In Residence

Telemedicine for the rest of us: Justin Fox proves the power of low-tech, low-budget solutions

Vital Signs » Spring 2010
Photo - Justin Fox, M.D., assists with surgery to repair a patient’s cleft lip during a medical mission to the Dominican Republic.

When Justin Fox, M.D., left community college to enlist in the Air Force at age 18, he had no intention of going back, let alone enrolling in medical school.

“I volunteered at a hospital when I was in 7th or 8th grade,” Fox said, “and I hated it. I never thought medicine was something I was going to pursue.”

A little more than 10 years later, Fox is wrapping up his third year as a surgical resident at Wright State, and this summer he will begin a prestigious two-year research fellowship at Yale University as one of just 29 Robert Wood Johnson Foundation Clinical Scholars nationwide.

At first glance, the path Fox has traveled to this unexpected point, early in a promising career as a surgeon and researcher, has been wandering and largely unplanned. Look a little deeper, though, and it becomes clear that his steps have always been guided by a keen eye for opportunity, a knack for innovation, and willingness to ask, “Why not?”

A beginner’s guide to the body (from the neck down)
Ten months into his military service, while stationed in Okinawa, Japan, Fox decided to give college another try. After taking a few classes abroad, Fox was granted leave to enroll in the University of Pittsburgh. After graduation, he was accepted to the F. Edward Hébert School of Medicine of the Uniformed Services University (USU) of the Health Sciences.

The USU medical school covers anatomy through two courses: neural (head and neck) and gross (everything below the neck). While the neural course incorporated an interactive CD-ROM, the gross course didn’t have a similar resource. Fox wondered if he might be able to do something about the discrepancy.

The course director, Alan Seyfer, M.D., FACS, “was incredibly supportive,” Fox said, and based on some demos Fox had developed, they put together a plan. Over the summer, Fox and a team of seven other students covered the entire anatomy course, dissecting two cadavers, photographing all of the key structures, and labeling and organizing the images for use on the CD, which the medical school still uses.

While he was proud of what he and his team were able to accomplish, Fox had no idea how important the project would prove to be to him.

“A lot of what has happened to me in medical school, and now into residency,” he said, “has stemmed in some way from that project.”

Publications, posters, and projects on the cutting edge
Based on the success of the anatomy CD, Seyfer asked Fox to help him digitize old clinical slides and work on publishing a case series.

“I like to write, and this was an outlet to write.” Fox said. “It taught me how to write for the medical literature, which was incredibly enlightening.”

Another benefit was the opportunity to be listed as co-author on nearly two dozen articles, many in major medical journals. At the same time, Fox was invited to present his anatomy CD project at an American Medical Student Association conference in Chicago. While there, he met a USU graduate student working on a series of first aid books for McGraw-Hill. The student asked Fox to join the project, and he ended up serving as an editor for the series, which was published in late 2008 and includes both basic clinical manuals and board preparation guides.

As word spread about Fox’s work, other professors began to approach him. The most influential of these potential collaborators turned out to be Lt. Col. Raymond Harshbarger, M.D., a plastic surgeon at the Walter Reed Army Medical Center.

Harshbarger specialized in pediatric craniofacial reconstruction and had done medical missions to Vietnam, Africa, South America, and the Caribbean during his residency training. As a military surgeon, he was focused on craniofacial reconstruction for soldiers wounded in Iraq and Afghanistan, often using innovative 3D computer modeling and advanced materials.

“He had this series of several hundred patients he’d seen,” Fox said, “and the Department of Defense had no way to track them. This is groundbreaking stuff, and nobody was archiving it to say, ‘Does it work? Does it not? Should this be extrapolated to civilian surgery?’”

Fox began working with Harshbarger to develop a case database, and an important new partnership was formed.

The limitations of medical missions
During his final year of medical school, Fox joined Harshbarger on a two-week medical mission to the Dominican Republic. Perhaps inspired by his earlier work tracking Harshbarger’s patients, he began thinking about new and better ways to prepare for and follow up with patients served during medical missions abroad.

Typically, Fox said, “you advertise for patients before you get there. You get there and you might see 80 or 100 patients the first day and decide who you’re going to operate on, and who you can’t.”

Because surgeons have to bring much of their specialized equipment with them, some patients will have conditions they aren’t equipped to treat. Others might be sick at the time or have other complicating issues.

“You’re left with maybe 30 to 50 patients,” Fox said, “and you set up your surgical case flow.

“The patients you operate on the first week,” he said, “you see back the following week. The patients you operate on the second week, you never see back.”

This gap in care troubled Fox.

“What do you do if the patients have complications?” he wondered. “You go into areas to help because they have poor access to medical care, or at least the care you have to offer. If you leave them with complications, you’re kind of setting the system back.”

The lack of follow-up care, coupled with the haphazard nature of the patient selection process, hardly seemed ideal. Fox was convinced there had to be a better way.

Global health on the World Wide Web
Based on his experiences with the interactive anatomy CD, Seyfer’s digital image archive, and Harshbarger’s case database, Fox believed technology might be able to help extend the reach of U.S.-based physicians. Some initial research into telemedicine turned up a few possibilities, but all were new, limited, and very expensive. Then Fox read about scientists using simple Internet wikis for remote collaboration.

“I thought, ‘If they can use it for basic science research, we could use it for clinical medicine.’”

Fox had no funding so he found a free service that would let him create a secure online wiki, with encrypted data, password protection, and various levels of access and permission. He then gathered several borrowed or donated digital cameras and laptop computers, took them with him to the Dominican Republic, and began documenting cases.

“I took pictures pre-op, during the operation, and after for the first week,” he said. “We followed the patients and created a medical chart, basically, through the wiki.”

Fox also taught surgical residents in the Dominican hospital to use the wiki. Six weeks later, the residents met with the patients again, took notes on their condition, shot new photos, and uploaded everything to the wiki for the surgeons in the U.S. to review.

“We could see how they were doing post-operatively while we were still in the States, record complication rates, and advise the patients,” Fox said. Fortunately, “we found very low complication rates. Basically, we proved we were able to do this safely.”

Bringing international telemedicine back home
After joining the surgical residency program at Wright State in 2008, Fox presented his work to the American Cleft Palate Craniofacial Association. That year he was also awarded a $2,500 Resident Research Grant by the Dayton Area Graduate Medical Education Consortium (DAGMEC). The grant covered the cost of laptops and cameras for clinical sites in Santiago and Santo Domingo. Fox worked remotely to train local health care personnel to use the equipment and upload information and images to the wiki.

“We had about 15 patients we were able to pre-screen and operate on,” Fox said, “in addition to those we saw and screened when we got there.”

The importance of the project, Fox said, was that “we showed it could be done with minimal technology. Three to four years ago, this was very specialized and expensive. Now we’re doing it wireless with a $100 camera and a laptop that was $400, and we’re able to see enough to treat patients.”

Fox hopes to bring his homemade solution to a global health problem full-circle and benefit patients in the Dayton area. Because local hospitals are often regional treatment centers for various medical conditions, they may serve patients who live several hours away. Closer to home, some patients in long-term care facilities need to be transported by ambulance for routine medical visits, a costly and time-consuming process.

“I thought if we could incorporate some kind of telemedicine here,” Fox said, “it might help avoid unnecessary transfers, which could reduce health care costs and still allow us to offer quality care.”

In May 2008, Fox earned a $10,000 grant through Miami Valley Hospital to expand on his work with the Virtual Outreach wiki to create customized software and a regional wiki focused on wound care services. The new wiki is now largely in place, and Fox will present his preliminary work to the American Telemedicine Association later this year. He is also working to partner with a nursing home or rehabilitation center to put the solution into practice.

New and exciting opportunities
As he looks ahead to the start of his research fellowship in July, Fox is excited about devoting two years to his telemedicine work before returning for the final two years of his residency program. After completing the program, he will owe the Air Force 13 years of additional service, but he isn’t worried about the commitment. On the contrary, he is confident that new and exciting opportunities will continue to arise.

“Ten years ago when I enlisted in the military,” he said, “I had no intention of doing any of this.”

In fact, he added, “I don’t think I’m that tech-savvy. I’ve just found ways to utilize what already exists.”

His experience, he believes, can be informative for others who may feel excluded from appealing opportunities, especially in the area of telemedicine.

“You don’t have to be some big institution and have a lot of money to be able to participate in this,” he said. “Even local community hospitals or nursing homes, or places with smaller budgets, can still incorporate telemedicine without necessarily spending a fortune to do it.” VS

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Photo: Justin Fox, M.D., assists with surgery to repair a patient’s cleft lip during a medical mission to the Dominican Republic.

Last edited on 09/22/2015.