MARCH, 2023

Dr. Harry Liu, PGY-4, Dermatology

You are passionate about “Choosing Wisely Canada”. Could you briefly describe the concepts to us (perhaps in the context of the programs you’ve worked in!) and why you believe it’s important in dermatology and healthcare in general?

For clarity, Choosing Wisely Canada (CWC) is a national campaign on resource stewardship. It is based on the notion that unnecessary tests, procedures, and treatments often do more harm than good, resulting in poor clinical outcomes and significant waste in the Canadian healthcare system. For example, unnecessary imaging tests for low back pain are associated with increased healthcare costs and unnecessary radiation to patients. My journey of advocating for the effective use of healthcare resources started in 2017 when I completed a systemic review under the supervision of Dr. Brian Rowe to investigate the effectiveness of interventions to decrease image ordering for low back pain in the Emergency Department. The paper was published and featured on the front cover of the journal, Academic Emergency Medicine, and became one of the Top 10 most accessed journal articles in 2018. Many readers reached out to me, and I had lots of meaningful conversations on resource stewardship which enhanced my interest on CWC.

One example of resource stewardship in dermatology is that antibiotics are sometimes routinely prescribed for bilateral swelling and redness of the lower leg (“bilateral cellulitis”). It is associated with antibiotic resistance and prolonged hospital stay.

I have also seen severe cutaneous adverse reaction like Stevens-Johnson syndrome from unnecessary use antibiotics for “bilateral cellulitis”. One of the recommendations developed by the Canadian Dermatology Association with CWC in 2020 is “Don’t routinely prescribe antibiotics for bilateral lower leg redness and swelling”. In residency, I combined my interests in resource stewardship and medication in dermatology together. I led a team to create casebased educational videos to teach medical trainees about these CWC dermatology recommendations to decrease unnecessary tests and treatments. I am proud to say that the project received the American Academy of Dermatology Resident Quality Improvement Award in 2022.

I firmly believe that resource stewardship is essential for our Canadian healthcare system. I hope more medical trainees can learn more about CWC so everyone can be empowered to initiate conversations with patients to help them decide what tests and procedures are right for them. It will ultimately lead to a sustainable healthcare system and stronger patient-physician relationships.

You’ve done a lot of work on skin of colour. Could you briefly talk about your work on this topic and how you’ve used (or plan to use) research on skin of colour to help patients of colour?

Common skin conditions often manifest differently on darker skin, and there are also skin conditions that are more common in skin of colour (SOC) patients. Studies have shown patients with skin of colour are underrepresented in medical training and textbooks, leading to missed diagnoses and healthcare inequalities. My first exposure to the topic was when I published a paper titled “Dermatology Education in Skin of Colour: Where We Are and Where Do We Go?” in the Canadian Medical Educational Journal in 2021. For that paper, the awareness of this disparity in dermatology was raised, and I became more and more interested in the topic. In 2022, I participated in the SOC Society Diversity in Dermatology Trials Task Force in Washington DC and developed a deep appreciation of the lack of SOC in clinical trials and research. It inspired me to publish several clinical cases on SOC patients in various scientific journals.

I am a firm believer that it is important for our medical trainees to become competent in the management of skin diseases in SOC patients because there are distinct differences in the prevalence, disease manifestations, and treatments required for certain skin conditions in this population. In the “Beyond Skin Deep” online multidisciplinary dermatology modules my team created for medical students, we included various cases that focused on the care of SOC patients to help medical students provide better care for them. There has been an increasing number of initiatives on SOC medical education, including the Skin Spectrum Summit in Canada and SOC Update in the US. I highly recommend any residents with an interest in SOC to attend these conferences. During my elective time next year, I am excited to visit the

University of Washington in Seattle to learn strategies for diagnosing and managing cutaneous lymphoma in SOC patients. After residency, I hope to develop a multidisciplinary specialized clinic with a focus on providing individualized dermatologic care to SOC patients.

It’s impressive that you have published over 20 peer-reviewed publications thus far. Could you talk about some of research work you did and what inspired you to do research? Do you have any tips for residents who are interested in doing research?

I have done research in several areas that I am curious about, including primary psychodermatology, rare complex dermatologic conditions, and medical education. Primary psychodermatology encompasses psychiatric disorders with skin manifestations, a very underserved area in dermatology. With my mentor Dr. Marlene Dytoc, over the last three years, my team reviewed the global prevalence and pharmacological interventions for all primary psychodermatologic disorders in randomized controlled trials. These conditions are often underdiagnosed, and the patients often have significantly reduced quality of life. It is a reminder of the importance of the multidisciplinary aspect of dermatology and how dermatologists can collaborate with other health professionals to provide better patient care.

The other fun part of being a resident is you get to see and treat many “Zebra” cases when working at a tertiary center, like the Vancouver General Hospital. For example, I saw and reported the first case of terbinafine-induced generalized pustular psoriasis that mimics Stevens-Johnson syndrome....

Continued on next page a novel presentation of cutaneous lupus erythematosus, and coined a new clinical presentation termed “yellow bullous striae distensae” with my co-resident. There is usually no established treatment for rare diseases. Researching those conditions and publishing the cases can help physicians be more comfortable diagnosing and treating rare diseases and potentially help other patients with similar conditions worldwide.

My biggest advice for someone starting research in residency is first to follow your curiosity instead of your passion because passion needs time to build up. An excellent research topic is the one you are most curious about, and it can be anything. For example, along with my co-authors, we reviewed the content of skin cancer posts on TikTok and reported the trending pattern of tanning. It then raised the seriousness of this issue in the dermatology community. In November 2022, TikTok banned videos that encouraged sunburn and tanning. Next time, I therefore encourage you to ask yourself what you are the most curious about now before embarking on the journey of starting a new research project.

You have been named the “Culture Changer in Medical Education” by the Canadian Federation of Medical Students over the past three years. What are some of the most challenging and most awarding moments of creating the educational resources and introducing them to medical students?

I would not be where I am today without all the teachers and mentors I have met along my journey of residency so far. They include several people I already mentioned, like Dr. Dytoc and Dr. Rowe, as well as Dr. Hui Zhou, Dr. Monica Li, and Dr. Tina Alster from residency. They have all inspired my curiosity and passion for medical education and mentorship.

The most rewarding parts of creating educational resources are certainly to see students being able to use these resources to provide better patient care. For example, I made various interactive cases, podcasts, and summary notes on PedsCases.com to help medical students to develop an approach to multiple topics in pediatric dermatology, including atopic dermatitis, pediatric vitiligo, neurocutaneous disorders, etc. There was no better feeling than when students contacted me and told me the resources helped them feel more comfortable diagnosing and treating these conditions. I also enjoyed using new platforms like social media to find innovative teaching methods. For example, with the lack of in-personal clinical skill teaching for medical students during the peak of the COVID-19 pandemic, I created concise educational videos and posts to help medical students learn clinical dermatology on the Instagram page of MEDSKL.com. I was thrilled to be able to share this innovative teaching method with other educators from different universities at the 2022 Canadian Conference on Medical Education in Calgary.

The most challenging part of doing all these is balancing the clinical work as a resident, studying over 3000 skin conditions, and doing scientific research. Also, I am always interested in exploring innovative ways and initiatives to teach medical students; sometimes, they may not work out perfectly. Hence, there is a bit of trial and error and unavoidable disappointment. Nevertheless, with the advancement of technology and continuous innovation, I am excited to see what medical education will be like over the next 5-10 years. I hope to be part of the transformative journey for medical learners.

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