his 

own running routine and sculpted calves. 

The lack of an appropriate outlet is also 

mirrored in Roy’s steadily mounting inner 

turmoil as his internship year progresses. 

Our protagonist’s ongoing awareness of the 

macabre, often futile nature of his various 

coping strategies gives the narrative further 

36 

depth and tension, and keeps the reader 

wondering just how much more Roy can 

take. 

Bergman’s development of secondary 

characters to further explore the 

complexities of internship is nicely 

accomplished. Notable among these is Barry, 

his clinical psychologist girlfriend, whose 

unwavering presence serves as a moral 

counterweight to his frenetic mood swings 

and constant disequilibrium. Indeed, Barry’s 

views often come across as a reminder of 

the humanity and basic conscientiousness 

that Roy begins the year with, but gradually 

loses, as he sinks further into the soulsucking 

drudgery of ward-based medicine at 

the House. 

Roy’s in-house sanity is provided by the 

enigmatic and brilliant senior resident, 

known only as the ‘fat man’, whose 

sacrosanct “Laws” of the House come to 

form the basis of most of Roy’s clinical 

decisions, often in flagrant disregard to 

everything his previous medical education 

has taught him. While some may seem 

trite at first (e.g. law #4 “THE PATIENT IS 

THE ONE WITH THE DISEASE”), others, 

such as law #13, come to signify one of the 

book’s pervasive themes: “THE DELIVERY 

OF GOOD MEDICAL CARE IS TO DO AS 

MUCH NOTHING AS POSSIBLE”. This 

statement may seem fairly counterintuitive 

at first, but gains considerable traction 

when considered in the context of Roy’s 

misadventures at the House. 

The House is also a rich resource on 

terminology for any new initiate to the 

medical sphere, and worth the read from 

that perspective alone. Here we find the 

origins of terms that many of us may be 

familiar with already, such as GOMER (‘get 

out of my emergency room’); BUFF (the 

careful art of making a chart look good, 

which often treads the fine line between 

perjury and embellishment); and TURF 

(using any excuse possible to hand off 

care of your patient to another service or 

department). While such catchwords may 

not be used very frequently today, the spirit 

of these terms almost certainly persists, as 

many with first-hand clinical experience will 

recognize. 

Dr. Bergman also addresses the notion of 

hierarchy throughout the book, and how 

embedded it is at all levels of training and 

administration. While his criticisms are 

often oblique and bordering on subversive 

(often at the expense of one of Roy’s senior 

colleagues or House staff), they are also 

poignant and hilarious. A particularly 

memorable image is that of the Leggo, Roy’s 

uptight and oblivious superior staff member, 

with his stethoscope in its default position 

winding down into his trousers (which Roy/ 

Bergman playfully mocks throughout the 

book). Interestingly, Bergman’s depiction 

allows the reader some first-hand insight 

into both the folly and utility of this 

entrenched system, the relics of which are 

still present today. 

At the end of the day, The House of God 

is a pleasant and engrossing read, and 

there is much to be gained in reflecting on 

Roy’s tumultuous foray into the world of 

hospital-based medicine. The prescience of 

this book and the ‘Laws of the House’ are 

worth noting today as we find ourselves 

in the midst of health care system that is 

underfunded, short-staffed, and overused. 

In critiquing the medical system in which 

we train and work (albeit through the lens 

of a 1970s intern), The House of God forces 

the reader to consider just how sustainable 

our current practices are. This message is 

especially pertinent in the context of our 

ageing population, since many of our current 

practices in medicine were founded in Roy’s 

era of relative resource abundance. 


Thank you 

The UAHSJ wishes to thank the 

Faculty of Medicine and Dentistry for 

their generous support of this project.

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