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Medicine Matters — Issue 30 – June 2019
STRONGER TOGETHER
Research News
DoM Research Day 2019
About 140 people gathered at Pier 21 on March 28 to learn more about the research taking place in the Department of Medicine. DoM Research Day 2019 featured 10 podium presentations and 84 posters by department members, undergraduate students, residents, research fellows, graduate students and research associates.
Dr. Heather Ross, who is the Loretta A. Rogers Chair in Heart Function and Site Lead at the Ted Rogers Centre for Heart Research in Toronto, was an entertaining and informative guest speaker on the topic of Remote Patient Monitoring in Heart Failure: Myth or Magic?
Congratulations to the Research Day award recipients
Best Undergraduate Presentation
Jordan Boudreau, Med 3
Public Knowledge of Prevention During an HIV Outbreak: Are the most at-risk individuals PrEPared?
Supervisor : Dr. Lisa Barrett, Division of Infectious Diseases
Best Core Resident Presentation
Dr. Alex Legge, PGY3 Internal Medicine 
The Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI) as a Predictor of Organ Damage Accrual and Hospitalizations in System Lupus Erythematosus (SLE) 
Supervisor : Dr. John Hanly, Division of Rheumatology
Best Sub-Specialty Resident Presentation
Dr. Daniel Belliveau, PGY5 Cardiology
Cardioembolic and Bleeding Outcomes of Patients Treated for Left Ventricular Thrombus Following Primary Percutaneous Intervention
Supervisor : Dr. Robbie Stewart, Division of Cardiology
Best Research Fellow/Graduate Student Presentation
Allie Carew, Research Associate
Haptoglobin Phenotype as a Predictor of Incident Cardiovascular Disease Within the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Randomized Clinical Trial of Strict Glycemic Control         
Supervisor : Leah Cahill, PhD, Howard Webster Department of Medicine Research Chair
Best Overall Poster Presentation
Scott Kehler, Research Fellow  
Does Cardiac Rehabilitation Improve Frailty Levels?    
Supervisors : Olga Theou, PhD, Research Office, and Dr. Kenneth Rockwood, Division of Geriatric Medicine
University Internal Medicine Research Foundation (UIMRF) Awards
Internal Fellowship - Clinician Investigator Program - Dr. Jasmine Mah , PGY2 Int Med
Supervisor: Dr. Melissa Andrew
Internal Fellowship Award – Clove Haviva, PhD
How Does Religiosity Influence the Health of Middle-Aged and Older Adults Across Levels of Frailty?
External Fellowship Award – Dr. Ben Whatley , Neurology
Validating an Automatic Detector for EEG High Frequency Oscillations and Evaluation the Clinical Utility and Impact of EEG Video Telemetry
Junior Department Member Award - Dr. Amanda Vinson , Nephrology
Kidney Graft Loss in Female Recipients of Male Kidneys: The Effect of Pre-Transplant Pregnancy

Junior Department Member Award - Leah Cahill, PhD
Eating Frequency and Timing as a Predictor of Developing Type 2 Diabetes
Pilot Funding Award - Dr. Jennifer Jones , Digestive Care and Endoscopy
Impact of Stakeholder-Defined Access Barriers on Healthcare Resource Use and Disease-Related Outcomes: Application of a Patient-oriented Systems Mapping Approach
DoM Strategic Research Incentive Grants
Dr. Karthik Tennankore ,
Division of Nephrology

Validation of a Risk Prediction Model for Urgent Dialysis after Ambulance Transport to the Emergency Department
Dr. Ian Davis ,
Division of Infectious Diseases

Does Increased Vancomycin MIC Increase the Risk of Complications in Patients with Methicillin Sensitive Staphylococcus Aureus Blood Stream Infections? A Retrospective Review
2019 Faculty of Medicine Resident Research Awards
On June 5, three of the five Faculty of Medicine Resident Research awards were presented to Department of Medicine residents - Congratulations!

Best Work in Clinical Research 
Dr. Alex Legge (PGY3 Internal Medicine)
Sponsor: Dalhousie Medical Alumni Association $1000
Project: The Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI) as a Predictor of Organ Damage Accrual and Hospitalizations in System Lupus Erythematosus (SLE)
Best Research Award for a senior resident (PGY3 or PGY4+) who has incorporated research into their primary training program 
Dr. Andrew Caddell (PGY5 Cardiology)
Sponsor: Dalhousie Medical Research Foundation $1000
Project: A Novel and Simplified Echocardiographic Measurement is Associated with Clinical and Echocardiographic Response to Resynchronization Therapy
Best Research Award for a senior resident (PGY3 or PGY4+) who has incorporated research into their primary training program 
Dr. Dan Belliveau (PGY5 Cardiology)
Sponsor: Dalhousie Medical Alumni Association $1000
Project: Cardioembolic and Bleeding Outcomes of Patients Treated for Left Ventricular Thrombus Following Primary Percutaneous Intervention
DoM Research Director
Dr. John Hanly, Division of Rheumatology began as Chair of the Department of Medicine Research Committee in 2011. In 2015, he became the Department of Medicine Research Director.

Dr. Hanly is a tremendous advocate for the advancement of research. Increasing research awareness and identifying accomplishments are among his top priorities. Dr. Hanly will finish his term in July 2019.

Thank you Dr. Hanly!
Dr. Melissa Andrew, Division of Geriatric Medicine will be the new Department of Medicine Research Director beginning July 1.
PROFILE: Dr. Alexandra Legge
Keeping an eye on the real prize
Dr. Alex Legge received one of Dalhousie University’s top awards during spring convocation – but that isn’t the real reward for her hard work.

The one-time Dal varsity basketball athlete added to her long list of accolades when she was honoured with the Governor-General Gold Medal in the Natural Sciences and Engineering as the most outstanding master’s graduate .
 
The award recognizes her achievements during her studies for a master’s degree in community health and epidemiology. It joins numerous other recognitions earned at Dal while completing a medical degree and an undergrad science degree with a major in neuroscience.
“It’s a patient population that I feel strongly about helping and enjoy working with,” said Dr. Legge.

“I find it very rewarding when we’re able to help them through illnesses that have had a huge impact on their daily lives and to really be able to help them feel better.”
For all her awards and prizes, what does she find rewarding? Caring for her patients and helping them feel better. And, in time, with her continued research on systemic lupus erythematosus (SLE), her real prize will be developing a tool that can help indicate a patient’s risk .
 
“One of the difficult things about SLE is that it is extremely unpredictable,” explained Dr. Legge. “For some patients, it is a relatively mild disease with minimal impact on their daily life. For others, they will develop organ damage and functional disability over time. And for some patients, it could be rapidly fatal.”

Given these differences and the disease’s unpredictability, the ability to identify which patients are at higher risk of negative outcomes could allow for intervention early enough to change the course of the disease.

Mentored by Dr. John Hanly , Dr. Legge furthered her research into developing such a prognosticating tool through her master’s studies, completed through the Clinician Investigator Program in the midst of her internal medicine residency. Her research into the autoimmune disease will continue as she joins the Department’s rheumatology subspecialty training program in July.
“SLE is a fascinating disease that can affect literally any part of the body,” said Dr. Legge. “It’s poorly understood – we still have a lot to learn about it, and a lot more we can hopefully do for patients with this disease to improve their lives.”
 
Her master’s work showed that the index they constructed predicted future health outcomes in SLE patients, including organ damage, hospitalizations and death.

The next steps include trying to replicate these results in other SLE cohorts and investigating whether the index would be useful for measuring response to treatment.
 
The disease disproportionately affects women – SLE occurs eight to nine times more frequently in women than men in the one in 2,000 people afflicted. Young and middle-aged women are most affected, incurring a social and economic cost during the peak years of their lives.
Department of Medicine Spring Party 2019
25 Year Service Award ~ Dr. Kenneth West
Retirement ~ Dr. Bryce Kiberd
Retirement ~ Dr. Mahesh Raju
Retirement ~ Dr. Franzjosef Schweiger
Promotion to Professor (July 1, 2019) ~ Dr. Gordon Gubitz
Promotion to Professor (July 1, 2019) ~ Dr. Paige Moorhouse
Promotion to Associate Professor (July 1, 2019) ~ Dr. Amir AbdelWahab
Promotion to Associate Professor (July 1, 2019) ~ Dr. Helen Bishop
Promotion to Associate Professor (July 1, 2019) ~ Dr. Ian Davis
Promotion to Associate Professor (July 1, 2019) ~ Dr. Barna Tugwell
Brian M. Chandler Lifetime Achievement Award in Medical Education ~ Dr. Stephen Couban
2019 Achievement Award ~ Dr. Jorin LindenSmith
Clinical Excellence Award ~ Dr. Lynn Johnston
Excellence in Leadership Award ~ Dr. Paige Moorhouse
Excellence in Quality & Innovation Award ~ Dr. Nabha Shetty
Faculty Excellence in Medical Education Award ~ Dr. Samantha Gray
Faculty Excellence in Medical Education Award ~ Dr. Stacey Williams
Faculty Excellence in Medical Education Award ~ Dr. Meredith Chiasson
Faculty Excellence in Medical Education Award ~ Dr. Allen Tran
Faculty Excellence in Medical Education Award ~ Dr. Tallal Younis
Stephen Couban Outstanding Faculty Award – Residents’ Choice ~ Dr. Ian Epstein
Research Lifetime Achievement Award ~ Dr. Kenneth Rockwood
PGY4-6 Resident Research Excellence Award ~ Dr. Daniel Belliveau
PGY1-3 Resident Research Excellence Award ~ Dr. Thomas Brothers
Chief Medicine Resident – Halifax ~ Dr. Douglas Motomura
Chief Medicine Resident – Halifax ~ Dr. Shannon Murphy
Chief Medicine Resident Saint John ~ Dr. Andrea Letourneau
MTU Chief Resident ~ Dr. Eric Pond
Excellence in Undergraduate Teaching ~ Dr. Thomas Brothers
Excellence in Summer Grand Rounds – 2018 ~ Dr. Shannon Murphy
Outstanding PGY1 Resident Award ~ Dr. Rachel Sullivan
Outstanding PGY1 Academic Performance Award ~ Dr. Sulaiman Alamro
Outstanding PGY2 Resident Award ~ Dr. Thomas Brothers
Outstanding PGY2 Academic Performance Award ~ Dr. Curtis Marcoux
Angie McGibbon Outstanding PGY3 Resident Award ~ Dr. Lazar Milovanovic
Outstanding PGY3 Academic Performance Award ~ Dr. Alexandra Legge
Outstanding PGY3 Academic Performance Award ~ Dr. Kyle Murnaghan
Congratulations to our Graduating Residents
PGY3 ~ Core Internal Medicine ~ Dr. Bader Alamri
PGY3 ~ Core Internal Medicine ~ Dr. Shahad Al Ghamdi
PGY3 ~ Core Internal Medicine ~ Dr. Badr Alhumayyd
PGY3 ~ Core Internal Medicine ~ Dr. Albert Chang – SJ Site
PGY3 ~ Core Internal Medicine ~ Dr. Amanda Formosa
PGY3 ~ Core Internal Medicine ~ Dr. Nichole Gill
PGY3 ~ Core Internal Medicine ~ Dr. Larry James
PGY3 ~ Core Internal Medicine ~ Dr. Pierre Landry
PGY3 ~ Core Internal Medicine ~ Dr. Alexandra Legge
PGY3 ~ Core Internal Medicine ~ Dr. Andrea Letourneau – SJ Chief Medicine Resident
PGY3 ~ Core Internal Medicine ~ Dr. Stuart McAdam
PGY3 ~ Core Internal Medicine ~ Dr. Ameena Meerasa – SJ Site
PGY3 ~ Core Internal Medicine ~ Dr. Lazar Milovanovic
PGY3 ~ Core Internal Medicine ~ Dr. Julie Mongeau
PGY3 ~ Core Internal Medicine ~ Dr. Douglas Motomoura – Chief Medicine Resident
PGY3 ~ Core Internal Medicine ~ Dr. Kyle Murnaghan
PGY3 ~ Core Internal Medicine ~ Dr. Shannon Murphy – Chief Medicine Resident
PGY3 ~ Core Internal Medicine ~ Dr. Eric Pond – MTU Chief
PGY3 ~ Core Internal Medicine ~ Dr. Brahim Redouane – SJ Site
PGY3 ~ Core Internal Medicine ~ Dr. Teresa Rodriguez
PGY3 ~ Core Internal Medicine ~ Dr. Jaclyn Vertes
PGY3 ~ Core Internal Medicine ~ Dr. Angella Woodman
PGY3 ~ Core Internal Medicine ~ Dr. Bethany Woodrow
PGY3 ~ Core Internal Medicine ~ Dr. Ronald Yan
PGY4 ~ General Internal Medicine ~ Dr. Lyndsay Sprigg
PGY4 ~ General Internal Medicine ~ Dr. Rayan Al Hazmi
PGY5 ~ General Internal Medicine ~ Dr. Yazan Ghanem
PGY5 ~ General Internal Medicine ~ Dr. Jessica Klassen
PGY5 ~ General Internal Medicine ~ Dr. Josee McBeath
PGY5 ~ General Internal Medicine ~ Dr. Victor Rogozovsky
PGY5 ~ Dermatology ~ Dr. Ashley Sutherland
PGY5 ~ Endocrinology ~ Dr. Heather Mackenzie
PGY5 ~ Gastroenterology ~ Dr. Matthew Miles
PGY5 ~ Hematology ~ Dr. Alissa Visram
PGY5 ~ Infectious Diseases ~ Dr. Jaclyn Leblanc
PGY5 ~ Medical Oncology ~ Dr. Myuran Thana
PGY5 ~ Nephrology ~ Dr. Keigan More
PGY5 ~ Neurology ~ Dr. Yousef Alnajar
PGY5 ~ Neurology ~ Dr. Michael Thorne
PGY5 ~ Physical Medicine & Rehabilitation ~ Dr. Zainab Al-Lawati
PGY5 ~ Physical Medicine & Rehabilitation ~ Dr. Paula Barker
PGY5 ~ Physical Medicine & Rehabilitation ~ Dr. Shahzad Tanwir
PGY5 ~ Respirology ~ Dr. Daniel Altman
PGY5 ~ Rheumatology ~ Dr. Mehveen Merchant
PGY6 ~ Cardiology ~ Dr. Opeyemi Fadahunsi
PGY6 ~ Cardiology ~ Dr. Joseph Kim
PGY6 ~ Cardiology ~ Dr. Adil Al Jabri
Education Corner
Successful CaRMS match

The Department of Medicine had another successful CaRMS match for PGY1s this year. Over the 10 days, the Department interviewed 190 applicants. Matches were made in the first iteration – 13 in Halifax, 2 regionally and 4 in Saint John, N.B.


Royal College exams

PGY3s and PGY4s in the Department wrote their Royal College exam in early March 2019 – a double cohort this round with both years writing. The Department wishes them all the best of luck as they head to their orals in June!
New Med 3 clerkship schedule

UGME has approved a new Med 3 clerkship schedule for the class of 2021. These changes provide three additional weeks of pre-CaRMS electives for the class of 2022 and onward. The result is a total of 10 weeks, which is closer to the national average.

To accommodate the change, the class of 2021 will start its year four weeks early, on Aug. 12, 2019, beginning with two weeks of PIER 1. There will be a three-week overlap with the class of 2020, Aug. 26 to Sept. 13.

Also, PIER 2 will now occur between Nov. 18 and 29, 2019, instead of in December. The biggest long-term change will affect Med 3 students’ December holiday break in 2019 and for future classes. Students will now have a rotation in Unit 2 split by the break, returning after New Year’s Day. It’s also worth noting that the March Break for Med 3 students will be March 9-13, 2020, differing from that of school-aged children.

A huge thanks to all of our divisions that worked together through the UMEC committee to ensure students were allocated in order to mitigate the impact of the double cohort on their learning.
KUDOS & CONGRATULATIONS
AFMC Clinical Teacher of the Year
The Association of Faculties of Medicine of Canada (AFMC) has named Dr. Trudy Taylor, Division of Rheumatology, its Clinical Teacher of the Year for 2019. Nicely done!
Education Allocation revamp
The Department’s Education Office gives a big shout-out to Undergraduate Coordinator Nina Nedic and Education Coordinator Sophie Montreuil for their work revamping the Education Allocation. An improved format includes new reporting features for stats and an overall smoother process for providing the Department with education deliverables. This was all successfully rolled out as the new fiscal year began. A job well done within busy schedules!
Gold-Headed Cane Awards
Congratulations to Dr. David Brake, whose dedicated service to his patients, community and profession was recognized with the presentation of the Gold-Headed Cane Award by the College of Physicians and Surgeons of Nova Scotia at its annual awards ceremony this spring.
Dalhousie University Faculty of Medicine honoured Dr. Kenneth Rockwood the same evening with the Dr. G.W. Archibald Gold-Headed Cane Award in the Humanities. Dr. Rockwood was recognized for his humanistic approach to care and teaching, serving as a role model for many others. Congratulations!
Consulting Resident Award - Emergency Department
Core Internal Medicine Resident, Dr. Margaret Sheridan, has been chosen as a recipient of the “Consulting Resident Award” for 2018-2019, as nominated and voted on by the Emergency Department physicians!! 
Governor-General Gold Medal
Dr. Alex Legge (CH&E Masters graduate) was awarded the Governor-General Gold Medal in the Natural Sciences and Engineering for the Most Outstanding Master’s Graduate. The award was presented to Alex at convocation during the last week of May 2019.

Dr. Alexandra Legge is a graduate of the Clinician Investigator Program (CIP) and is currently a PGY3 in Internal Medicine. She is scheduled to continue her training in the Rheumatology Residency Training Program in July 2019.
Physician Leadership Development Program graduates
Congratulations to Dr. Tammy Keough-Ryan (Nephrology), Dr. Ashley Miller (GIM) and Dr. Suzanne Ramsey (Pediatric Rheumatology) on completing the six-month Physician Leadership Development Program at Doctors Nova Scotia.

Doctors Nova Scotia designed the program in partnership with Joule, a CMA company, and in consultation with NSHA, the IWK and Dalhousie.

In addition to building leadership skills, 22 participants focused on strengthening systems thinking. They applied these skills as they worked on developing approaches to issues within health care.
Class of 2018-19
Physician Leadership Development Program

The course was developed specifically for physicians to build leadership capacity.

Remembrance
Dr. Stephen Couban, 1961 - 2019
Dr. Couban has been a part of our medicine family since he started Medical School at Dalhousie in 1982. He practised as a family physician from 1987-89 after which he returned to Dalhousie to complete his fellowships in Internal Medicine and Hematology.

In 1997, after a fellowship in bone marrow transplant at University of Toronto, he returned to our Department in the Division of Hematology as an assistant professor, where he had a long and productive career. Stephen became a national and international leader in hematologic oncology, specializing in bone marrow transplant.

He was a respected leader, serving internally as:
  • Director, Blood and Marrow Transplant Program
  • Service Chief for Hematology
  • Service Chief for the Medical Teaching Unit
  • Division Chief for Hematology
  • Deputy Department Head
  • Physician Lead for the Ambulatory Committee for the QEII Redevelopment Project

He held many committee and leadership roles at the faculty and the health authority as well as nationally and internationally in hematology.

Stephen was a mentor to so many in our Department and embodied all the characteristics of an academic physician. He loved his work and his patients and he strongly believed in the Department of Medicine. Most of all, he was a wonderful colleague and friend to so many of us.

We are going to miss him greatly. We know he has left a tremendous void in our Department. We are indebted to him for all he gave us during his time with us. The world and the Department are a better place because he was here.

Dr. Christine Short
Department of Medicine Head/Chief
"We are going to miss him greatly. We know he has left a tremendous void in our Department. We are indebted to him for all he gave us during his time with us. The world and the Department are a better place because he was here."

-Dr. Christine Short
Dr. Paul Louis Landrigan, 1925 - 2019
"Dr. Paul Landrigan was known for his kind heart and compassion for others."
Dr. Landrigan attained a medical degree from Dalhousie University in 1953. He studied internal medicine at Dalhousie University and the University of Toronto. He became a fellow of the Royal College of Physicians and Surgeons of Canada in 1962.

In 1963, he was appointed the first Head of the Department of Respirology at the Victoria General Hospital and subsequently Chief of Medicine at the Halifax Infirmary.

A few of Dr. Landrigan's accomplishments include:
  • Governor of the American College of Chest Physicians
  • President of the Canadian Thoracic Society
  • Member of the Board of Directors of the Canadian Lung Association

WELCOME
Dr. George Zawadowski
Division of Cardiology
6-month locum
- joined the Department in February
Dr. Christina Fraga
Division of Hematology
6-month locum
- joined the Department in June
Dr. Matthew Miles
Division of Digestive Care & Endoscopy
2-month locum
- joins the Department in July
Dr. Keigan More
Division of Nephrology
1-year locum
- joins the Department in July
Dr. Michael Stewart
Division of Digestive Care & Endoscopy
Assistant professor
- joins the Department in July
Heather Fraser, Team Lead from the Division of Palliative Medicine, is now the Department's Research Program Administrative Coordinator, April 2019.
Emily Gaunce, Masters of Health Administration Student will be working on the Ambulatory Care Quality Improvement Project this summer.
Chad Shearer, is the Physician Resource Officer while Kathryn McIlrath is on maternity leave in July 2019-2020.
Michelle Boudreau, is admin assistant in Cardiology to Drs. Stewart and Horne.
Farewell
Dr. Wendy Winsor resigned from the Division of Digestive Care and Endoscopy in December 2018 and returned to Newfoundland. We wish her the best in future endeavours.
We finally let Kathryn Nelson enjoy her retirement. Kathryn joined the Department in 1998 and retired in January 2019. She held positions of Executive Assistant and Research Coordinator. Kathryn was famous for her witty emails. Thank you for returning to help us out this year for one last Research Day and Staff Appreciation Tea.
Golf Day
Department Golf Day
A longstanding Department tradition creates a friendly, competitive environment at the Chester Golf Course for DoM Staff members. (June 3, 2019)
To learn more about recent media headlines, visit In the Media on the Department of Medicine website.
Gene therapy offers new hope for Fabry Disease
(May 10, 2019)

Fabry disease is a genetic disease that prevents the breakdown of certain fatty materials...

Dr. Michael West,
Division of Nephrology

Dr. David Brake receives CPSNS Gold-headed Cane Award
(May 1, 2019)

Dr. David Brake’s service to his patients, community and profession was recognized May 3...

Dr. David Brake,
Division of General Medicine

Hospice Halifax celebrates ribbon cutting with partners
(April 17, 2019)

NSHA President and CEO Janet Knox joined Premier Stephen MacNeil, Mayor Mike Savage and others for the official opening of a new hospice Wednesday, April 17, 2019...


Mobile monitoring could transform heart treatments
(March 28, 2019)

As cardiac failure approaches epidemic proportions, Dr. Heather Ross advocates the use of mobile technology in monitoring patients’ health...

Department of Medicine Research Day

Spotlight on Dean of Medicine - Dr. David Anderson, Hematologist
(March 18, 2019)

This article features Dr. David Anderson in his current role, Dean of Medicine in the Faculty of Medicine, Dalhousie University...

Dr. David Anderson,
Faculty of Medicine Dean &
Division of Hematology

Virtual medical neighbourhoods
(Winter 2019)

A new pilot study, initiated by gastroenterologists Dr. Jennifer Jones and Dr. Stacey Williams...

Dr. Jennifer Jones
Dr. Stacey Williams
Division of Digestive Care & Endoscopy


J & W Murphy Foundation donates $4 million to palliative care
(February 27, 2019)

A life-changing donation of $4 million dollars to palliative care from the J & W Murphy Foundation...

Dr. David Anderson,
Division of Hematology &
Faculty of Medicine Dean


Health research boosted by $3.4M in federal funding
(February 7, 2019)

Seven researchers affiliated with Dalhousie University and Nova Scotia Health Authority......

Dr. Karthik Tennankore,
Division of Nephrology

Susan Howlett, PhD
Pharmacologist / Division of Geriatric Medicine


Virus research targets immune-system aging
(Winter 2019)

Infectious diseases specialist Dr. Lisa Barrett is studying the blood of patients with chronic viral infections...

Dr. Lisa Barrett,
Division of Infectious Diseases

Help us share good news and celebrate one another.

If you have ideas for the next issue of the newsletter, email anne.veinotte@nshealth.ca.
Upcoming Events
Department Meeting - September
Royal Bank Theatre or via Skype
please note date change: ~ September 18th ~ 3 rd Wednesday ~
12 p.m. – 1 p.m.
DoM Research Evening
Prince George Hotel
Thursday, November 14, 2019
Medicine Matters Conference 2019
Collaborative Health Education Building
Friday, November 15, 2019