Alberta Doctors' Digest - Jan/Feb 2014

Alberta Doctors'

DIGEST January-February 2014 | Volume 39 | Number 1

From doctor to acute care patient to doctor again Dr. Ian J. Rigby credits his family and peers for his comeback from a serious accident Medical students lobby government for youth tobacco reduction Ban of flavored tobacco products advocated

Tans, tyrants and treats Emerging Leaders in Health Promotion grant recipients teach children the importance of prevention

The AMA’s website and social media year in review

In a nutshell: explosive and unpredictable Patients FirstÂŽ

How do you tell if this infant has a treatable screened condition?

Alberta’s Newborn Metabolic Screening Program Newborn blood spot screening information is available online through www.albertahealthservices.ca/newbornscreening.asp

Newborn blood spot screening – every infant, every time

CONTENTS DEPARTMENTS

Patients First® is a registered trademark of the Alberta Medical Association.

Alberta Doctors’ Digest is published six times annually by the Alberta Medical Association for its members.

Editor: Dennis W. Jirsch, MD, PhD

4 From the Editor 8 Health Law Update 12 Mind Your Own Business 14 Insurance Insights

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Editor-in-Chief: Marvin Polis

20 Residents' Page 22 PFSP Perspectives 29 In a Different Vein 32 Classified Advertisements

FEATURES

6 From doctor to acute care patient to doctor again

President: Allan S. Garbutt, PhD, MD, CCFP

President-Elect: Richard G.R. Johnston, MD, MBA, FRCPC

10 Meet the Alberta Medical Association Board of Directors 2013-14

Immediate Past President: R. Michael Giuffre, MD, MBA, FRCP, FRCPC, FACC, FAAC Alberta Medical Association 12230 106 Ave NW Edmonton AB T5N 3Z1 T 780.482.2626 TF 1.800.272.9680 F 780.482.5445 amamail@albertadoctors.org www.albertadoctors.org March/April issue deadline: February 14

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor.

The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.

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Dr. Ian J. Rigby credits his family and peers for his comeback from a serious accident.

11 AMA seeks 2014 nominations for our highest awards

The AMA is calling for Achievement Award nominations for individuals

who have contributed to the improvement of the quality of health care.

17 Tans, tyrants and treats

Emerging Leaders in Health Promotion grant recipients teach children the importance of prevention.

19 The AMA’s website and social media year in review

In a nutshell: explosive and unpredictable.

26 Medical students lobby government for youth tobacco reduction

Ban of flavored tobacco products advocated.

27 Calling for 2014 TD Insurance Meloche Monnex/ AMA Scholarship applicants

Picture it: $5,000 of assistance for additional training in a clinical area of recognized need in Alberta.

© 2014 by the Alberta Medical Association Design by Backstreet Communications

AMA Mission Statement The AMA stands as an advocate for its physician members, providing leadership and support for their role in the provision of quality health care.

Cover Photo:

Dr. Ian J. Rigby's positive outlook is infectious (

provided by Marvin Polis)

More WAYS TO GET ALBERTA DOCTORS’ DIGEST We’re using QR codes to enhance your experience. Scanning this code will take you to the Alberta Doctors' Digest page on the AMA website including pdf, ebook and podcast versions. There are also QR codes embedded in a few articles in this magazine issue. Scan the codes using your smart phone or tablet device to go to the alternate content. If you don’t have a QR code reader app on your phone or tablet, download one for free from www.scanlife.com.

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From the Editor

What should we eat?

Just ask a hunter-gatherer Dennis W. Jirsch, MD, PhD | Editor

I

was talking to a patient after minor surgery who asked me, out of the blue, “What should I be eating, doc?” A simple enough question, but I was flustered. I’m used to the declension of food for a surgeon’s purposes into clear fluids, full fluids, soft diet, etc., but not this. I couldn’t even recall the major food groups for certain and kept remembering an old college joke that listed beer as a food group.

It was a good question, though.

The looming health issue of our time

must be the raft of chronic illnesses that afflict us as we become ever more tubby and obese.

I’ve watched Morgan Spurlock’s “Super-Size Me” documentary1, and have been astonished at the enormous weight gain, fatty liver and general dysfunction that followed just one month’s fast-food piggery, so the diet question stands. We may not go to hell-in-a-handbasket as quickly as Spurlock did, but the looming health issue of our time must be the raft of chronic illnesses that afflict us as we become ever more tubby and obese.

We suffer from a variety of conditions – Type 2 diabetes and obesity are mentioned most often – that have been termed “mismatch diseases” by evolutionary biologists.

It would seem that our bodies have become adapted, through countless eons, to very different conditions than the ones we now face.

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To evolutionary biologists, our plight is understandable.

Something like 600 generations ago (that’s 10,000 to 12,000 years ago; a trifle in evolutionary time) humans were hunter-gatherers. We ate, as far as we can know these things, diets of fruits, berries, tubers and animal protein from whatever critters we could get our hands on.

Plus we were (you guessed it!) healthy. And if violence or respiratory or intestinal illness didn’t supervene, we could expect to live 70 years without dental caries, and without the chronic afflictions that now assail us.

With the agricultural revolution, we settled down as farmers and developed an intimate relationship with cows, pigs and chickens – but that’s another story.

In spite of a possibly more reliable food supply, the fossil evidence shows our agrarian ancestors were, at least initially, less rather than more healthy with their new grain-derived foodstuffs compared to their hunter-gatherer counterparts. The industrial revolution took place short millennia later and brought more sobering news: as we became even more adept at refining grains into sugars and starch, we took advantage of labor saving machinery to adopt ever more sedentary lifestyles.

Harvard evolutionary biologist Daniel Lieberman2 puts it well: “We are big brained, moderately fat bipeds who reproduce rapidly but take a long time to mature. We are also adapted to be physically active endurance athletes who regularly walk and run long distances and who frequently climb, dig and carry things. We evolved to eat a diverse diet that includes fruits, tubers, wild game, seeds, nuts and other food that tend to be low in sugar, simple carbohydrates and salt but high in protein, complex carbohydrates, fiber and vitamins.”

Just why our current diets don’t work – and I mean the melange of things most of us eat, and not the extreme McDonald’s binge of Morgan Spurlock – is a matter of debate. Though the chronic illnesses that afflict us are many in number, and growing, some argue that we >

> can perhaps learn much by investigating facets of the metabolic syndrome or the common association of Type 2 diabetes with obesity, coronary artery disease and hypertension. Current thinking about possible disease mechanisms involved with metabolic syndrome and other, generally age-related chronic diseases, including Alzheimer’s dementia, would have us regard processed sugar and starch as tantamount to poison, both making us obese and prompting a chronic inflammatory state that can wreck our organs. In the same way that we have created problems with our profligate use of carbon based fuels, we may now have problems based on our energy supply in the form of overabundant reliance on starch and sugar.

In the same way that we have created problems with our profligate use of carbon based fuels, we may now have problems based on our energy supply in the form of overabundant reliance on starch and sugar.

So much for progress. To deflate our collective egos further, we’re probably not eating the right stuff but our recent preoccupation with germs may be harming us too.

The hygiene hypothesis3 proposes that several of our chronic inflammatory diseases (allergies, autoimmune disease, inflammatory bowel disease, multiple sclerosis, etc.) may be self-induced in the sense that the novel microbial environments we have engineered may fail to curb normal inflammatory responses. The chronic inflammation of obesity and the disturbed microbial environment may, at end, disturb evolution’s adaptive immunoregulation.

We’re up against tough stuff here, I think. We might benefit from dropping mega-quantities of starch and sugar from our diets, but the other half of the equation has to involve the cultural evolution that has produced changes in our lives. These changes are going to be

difficult, and likely impossible, to undo. Hunter-gathers lived life as small nomadic groups that were doubtlessly interdependent. Our burgeoning populace, truly global, meshes our lives with countless other cogs in economic systems that are anything but congenial. The stresses of modern, frenetic lives are perhaps no greater than we experienced in our pre-history, but they are very likely more continuous and unrelieved.

In a very real sense, “we can’t go home again.” Even if we are convinced that a diet more concordant with our evolutionary history – sometimes termed a “Paleo” (or Paleolithic) diet – may be better for us, persisting will be hard slogging. First off, there’s no one Paleo diet. We’re truly omnivores and the “catch-as-catch-can” scavenging habits that likely characterized our ancestors may find us balking at unpalatable roots, seeds and other nasty bits.

Perhaps more than we can imagine. Our uphill-battle would have us contend too with our generally puny willpower, since we prefer prompt payoffs (burgers and pastries) even in the face of larger benefit (less chronic illness) somewhere down the line.

Lest I get too gloomy, let me tell you what I’m going say if anyone ever asks me again what to eat. Along with an admonition to exercise (modestly), I’m going to repeat the sensible dietary advice of food writer Michael Pollan4.

“Eat (real) food. Not too much. Mostly plants.”

As I’ve said though, easier said than done.

I want to go to the fridge and have some apple pie. In deference to the diet pundits, I’ll have it with cheese, rather than sugar-laden ice cream.

That’s it. Apple pie and cheese. Skip the ice cream.

Call me a health nut.

References 1. http://en.wikipedia.org/wiki/Super Size_Me. 2. Lieberman Daniel E. The Story of the Human Body: Evolution, health and disease. Pantheon Books, New York, 2013.

3. http://en.wikipedia.org/wiki/Hygiene_hypothesis.

4. http://www.nytimes.com/2007/01/28/magazine/ 28nutritionism.t.html?pagewanted=all&_r=0.

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Cover Feature

From doctor to acute care patient to doctor again Marvin Polis | Editor-in-Chief,

Alberta Doctors’ Digest (with assistance from Shelby MacLeod)

“A quadriplegic ER physician? How is this even possible?” one of my inner voices says.

and learn about the results of their decisions as the “patient” responds in kind.

“You’re being closed minded,” says the voice of the little guy standing on my other shoulder.

I learn that, although Ian focuses on classroom instruction now, he actually used to fly with STARS as an in-flight physician before his accident. It was a demanding and unpredictable job that took him around the province and required him to be on-call for emergencies.

Some of his duties were to perform emergency treatments, provide back-up information to flight crews, evaluate critical patients, and to fly to rural hospitals to perform procedures.

When working there he felt like he “really made an impact.” Little did he know that STARS would one day impact, and save, his own life.

Dr. Ian J. Rigby is at the STARS base that day doing something he has done for some time – mentoring flight crews on medical subject matter. Today’s topic: toxicology.

I walk into the lecture room during the mid-morning break. “You must be Dr. Rigby,” I say. “No, I’m Ian,” he says with a warm aura that makes me feel we are going to get along like old friends.

Dr. Ian J. Rigby's positive outlook is infectious. ( provided by Marvin Polis)

I

t’s a bone-chilling Monday morning as I carefully traverse the parking lot outside the Shock Trauma Air Rescue Society (STARS) air ambulance base at the Calgary International Airport. “Thank goodness for all wheel drive,” I say to myself. There had been a fresh accumulation of snow courtesy of mother nature and I find myself wondering how a wheelchair could possibly get through to the ramp near the building. Not something I consider every day.

But today I’m on a unique assignment.

I’m to meet a quadriplegic emergency room (ER) physician. During my career I’ve interviewed thousands of people on countless topics, but this would be a first.

AMA - Alberta Doctors’ Digest

For the next few hours, I discretely move about the room shooting photos and video and observing Ian interact with the flight crew. Their subject matter is very serious stuff, but Ian’s charisma, compassion and sense of humor are electric. To most observers, toxicology would be pretty dry, but these people are having great fun while learning. I’m even having fun, although most of the technical talk is going over my head!

“This doc is a natural mentor,” I think to myself.

Ian and I have a wonderful chat during lunch and as the day progresses he is now leading the session downstairs at the STARS patient simulator. The simulator is a high-tech mannequin that can mimic the symptoms of a human patient.

Health care professionals can react

One of Ian’s winter passions was skiing. He was on the third day of a back-country ski trip with a group of friends on January 6, 2012, when the accident happened. The edge of his ski caught on something in the snow.

He hit a tree. Broke his neck.

Ian was air lifted to Calgary by STARS – the same crew that he had worked with – and was taken to his own emergency department in Calgary.

At the Foothills Medical Centre, Ian learned that he broke his C7 vertebra, which left him paralyzed from the chest down and impaired some of his hand movement.

He says it was a “surreal experience” being a patient in the same department that he worked in as >

> a doctor, but it was also positive, thanks to the demeanor of the medical staff. During the next six months of his treatment he ended up in nearly every department of the hospital, from acute care to rehab.

The time spent in the hospital did not deter him from returning to work, though. With support from his family, friends, and co-workers, he was slowly able to reintegrate into his job and take on tasks as he was able at the Foothills Medical Centre and the Peter Lougheed Centre.

While his accident brought challenges, it gave him a different perspective on practicing medicine.

When discussing his previous beliefs as a doctor he says, “We are immune to illness. We work in this system

where we take care of people; we aren’t the ones receiving care.”

Since his accident, Ian urges other doctors to pause when they are only thinking about patients and consider their own well-being and what they would do if they were ever unable to work (see Insurance Insights in this issue of Alberta Doctors’ Digest and the accompanying video about Ian).

Fast forward. It’s now Tuesday morning and I meet Ian at the Foothills where he takes me into the ER and shows me how he actively works with residents to diagnose and treat patients. Here I meet some of the residents Ian currently mentors, as well as some of his former residents who are now practicing

physicians. I’m struck by their camaraderie, sense of humor and positive outlook, despite the tough pressures they face everyday.

For Ian, “the people in the system make the system.” He tells me how fantastic this team of doctors is. He doesn’t really have to. It’s obvious.

As we shake hands and say our goodbyes, we have a brief discussion about unintended consequences.

For me, the unintended consequence is that my faith in people to overcome obstacles is cemented. Ian’s positive outlook is infectious. And I’m now infected.

To view a video about Dr. Rigby's experience please visit http://bit.ly/1j84bVB.

Clockwise from top left: Dr. Ian J. Rigby before his accident; examining a patient at Foothills Medical Centre; instructing a flight crew at the STARS patient simulator; comparing instructor notes during a patient simulation. ( Top left photo provided by Dylan Page http://dylanpagephoto.com. Other photos provided by Marvin Polis.)

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Health Law Update

End of life decisions – what has Rasouli done for us lately?

Jonathan P. Rossall, QC, LLM | Partner,

A

year or so ago, I wrote on the Ontario Court of Appeal decision in Rasouli, which turned on the refusal of the Ontario’s courts to sanction the wishes of physicians to withdraw life support in the face of family objections.

To re-cap quickly, Hassan Rasouli underwent what was considered to be minor brain surgery in October of 2010, only to suffer from a bacterial meningitis infection which ultimately left him severely brain damaged. The prognosis from the medical practitioners was that there would be no meaningful recovery and they planned to withdraw life support measures. There were no personal directives or consents available to provide written guidance as to the wishes of the family. However, Rasouli’s wife (also a physician) intervened and obtained a court injunction preventing the physicians from acting.

The wrinkle in the case was that Ontario maintains a Consent and Capacity Board, which is a quasi-judicial panel struck under Ontario’s Health Care Consent Act to decide issues of consent. That, said the courts below, was the appropriate avenue of recourse for the physicians which, for reasons unknown, had not been adopted.

With little fanfare, the Supreme Court has recently affirmed the Ontario Court of Appeal’s decision in a five-to-two decision. In essence, the majority of the Court said that the doctors must either obtain consent from the patient’s family, or the approval of the Ontario Consent and Capacity Board before changing treatment for Mr. Rasouli. Failing that, his life (such as it is) will continue.

It is important to note that this decision really only applies to Ontario cases, because of the overlay of the Health Care Consent Act. Alberta has no such legislation or board (although British Columbia, Manitoba, Prince Edward Island, Quebec and Yukon do), and it is entirely likely that the case would have taken a very different turn if decided here. In a way it is unfortunate that it wasn’t

AMA - Alberta Doctors’ Digest

McLennan Ross LLP

because the case does raise (without answer) several critical ethical and medical issues.

First, does “withdrawal of treatment” equal “treatment?”

The Chief Justice of the Supreme Court did provide some guidance on that point by stating that … “treatment” and “health-related purposes” are not confined to procedures that are of medical benefit in the view of the patient’s medical caregivers.” She went on to say that “… the term ‘treatment’ should be broadly interpreted to include ‘anything that is done’ for a patient in a variety of circumstances – palliative, therapeutic, preventative, diagnostic or cosmetic.…” Thus, a procedure (such as withdrawal of a feeding tube or extubation) may be seen as treatment even if they have a negative effect on the patient’s prognosis.

Is there a place in Alberta for

institutions that dedicate themselves to sustaining life in the face of medical decisions to the contrary, at the expense of the family or insurers?

Second, the courts throughout were very careful to steer far clear of any arguments relating to resource allocation and the role that this may play in end-of-life decisions.

But, given Canada’s rapidly expanding, aging population transposed against a relatively static supply of health care providers, facilities and resources, it is inevitable that some very tough policy decisions are going to have to be made. Those will include whether resource allocation and availability should play a role in determining appropriate courses of action in the context of complex end-of-life decisions. Alternatively, the specter exists of the minister determining certain types of extraordinary treatment to be non-medically necessary (as that term is defined in the Alberta Health Care Insurance Act or the Canada Health >

> Act), thus downloading the cost of such care to the family of the patient.

wants to be “liable” for the controlled or orchestrated death of a patient.

This, in turn, raises the issue of privately supplied health services. Is there a place in Alberta for institutions that dedicate themselves to sustaining life in the face of medical decisions to the contrary, at the expense of the family or insurers?

What about resource allocation within facilities? Even if the physicians or administration bow to the wishes of patients to sustain the life of a loved one, does it follow that an intensive-care bed (potentially needed by a victim of a car crash or other such event) is necessarily required? Does the family have the right to insist on the location, as well as manner of treatment?

Third, an increasingly educated patient population, combined with the increasing availability and access to patient health information in the electronic health record world has many physicians and hospital administrators looking over their shoulders from a liability and risk-management perspective. No one

Fourth, the role of faith and religious belief needs to be explored in more detail. Mr. Rasouli is Muslim and part of the evidence provided by his family related to deeply held religious beliefs which prevented life-ending decisions from being made. What role should such beliefs play in medical/ethical decisions? The courts have wrestled with these issues before in the context of situations such as Jehovah’s Witnesses’ refusal to accept blood donations, but not a lot of work appears to have been done in the context of end-of-life decisions.

As usual, more questions than answers.

Interestingly, this debate comes on the heels of the Taylor vs. A.G. British Columbia decision that I wrote about in the last issue of the Alberta Doctors’ Digest. I think the discussions are closely linked, but unfortunately the Supreme Court is now zero-to-two in terms of providing meaningful judicial guidance.

Could your patients benefit from bariatric surgery?

The Physician Learning Program, in partnership with Alberta Health Services, has developed a five minute video to inform physicians about referrals of appropriate patients for surgical interventions.The video is found at: http://www.albertaplp.ca/bariatricsurgeryreferral This video addresses certain issues. Bariatric surgery is:

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Feature

Meet the Alberta Medical Association Board of Directors 2013-14

(

provided by Curtis Comeau Photography)

Seated, left to right: Dr. Kathryn Andrusky; Dr. Richard Johnston, President-Elect; Dr. Allan Garbutt, President; Dr. Michael Giuffre, Immediate Past President; Dr. Paul Parks Standing, left to right: Christine Fleck, Manager, Executive Office; Dr. Robin Cox; Dr. Padraic Carr; Dr. Sarah Bates; Dr. Neil Cooper; Michael Gormley, Executive Director; Stefan Link, MSA observer; Dr. Ernst Schuster; Dr. Paul Boucher; Dr. Christine Molnar; Dr. Sylvia McCulloch, PARA observer Absent: Dr. Jasneet Parmar

AMA - Alberta Doctors’ Digest

Feature

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AMA seeks 2014 nominations for our highest awards

T

he Alberta Medical Association (AMA) is calling for Achievement Award nominations for individuals who have contributed to the improvement of the quality of health care in Alberta.

The Medal for Distinguished Service is given to a physician(s) who has made an outstanding personal contribution to medicine and to the people of Alberta, and in the process has contributed to the art and science of medicine while raising the standards of medical practice.

The Medal of Honor is awarded to a non-physician(s) who has raised the standards of health care and contributed to the advancement of medical research, medical education, health care organization, health education and/or health promotion to the public.

Nominations must be submitted by April 30. The awards will be presented at the AMA’s fall 2014 annual general meeting in Calgary.

In 2013, three physicians were recognized with Medals for Distinguished Service.

• Dr. Werner J. Becker, Calgary • Dr. Cyril B. Frank, Calgary • Dr. Suna A. Smith, Camrose In 2013, one individual was recognized with the Medal of Honor.

• Darlene Schindel, Spruce Grove To read more about recent honorees visit the AMA website at (http://bit.ly/SF008r).

To request a nomination form for these awards, please contact Janice Meredith, Administrator, Public Affairs, AMA: janice.meredith@albertadoctors.org, 780.482.2626, ext. 291, toll-free at 1.800.272.9680, ext. 291 or visit the AMA website (http://bit.ly/SF008r).

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Mind Your Own Business

$ per sq. ft. is just one consideration Here’s what you need to know about creating or renewing a lease Practice Management Program Staff

O

ne of the more stressful events of being in business for physicians is the creation or renewal of a lease agreement between a physician practice and a landlord. There are many legal terms and financial details that are not familiar within a lease and all of these should be contemplated to ensure that you reduce your risk and increase your practice flexibility. Many of these considerations are the same with establishing or renewing or lease. If this is your first time negotiating a lease, you will have a stronger negotiating position if you are flexible about the location that suits your needs. The negotiation process is all about business – if the discussions to negotiate the lease feel awkward or uncomfortable, it is likely a good sign that you are doing it right. The principles discussed here could be applied in general to a rural or urban practice, as well as a small or large group of physicians.

Key considerations to ensure success. How early should the lease negotiations process begin?

New practice lease: 12 to 24 months in advance is not unreasonable when considering opening a new practice as there are many variables in addition to the space you need to lease. For more details, please see the Alberta Medical Association (AMA) guides for starting your own practice at www.albertadoctors.org/news/ news-archives/start-your-own-practice.

Established practice lease: Eight to 12 months is recommended if you are renewing an existing lease.

If you are prepared to relocate in order to gain improvement to a number of priorities related to your space, you will need to have enough time to conclude that you and the existing landlord cannot come to agreeable terms. Therefore, you may need to have 12 to 24 months to ensure you have time. Your existing lease may provide terms that enable you to go on a monthly lease at an expiry date, but this can have many risks associated with it.

AMA - Alberta Doctors’ Digest

How important is it to do my homework on the commercial real estate marketplace?

Any commercial real estate environment can change over time and it is to your advantage to do your research in advance. You should know what other space might be available in your area, its value, and what is included.

Be as well informed as possible in order to make an informed business decision.

As a physician, you are at a disadvantage at the outset.

Landlords tend to have lots of experience with lease negotiations and will bring a standard written lease language for your consideration that is written to benefit them, not you. It may feel overwhelming and it is often too easy to accept their terms, especially if you don’t have the benefit of time, expertise and options available to you. Doctors are among a group of sought-after tenants and it is important to remember this when entering into new or renewal negotiations.

Should I obtain professional advice and/or assistance?

Knowledge and expertise can ensure that you obtain the best outcome possible. Experts such as lease negotiators, lawyers and/or management consultants all offer possible knowledge that can guide or lead your decision making. You deserve the best and the fees associated with this could result in enormous peace of mind and many options that will protect you over the length of the lease.

How do I determine my lease requirements?

Ideally, whether you are a new practice or an existing practice, you would have a long-term business plan. If you are renewing your lease, you should ask yourself if you have considered the five to 10 year future needs of your practice. Do you want to have an option for additional space if and when it becomes available in the existing building? Terms written into today’s lease could >

> give you an advantage down the road and this indication might make your landlord more flexible on conditions with the knowledge that you are willing to consider staying longer.

Are you prepared to relocate?

Your lease is an important business decision and you want to keep the upper hand in the negotiations. Your negotiating position will be much stronger if you do not let the landlord know that you want to stay. If the landlord believes you are willing to relocate, you are likely to be able to achieve inducements from the landlord to stay and these inducements may not be achieved in any other way without paying for them. Another location may be well suited for your current and future clinic requirements and may provide financial benefits.

How important is the wording in the lease beyond the price of the rent?

In a written lease agreement, it is important to look well beyond the monetary amount of the rent. It is common for a standard lease to be 20 to 30 pages with more than 100 distinct legal clauses and perhaps a number of sub-agreements. You may require some of these clauses to be amended or deleted to be in your best interest.

Summary The lease is one of several important business decisions and it is important to be as informed as possible to make the best business decision.

Family Physician/GP, Private Family Clinic, Edmonton, Alberta Clareview Medical Clinic, 3504 137Avenue NW, Edmonton, Alberta, T5Y 1Y7, Canada This is your chance to live in a Canadian city ranked among the best places to live in North America. It is a city with education and arts as the center of its cultural life, an outstanding place to raise a family, earn excellent income and enjoy a very comfortable lifestyle.

Edmonton is a vibrant and energetic city.

It is diverse and highly connected by a welcoming sense of community. Northeast Edmonton has the advantage of easy access to shopping, cultural events, youth activities and the downtown, while still providing families with space and autonomy. The public school system is second to none featuring a wide variety of programs and extracurricular activities, including sports, the arts, hobbies, and academic pursuits.

The city has hundreds of churches and religious buildings representing a wide variety of religious sects.

Depending on the size and area, an upscale 3 bedroom, 2500 sq. ft. home within city limits can range from $600,000 to $1,000,000.

apartments, and condominiums in the local area. The Clareview clinic is located in the densely populated Clareview community, on a major thoroughfare serviced by several transit bus routes.

8) The clinic currently accommodates various medical students as part of their curriculum.

The Clareview Medical Clinic:

Incentives include:

1)

-

2) 3)

Post-secondary education opportunities include the renowned University of Alberta, MacEwan University, and Northern Alberta Institute of Technology (NAIT).

4)

Edmonton is a highly diverse city, exemplified by the numerous religious, ethnic and cultural roots of its citizens.

7)

5) 6)

Physician income is Fee-For-Service, with average annual income of $325,000+.

Revenue is split 70% /30%, physician/ clinic to cover capital costs and operating expenses.

Average patient intake per hour ranges from 6-10 depending on individual physician work style and patient acuity.

The on-call is shared by the physicians, and is not onerous.

Patient records are electronic.

The patient mix is currently 60% appointment and 40% walk-in patients.

The patient population is a cross-section ranging from middle class to low income families, living in detached homes,

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Practice setup assistance, and advertising.

Immigration assistance and/or referrals for you and your family, if required.

Medical licensing and credentialing assistance.

Housing and travel assistance.

Pre-approved banking services.

Contact: Phil Jost, HSM,MBA VP Operations & Regional Manager CanAm Physician Recruiting Inc. Office: 902-439-3400 Toll Free - Canada/USA: 866-446-4447 Email: phil@canamrecruiting.ca www.canamrecruiting.com

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Insurance Insights From doctor to acute care patient to doctor again: How insurance helped Dr. Ian Rigby Terry Marr | Marketing

and Communications Consultant, Sun Life Financial

I

n January 2012, Dr. Ian J. Rigby, an emergency room (ER) physician at Foothills Medical Centre, was happy to be enjoying a ski vacation in eastern British Columbia. The trip, an annual event with 11 close friends, gave him time off to relax, enjoy some camaraderie and de-stress.

As he skied down the mountain on the last day of his vacation, Dr. Rigby had no idea that his life was about to change significantly. In a split second, Dr. Rigby went from swooshing down the slope to catching an edge and hitting a tree. The crash broke his neck. It was a C7 fracture resulting in permanent paralysis from the chest down.

“I wasn’t doing anything stupid,” Dr. Rigby explains.

“It was an accident – just one of those things that can happen to anyone.”

The injury reversed Dr. Rigby’s role at Foothills Medical Centre. For the next six months he was a patient; spending 12 weeks in the acute care unit then three more months in the neuro rehab unit. His inpatient care was followed by extensive outpatient rehab.

Eighteen months after his accident Dr. Rigby was back at Foothills Medical Centre, not as a patient, but as a part-time ER physician.

Finding a solution to some challenges Dr. Rigby was happy to be back practising, however, adjusting to maneuvering through the fast-paced ER in a wheelchair presented some difficulties. “It was a challenge using a manual chair in the ER since it required a lot of pushing which resulted in a lot of fatigue,” he explains. “And power chairs can’t easily get around bedsides due to their size.”

AMA - Alberta Doctors’ Digest

Searching for a solution, Dr. Rigby learned about a “SmartDrive,” a special lightweight battery and rear wheel that easily converts a manual wheelchair to a power chair. The device would address his fatigue and allow him to use his narrower manual chair. But there was one drawback – a $6,500 price tag.

Undeterred, Dr. Rigby put in a request to see if the cost could be paid through his Alberta Medical Association (AMA) Disability Insurance (DI) policy. DI was already helping to replace a portion of his lost income.

Dr. Rigby is a point of pride Robert Kling of Sun Life Financial received Dr. Rigby’s request for the “SmartDrive.” After reviewing the information Kling felt that the device would definitely help Dr. Rigby and approved the expense under the “Return to Work Assistance” provision in the policy.

Kling has high praise for Dr. Rigby when he says, “He is a remarkable individual who has had to overcome extreme obstacles, given his unfortunate accident.”

Kling adds, “Dr. Rigby is a highly motivated, greatly skilled and committed medical professional to whom such funding isn’t just an investment in his success, but a point of pride about how the AMA insurance contract can go beyond words on a page in order to improve the lives of those whose needs are so pressing.”

A perfect example of an “abilities” policy Kling’s praise for Dr. Rigby doesn’t just reflect his return to Foothills Medical Centre. In addition to his ER duties, Dr. Rigby teaches one day a week at Peter Lougheed Centre and he trains air ambulance flight crews through the non-profit Shock Trauma Air Rescue Society (STARS) program. (STARS provides safe, rapid, highly specialized emergency medical transportation for the critically ill and injured.) He’s also doing some further teaching with rural doctors. >

> “Dr. Rigby is a perfect example of how a ‘disability’ policy can be transformed into an ‘abilities’ policy,” says Kling.

A bad situation which was positive When summarizing his experience with ADIUM Insurance Services Inc. and Sun Life Financial, Dr. Rigby says, “My family and I have been super grateful for the insurance. The application process sailed through easily, with no surprises and everyone has been delightful to deal with.” He adds, “It was a really bad situation which has been very positive.”

Paying the price of ignoring your coverage John Sealey, a disability claims consultant, helps physicians, medical students and residents with their AMA DI claims. From making sure the claimant understands their coverage, to helping them complete the required forms, Sealey is available throughout the entire process.

When describing his experience with physicians during his 35 years as a DI consultant Sealey says, “I have only met two physicians who I believe were properly insured and that’s because physicians usually buy Disability Insurance when they complete their residency and then never look at it again. They also don’t buy enough Professional Overhead Expense Insurance which is relatively inexpensive and tax deductible.”

When something major happens that prevents a physician from practising, Sealey says that’s when many physicians realize they’re going to “pay the price” for not reviewing their insurance coverage. “I’ve witnessed physicians who learned they were going to experience a long recovery and then realized they didn’t have enough money to live on or to keep their practice going,” he explains. Sealey adds, “It’s probably one of the biggest things to aid in your recovery – to be properly insured – knowing your office is still running, you don’t have to dip into your savings, you’re not laying off your secretary of 20 years and you can feed your family.”

A simple solution

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McAthey says there’s a simple solution even for the busiest physician. “With the Guaranteed Insurability Benefit rider, which only costs $40 a year, a physician can increase their coverage every April, without providing proof of good health up to age 55. It’s something physicians can quickly do, just once a year, to make sure they have the coverage in place so they don’t have financial worries in addition to trying to focus on their recovery.”

Dr. Rigby agrees with McAthey and Sealey. When asked how DI coverage has helped him, Dr. Rigby emphatically says, “It’s tough to overstate how important this has been. When ‘they’ say Disability Insurance allows you to focus on your recovery, it’s true. What it has done for us (Dr. Rigby and his wife), has been immense!”

What advice does Dr. Rigby have for other physicians, resident physicians and students? “As we go through training we forget that what we do is our livelihood.

We think of ourselves as clinicians. However, this is our business. As a result, Disability Insurance should be very high on every physician’s priority list.”

Protect yourself and your assets

To view a video about Dr. Rigby's experience please visit http://bit.ly/1j84bVB. To learn more about affordable group Disability Insurance through ADIUM Insurance Services Inc., contact: Edmonton and Northern Alberta Kelly Guest, EPC T 780.482.0306 kelly.guest@albertadoctors.org Calgary and Southern Alberta Mona Yam, BA, BComm, CLU, CFP T 403.205.2088 mona.yam@albertadoctors.org

Physicians make two common mistakes Glenn McAthey, director of AMA’s ADIUM Insurance Services Inc., which oversees the AMA group insurance plan, confirms Sealey’s experience. McAthey says there are two common mistakes physicians make with Disability Insurance. “The first error is not taking advantage of the opportunity to buy DI and having affordable coverage in place through their association’s plan. Disability Insurance covers a wide range of circumstances, including stress leave, which is not uncommon for physicians. Being unable to work happens,” McAthey warns.

The second error McAthey often sees is that: “Physicians are chronically underinsured and that’s because too often, physicians don’t review their coverage and keep it up-to-date.”

Alberta Doctors’ Digest

now on iTunes!

Did you know that you can now download a podcast of Alberta Doctors’ Digest from iTunes? If you don’t have time to read the whole issue, listen to the professionally produced interviews and stories while you commute to your office or do other things at work or at home. You’ll find each issue at http://bit.ly/Wg7YpO. January - February 2014

Don’t risk your financial future.

Take control

with the AMA Disability Insurance plan If your income was reduced or eliminated due to a serious illness or injury, what would happen to you and your family?

The AMA Disability Insurance plan can help protect you and your family from the financial difficulties that could arise by:

3 3 3

Providing you with a monthly tax-free benefit, Helping you avoid using your retirement savings, and Helping you cover day-to-day expenses like your mortgage, household bills, car payment, and your children’s education.

Applying for affordable coverage is easy!

Go to www.albertadoctors.org to download the application.

Click Member Services and follow the links.

or

Scan to apply!

Protect what you’ve worked so hard to build.

To learn more about affordable group disability insurance through the AMA, contact: Kelly Guest, EPC, Insurance Advisor (Edmonton and Red Deer North) ADIUM Insurance Services Tel: 780.482.0306 Email: kelly.guest@albertadoctors.org

ADIUM Insurance Services Inc. CMA Alberta House 12230 106 Avenue NW Edmonton AB T5N 3Z1 Phone: 780.482.0692 or 1.800.272.9680 ext. 692 Email: adium@albertadoctors.org

Mona Yam, CFP, CLU, BComm, BA, Insurance Advisor (Calgary and Southern Alberta) ADIUM Insurance Services Tel: 403.205.2088 Email: mona.yam@albertadoctors.org

Feature

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Tans, tyrants and treats Emerging Leaders in Health Promotion grant recipients teach children the importance of prevention Alexis D. Caddy | Communications

Consultant, Public Affairs, AMA

D

uring Alberta’s long, cold and harsh winter, many of us are happier thinking about all the wonderful things we could be doing if it were a beautiful summer’s day. We wouldn’t think twice about spending the day outside in the sun, heckling the opposing team at a sports game or grabbing an ice cream cone on a hot summer’s day.

While these three activities may seem harmless, repeating them often could have negative consequences such as developing skin cancer, being perceived as a bully and becoming obese.

Emerging Leaders in Health Promotion grant recipients recognized the unseen dangers these activities could have and wanted to educate children about how to prevent them.

Tan skin isn’t healthy skin

The presentation included the use of several types of media (i.e., pictures, video) to help the students see the damage resulting from unprotected exposure to ultra violet (UV) light. The pictures included images of skin cancers, wrinkles and burns, and the video used a comical approach to show the damaging effects of tanning beds.

“As a resident, I’m seeing many young patients with skin cancer who used tanning beds frequently and didn’t know the risks of doing so,” said Dr. Shoimer. “Although we’ll never prevent all young adults from using tanning beds, at least they will know the risks associated with their behavior.”

Dr. Shoimer hopes that by educating junior high students about sun safety, they’ll realize that tanned skin is actually damaged skin and it’s important that they learn to love the skin they’re in. >

According to the Canadian Skin Cancer Foundation, skin cancer is the most common type of cancer, but it is also one of the most preventable. Prevention is as simple as putting on sunscreen, wearing a hat when outdoors and not using tanning beds.

Dr. Ilya Shoimer, a dermatology medical resident, heard that tanning bed use in teenagers had increased in Alberta and wanted to teach junior high students the importance of sun safety. He recognized that although it is an important issue to address, teenagers did not appreciate the risks associated with tanning bed use.

“We wanted to target junior high students because at this age they begin to focus more on their appearance, especially around graduation time,” says Dr. Shoimer.

“This age group also has a basic understanding of health and disease prevention, so they are open to learning about sun safety.”

Dr. Shoimer and members of his team visited several junior high schools to give presentations about sun safety.

A photo of basal cell carcinoma used to demonstrate the dangers of UV rays. ( provided by Canadian Dermatology Association)

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> Teaching kids how to deal with bullying Bullying is a widespread problem that has serious negative effects, including mental illness, substance use and suicide.

Several high-profile teen suicides (e.g., Amanda Todd and Rethaeh Parsons) sparked a Canada-wide discussion on bullying prevention and the importance of early intervention.

“We’re not going to stop or prevent bullying overnight, but all changes start with small steps,” said Dr. Duchcherer.

An apple a day keeps the doctor away

Dr. Maryana Duchcherer, a psychiatry resident physician, recognized this discussion as an opportunity to help educate elementary school-aged children about bullying.

“We know that bullying has serious psychological and emotional effects on children and their families,” said Dr. Duchcherer. “I wanted to teach children how to recognize the different types of bullying and to empower them by teaching how to intervene.”

Dr. Duchcherer led a team of volunteers, which included school staff and other health care professionals, to help bring this initiative to life. The group decided to target elementary-aged children because studies show this is the age group to target. They knew that, they would need a really fun and creative idea to make the project interesting to the children. So they brought in technology and a little imagination.

Following an interactive presentation on bullying, the children were split into groups and given an iPod to make a movie about what they learned. Each group acted out a scene which focused on one of the different types of bullying, showed an example of the behavior and how to resolve the problem. The students then shared the videos and what they learned about bullying with the entire school at an assembly later in the year.

The program was a big success and many students who didn’t participate in making videos asked if they could participate next year.

Canada’s Food Guide is a great place to start for nutrition advice. Reproduced with permission from Health Canada 2013.

The prevalence of childhood obesity and diabetes is on the rise. The availability of processed foods and a decrease in children’s physical activity levels aren’t helping either. That’s why Jody Platt, Danielle Carpentier and two of their fellow medical students at the University of Calgary decided to address this issue by creating a program to teach children the importance of eating healthy.

“Prevention plays an important role in maintaining good health and it’s so important for children to learn that concept,” said Ms Platt. “When children learn good eating habits early they are more likely to continue them into adulthood.”

“An Apple a Day” was created for elementary students by focusing on healthy eating and nutrition advocacy by teaching children how to make healthy food choices.

The program was run in several grade three and four classrooms by medical student volunteers. It included a presentation about how to read a nutrition label, followed by interactive activities and games so the children could apply what they learned.

The activities included picking which snack was the healthier option from a group of photos, drawing a healthy or balanced meal on a paper plate, and matching how much sugar is in a serving of pop or juice.

The kids really enjoyed the activities and particularly enjoyed the healthy snack given to them at the end of the program. In addition, the teachers liked the program concepts, enjoyed how interactive it was, and appreciated that their students had a chance to learn from medical students.

“I’m very passionate about treating and caring for sick children and their families,” said Ms Platt. “This includes working to decrease the rates of preventable illnesses.”

Scan for more information about the AMA Emerging Leaders in Health Promotion grant program or visit www.albertadoctors.org/emerging-leaders.

L to R: Daniel Bogdan and Roman Balunchynskyy making a video about bullying. ( provided by Dr. Maryana Duchcherer)

AMA - Alberta Doctors’ Digest

Feature

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The AMA’s website and social media year in review In a nutshell: explosive and unpredictable

N

othing is very old in the online world. Even the “granddaddies” of social media – Facebook and YouTube – have only been around since 2004 and 2005. Change is constant, so a single year can bring many changes (and some surprises).

So what went on at the Alberta Medical Association’s (AMA’s) website? The year started with the sudden imposed agreement in November 2012. Within a few days, we’d posted new imposition web pages that stayed up during the whole crisis.

allowed us to post updates in one long stream with keywords to tie similar posts together.

Flickr also seemed another long shot last year. Why would the AMA need an account on a photo-sharing site? Well, Flickr turned out to be a great place to display photos of the two Primary Care Summits, the AMA Youth Run Club launch and the recent exhibit of physicians’ photos at the Canadian Conference on Physician Health.

What about 2014? The only certainty is that it’s bound to be unpredictable.

Some new website tools (e.g., news streams and photo banners for inner site pages) helped us to update negotiations news daily and to highlight new AMA resources for members.

The number of people who visited our website this past year exploded – 106,629 people vs. 71,937 the year before.

Most people visited during the height of the negotiations crisis, from November 2012 to May 2013. The great thing about this is that members and other stakeholders all saw our website as a key source for negotiations and other AMA news and resources.

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And what about social media? As of January 2013, the AMA had Twitter and YouTube social media accounts.

During the year, we added Facebook, Tumblr, Flickr, LinkedIn (for AMA job postings) and Mention (media health care updates).

One of the surprises of the past year was how many visits to our website came from Facebook: 13,971 vs. 270 the year before. Most of these visits happened during the negotiations crisis. This discovery led to us opening an AMA Facebook account last spring to make it easier for members and others to find and share our news and resources.

At the beginning of the year, Tumblr (a social media blogging site) didn’t seem a great fit for the AMA. But Tumblr came in very handy last June when southern Alberta was inundated by flooding. We needed a way to update our members and other stakeholders about help available, closures and the status of our southern office, which itself was flooded. A Tumblr module on our website

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January - February 2014

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Residents’ Page Resident physicians partner with Alberta shelters for the PARAdime initiative Dr. Allison Sweeney | Rural

Family Medicine Resident Physician

O

n a frigid day last February, cold winds blew along the partially deserted streets of Red Deer. Car exhaust lingered in the air, warning anyone in its path of the treacherous conditions outside. As resident physicians exited their vehicles to deliver donations to the Safe Harbour Society shelter, even the warmth of wool mittens and toques could not protect them from the assault of winter. This frozen landscape was a bone-chilling reminder why the PARAdime campaign exists: to serve countless individuals in Alberta communities who struggle to find the most basic of life’s necessities as a result of poverty and homelessness. Shelter is essential for life in our Alberta winters.

Filling a prescription or returning

for a follow-up appointment – health care basics that the rest of us often take for granted – are sometimes out of reach when survival is a struggle.

In a quest to play a greater role in the community of Red Deer, resident physicians arranged to meet with a representative from the Safe Harbour Society, a local shelter, to gain insight into the organization and what it does. It was an eye-opening experience for us to hear about the challenges that many of our less fortunate neighbors and sometimes patients face on a daily basis.

Our discussions with the shelter staff left us reflecting on the experience of some of our patients who do not have homes; where do they go after being discharged from the hospital and how much more difficult is it for them to stay healthy when meeting their basic needs, such as food and shelter, is already a struggle?

AMA - Alberta Doctors’ Digest

A strong sense of community is often what attracts graduating medical students to pursue a career in rural medicine. Knowing your neighbors, having the clerks at the local grocery store know your name, and the friendly wave of a colleague at the neighborhood park are all aspects of community life that are not always available in the city.

Rural physicians have the unique opportunity to know patients outside of the hospital walls and clinic doors, but even here, we are not always as aware of the day-to-day realities of the less fortunate within our communities.

Access to food and shelter are fundamentally important to health. Filling a prescription or returning for a follow-up appointment – health care basics that the rest of us often take for granted – are sometimes out of reach when survival is a struggle.

When the time came for resident physicians in Red Deer to be involved with PARAdime, a charity drive for the homeless, we decided the Safe Harbour Society would be a perfect organization with which to partner. The PARAdime encompasses the true spirit of rural medicine; being accountable to one’s neighbors and seeking to improve the community as a whole. Last year’s PARAdime drive marked the fourth annual campaign for Calgary and Edmonton, but was the first time Alberta’s rural resident physicians were involved in the initiative. Word spread quickly within the rural medical community, and soon Grande Prairie and Lethbridge resident physicians were also supporting their local shelters. After several months of collections from residents and attending staff physicians, numerous backpacks filled with warm clothing, non-perishable food and other survival necessities were delivered to the Safe Harbour Society.

On that very cold drop-off day, we were inspired when we saw two of the backpacks going directly to individuals who had to leave the shelter that day. They would have otherwise had only the clothes on their backs, as they headed out into the cold. The backpacks ensured that these individuals left a little warmer with the knowledge that they were not quite so alone. For us, it was powerful to know that the bags were making a direct and immediate difference for two members of our community. >

21 >

The PARAdime initiative is a

reminder that the goal of keeping Albertans healthy cannot stop at the doors of our medical centers.

Following the delivery of the last bag, we climbed back into our warmed vehicles and returned to our homes a little wiser, a little more aware and a much more grateful for what we have. The PARAdime initiative is a reminder that the goal of keeping Albertans healthy cannot stop at the doors of our medical centers; the nature of people’s experiences in the community plays an integral role in their health and in the well-being of our community. It is our duty as good neighbors and responsible citizens to address the gaps created by economic and social disparity – our communities will be stronger for it.

The donations collected for the fifth annual PARAdime will be delivered by the resident physicians to local shelters in their area for Resident Physician Awareness Day in February 2014.

L to R: Dr. Andrew Wing, Dr. Jonathan C. Somerville, Dr. Paula L. Burke, Dr. Murray J. Rodych and Dr. Allison Sweeney.

January - February 2014

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PFSP Perspectives Let’s make 2014 the unofficial year of the mentor Here’s what’s in it for you Vincent M. Hanlon, MD, Assessment Physician, PFSP

T

he 2013 edition of the Canadian Conference on Physician Health this past November in Calgary has come and gone. The conference had two themes: the intergenerational sharing of wisdom, and the challenging reality of digital connectivity in our personal and professional lives.

As I observed more than 200 participants (including 17 residents and 13 students) engage with these themes, my curiosity in mentoring was rekindled.

advisor.” Mentoring appears to have been around for a long time. What are we talking about here?

Dr. Erica A.R. Dance, emergency physician and member of the Learner Advocacy & Wellness office at the University of Alberta, Faculty of Medicine, caught my ear after she attended a session on resident wellness in the e-c@fe, and presented one herself on the pitfalls of social media.

She said she liked the informality and intimacy of the cafe setting, and had an opportunity to mentor a younger colleague. She felt good about that.

The benefits of mentoring

Dr. Derek Puddester, while introducing keynote speaker, Dr. Michael Myers, recalled and thanked Dr. Myers for having been a mentor for him while Dr. Puddester was still a resident.

Dr. Kevin D. Busche, in his Saturday afternoon session, “Mind the gap – teaching across the generations,” lists one of the positive descriptors of the boomer cohort as being “great mentors.”

During the conference planning, I definitely benefited from working with more experienced committee members. I may have been mentored without realizing it.

The topic of mentoring raises a lot of questions. What is it? Who’s it good for? Any evidence to support or dismiss it? Why do we do it? Who does it well? How is a mentor different from an experienced teacher, a 12-step sponsor or your mom?

My Apple dictionary says the word mentor comes from the Greek Mentõr, the name of the advisor of young Telemachus, who was the son of Odysseus in Homer’s Odyssey. Mentõr was “an experienced and trusted

AMA - Alberta Doctors’ Digest

To help answer that question, Dr. Busche, who acts as a mentor within the neurology department at the University of Calgary, directed me to the University of Ottawa (U of O) Faculty of Medicine’s “Handbook of Faculty Mentoring.” It includes a definition of the traditional understanding of mentor: “A mentor is an individual who takes an interest in the professional development of a junior colleague, and provides a source of guidance and support.”

Ten years ago Ehrich, Hansford and Tennent reviewed 300 research papers on mentoring in the disciplines of education, business and medicine. They reported that, “[M]entoring has enormous potential to bring about learning, personal growth and development for professionals.” Both parties benefit, but mentors less than mentees. Mentors benefited from things like collegiality, sharing ideas, reflection and personal growth. Mentees, on the other hand, described the benefits of support, encouragement, problem solving, help with teaching problems and constructive criticism.

It’s important to recall the gender discrepancy within the profession that only began to change in the 1970s when increasing numbers of women began to study medicine.

The U of O’s faculty-wide mentoring system was initiated in response to a 1993 Task Force on Gender Issues at the U of O. Similarly, the Ontario Medical Association’s (OMA’s) Mentorship Program was born out of a concern over the lack of female physician mentors for women in medical training. As the initiative gatherer momentum, the male medical students’ request for equal opportunity was noteworthy: The Mentorship Program is a province-wide initiative of the OMA. The program was developed in September 2001 in response to concerns expressed by female medical students about the lack of female physician mentors. After witnessing the success of the program within the female student population, the male medical students voiced their concerns about >

>

the lack of mentor opportunities. In response to this demand, the OMA now facilitates male student and male physician participation. The program has since grown to include more than 375 mentor-student relationships!

The Royal College of Physicians and Surgeons has had, for more than a decade, a Mentor of the Year Award. The award recognizes individuals “who have had a significant impact on the career development of students, residents and/or fellows.” Being a role model of the professional competencies defined in the CanMEDS framework is an essential qualification.

Recent Alberta recipients of the Mentor of the Year Award include: Dr. Andrew N. Lin (2012), Dr. Suzette Cooke (2011) and Dr. M. Elizabeth MacRae (2010).

What do residents have to say about mentoring? The Canadian Association of Interns and Residents’ (CAIR) 2013 Position Paper on Mentoring cites Berk et al’s inclusive definition of mentoring: A mentoring relationship is one that may vary along a continuum from informal/short term to formal/ long term in which faculty with useful experience, knowledge, skills, and/or wisdom, offers advice, information, guidance, support or opportunity to another faculty member or student for that individual’s professional (and personal) development.

Kathy Kram expands the concept of a single mentor-mentee interaction and proposes a more complex web of mentoring relationships: “[I]ndividuals receive mentoring assistance from many people at any one point in time, including senior colleagues, peers, family and community members.”

(Kram, 1985; Higgins and Kram, 2001) I invite you to take 60 seconds to recall a mentor, present or past, in your own life, or a person you have mentored. How was that experience? Mutually beneficial?

Transformative? Disappointing? The ongoing evaluation of mentoring relationships by both parties is an essential part of the activity. Evaluation is necessary, partly because of occasional failed mentorships and the negative consequences of mentoring gone off the rails.

Nine circles of mentorship hell Janet Bickel, in Women in Medicine – Getting In, Growing, and Advancing, describes, with a nod to Dante, the “nine circles of mentorship hell.” The so-called dark side of mentoring may involve furthering a political or sexual agenda, failure to define limits, problems with honorary authorship and inappropriate praise or criticism.

Ehrich et al. note that problems for mentors may include “lack of time and training, personal or professional incompatibility, undesirable mentee behaviors and attributes such as lack of commitment and unrealistic expectations.” From the perspective of the mentee, negative issues that arise can include lack of mentor time, interest or training, incompatibility, defensive or critical behaviors and culture or gender biases.

Components of a successful mentorship program The CAIR position paper on mentoring lists five basic components of a successful mentorship program. These elements were adapted from similar recommendations made by Ehrich et al.

1. Support from organizations and programs, including opportunities for multiple mentors.

2. Clarification of roles, responsibilities and goals for both mentors and mentees.

3. Matching of mentors and mentees.

4. Training for mentors and mentees.

5. Monitoring and ongoing evaluation of mentoring program/relationship.

Is there a “critical mass” of mentoring relationships necessary to help maintain or improve the health of our medical family? Probably. On the Physician and Family Support helpline we hear that mentoring relationships can be beneficial in dealing with adverse events, in defining appropriate career choices and making career transitions, and in learning to balance work and family responsibilities.

Are you willing to help make 2014 the unofficial year of the mentor?

Photos from the conference exhibition As part of the Canadian Conference on Physician Health this past November, there was a juried display of physician photography entitled "How Doctors See the World." This article is partly in response to an invitation to comment on this initiative and, more broadly, on the relationship of art to physician well-being. On the following pages are some images from the photography exhibition.

I hope they connect with you in some way. More images can be found in the November/December 2013 edition of Alberta Doctors' Digest and at http://bit.ly/1cZDawX. References available upon request.

Daniel C. Feldman explores the reasons behind failed mentorship in “Toxic Mentors or Toxic Proteges? A Critical Re-examination of Dysfunctional Mentoring.” He discusses things like mentoring as an entitlement, protegés as victims, mentors as missing persons, failed linkages and the paradox of equal inequalities.

January - February 2014

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The Here and Now. (

by Dr. Natalia Ng)

Volcanic rocks in the Indian Ocean. (

by Dr. Farook Oosman)

AMA - Alberta Doctors’ Digest

Red maple leaf in Ottawa's Rideau Canal. (

by Dr. Stewart Hamilton)

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Moon setting over the Rockies. (

by Dr. Farook Oosman)

Blue Canoes in the Bow River near Banff. (

by Dr. Stewart Hamilton)

Pediatrics at the old Port Arthur General Hospital in Thunder Bay ON. (

Dr. Rène Lafrenière's clock collecting and repair. (

by Dr. Hans Berkhout)

by Dr. Vincent Hanlon) January - February 2014

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Feature

Medical students lobby government for youth tobacco reduction Lindsay Bowthorpe and Michael Arget

M

edical students in Alberta lobbied the provincial government for tobacco reduction legislation at the Alberta Legislature last fall.

“We advocated for banning the sale of flavoured tobacco products in order to prevent youth tobacco use,” said Lindsay Bowthorpe, Chair of the University of Alberta’s Political Advocacy Committee (PAC).

On November 4, 2013, almost 50 first and second-year medical students from the University of Alberta and University of Calgary (U of C) met with Members of the Legislative Assembly (MLAs) from all political parties as well as several government ministers including the minister of health, as part of the annual Political Action Day. The event was funded in part by a grant from the Alberta Medical Association and is organized by the corresponding PAC at each university.

Students were placed into groups of three and had meetings throughout the day. There were also brief presentations and welcomes from Health Minister Fred Horne, Dr. Raj Sherman (leader of the Alberta Liberal Party) and Mr. David Eggen from the New Democrats.

“We chose to target tobacco due to the alarmingly high use of flavored tobacco products by Alberta youth,” Bowthorpe said.

A recent study published by the Propel Centre for Population Health Impact cited that 56% of Alberta youth who are using tobacco products are choosing flavored varieties.

Bowthorpe says that flavored tobacco products are designed to appeal to youth in order to get them addicted to tobacco from a young age.

“Cigarillos come in containers that look like tubes of lip gloss. The candy and fruit flavorings appeal to youth – peach, strawberry, chocolate, vanilla etc.,” she said.

Menthol products were also targeted in the lobbying effort as they are easier to smoke than regular cigarettes which enable youth to begin smoking them more easily.

AMA - Alberta Doctors’ Digest

“Menthol numbs the throat, opens up the airways and leads to deeper inhalation and more nicotine absorption, while also masking the harshness of tobacco smoke.

When you smoke menthol, you don’t feel like you are smoking at all,” Bowthorpe said.

“Political Action Day provides a great opportunity for future physicians to learn about a health issue (tobacco) and how to advocate to government to encourage better health for Albertans,” said Michael Arget, chair of the U of C’s PAC. Political Action Day is in its sixth year and provides medical students with experience in lobbying government on medical issues.

“I really appreciated the opportunity to meet with MLAs about a health issue and be taken seriously as a future physician,” said Solveig Nilson, a first year medical student from the U of C. This year’s lobby day coincided with a debate of Bill 206, a private member’s bill that proposed the prohibition of flavored tobacco products. This experience allowed the medical students to develop an appreciation for the political process. Bill 206 passed third reading on November 25, 2013.

For more information about the Political Advocacy Committees, please contact: Lindsay Bowthorpe at lbowthorpe@ualberta.ca Michael Arget at mjarget@ucalgary.ca For more information about the Propel Study please visit: https://uwaterloo.ca/propel/sites/ca.propel/files/ uploads/files/flavoured_tobacco_use_yss_20131007.pdf We would like thank Greg Sawisky, MD Candidate, Class of 2016, University of Alberta for his editorial assistance.

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Calling for 2014 TD Insurance Meloche Monnex/AMA Scholarship applicants

Picture it: $5,000 of assistance for additional training in a clinical area of recognized need in Alberta. If that fits your situation, apply for the TD Insurance Meloche Monnex/Alberta Medical Association (AMA) Scholarship by March 31.

Scholarship applicants must be seeking additional training in a clinical area of recognized need in Alberta, be an AMA member, plus be enrolled and accepted in a clinical program of at least three months duration in a recognized educational facility.

The proposed program must be supplementary to completion of a Royal College of Physicians and Surgeons of Canada or College of Family Physicians of Canada certification program, or the physician may be in an established practice and wishing supplemental training.

To request a scholarship application form, please contact Janice Meredith, Administrator, Public Affairs, AMA: janice.meredith@ albertadoctors.org, 780.482.2626, ext. 291, toll-free at 1.800.272.9680, ext. 291, or visit the AMA website (http://bit.ly/S9aI6M).

Scholarship recipients of the last three years follow: • 2013 Dr. Jennifer K. Grossman, Calgary (fellowship in primary immune deficiencies, National Institutes of Health) • 2012 Dr. Gabriel Fabreau, Calgary (fellowship in general medicine, Harvard Medical School) • 2011 Dr. Sayeh Zielke, Calgary (fellowship in Echocardiography and Adult Congenital Heart Disease) Visit the AMA website (http:// bit.ly/S9aI6M) to find out more about recent recipients.

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January - February 2014

In A different vein

29

The decline of decay: Dentistry then and now Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | co-Editor

My curse upon your venom’d stang, That shoots my tortur’d gums alang, An’ thro’ my lug1 gi’es mony a twang, Wi’ gnawing vengeance, Tearing my nerves wi’ bitter pang, Like racking engines!2 Where’er that place be priests ca’ hell, Where a’ the tones3 o’ misery yell, An’ ranked plagues their numbers tell, In dreadfu’ raw4, Thou, Toothache, surely bear’st the bell, Amang them a’!

thrived. This is not a coincidence and fees (and costs) are the highest in the country. But the dentists govern themselves well. They introduce new developments quickly, led by people who know what they’re talking about. In contrast, I can tell you that for Cancer Services (where Alberta led the country up to six years ago) we are now well in the bottom third of provinces.

Getting decisions on anything has reached a point where many of us shake our heads, shrug our shoulders and sit back. We now have ambitious, well-meaning amateurs and pseudo-experts making key funding and medical decisions.

Robert Burns (1759-96): Address to the Toothache. Burns grew a beard (shaving was painful) then had the tooth pulled by a “tooth drawer.” He never recovered. Bacterial endocarditis on a rheumatic heart saw him out in July 1796 at age 37.

My father, aged 26, went to India in 1932 as a mining engineer and – unbelievable as it is to the younger generation – he had all his teeth extracted. In the pre-penicillin era if you needed an extraction, an infection might follow. Dentistry in India was such that a sinus venous thrombosis and death was not uncommon. So out they all came under local anesthesia (that he said made the hair on the back of his head stand on end) and he had false teeth for the rest of his life.

There’s a lot you can learn from the mouth and teeth – as much as looking at the hands. For example, you can sometimes tell whether a patient is right or left handed by their teeth – there’s often more tartar build-up in the left dentition in a left-handed person (they have difficulty brushing the left side teeth – unless they use a batteryoperated toothbrush.) And if you see a purplish dark patch at the back of the tongue, why, you could ask the patient if he (or she) is a sommelier or a wino (chronic staining from holding red wine in the mouth).

A modern dental office is a welcoming place. The smell is more likely a waft of freshly brewed coffee with only the occasional whiff from the days of Dan the Dreaded Dentist. Today’s newspaper is there. There is a friendly receptionist. Injections are rarely painful. Hygienists give you mini-lectures on prevention. Modern equipment shines and sparkles.

Dentistry in Alberta has been fairly free from the dead hand of the Not Your Father’s Party (soon to be renamed the “Not Your Grandfather’s Party”) and the stifling quagmire of Alberta Health Services. Many dentists have

I am now a shill for modern dentistry.

It was not always so …

Dentistry in Alberta has been fairly

free from the dead hand of the Not Your Father’s Party.

And so I inherited a rational fear of the dental office – a visit to the dentist was like a visit to the headmaster’s office: unpredictable and likely to be unpleasant. The moody leafing through torn, sticky old copies of The Edinburgh Tatler in the waiting room and that pale, dental smell of – what was it? Oil of cloves (eugenol), acrylic monomer and formocresol with a hint of tooth dust – an odor producing tachycardia and quiet misery. >

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> My first spar with dentistry was at the age of four. Some milk teeth had to come out. I was taken to the dentist in North Berwick on the bus by my mother. Before you could say “spit out” I was in this huge chair, my mother having been banished from the room. A strange woman crept up with a mask in her right hand. “Breathe in, Alexander, normally now…” What! No way! I kicked and twisted but was held down by superior power.

The nitrous oxide took its effect … and then …. swirling darkness, black with a light hole in the center where a face far away was saying, “Wake up Alexander, wake up….” Qualified gasmen now administer general dental anesthesia after some disasters in the dental office.

“Next. Alexander.”

Get up slowly, with a cringing smile that might inspire mercy. Tread the linoleum floor into the surgical area.

Sit in the huge chair with instruments of torture spiking out of it.

Even the initial inspection was uncomfortable. The probe or the little mirror always seemed to catch my upper or lower lip squeezing that soft sensitive flesh against an upper or lower incisor.

“Where’s it been hurting?” Mr. Miller would ask tapping the teeth until he whacked the offending tooth.

“Is that it?” “Yuh-huh,” you would say, sweat breaking out.

The entrepreneurial physician in Alberta receives no rewards for being

unique, inventive or efficient and may get only grief, pain and extra work filling out suggestions, applications and appeals which disappear into the Alberta Health Services (AHS) morass.

Dentists in Britain were (like surgeons) not blessed with the moniker of doctor since they only did things with their hands, not their brains. Most operated under the dead hand of the National Health Service and the only reason ever to go to a dentist in the 50s, 60s and early 70s was if you had a “sair tooth” or a “gumboil.”

“Uh-huh. It’s going to need a filling,” Mr. Miller would say with a sigh. “You don’t want a local do you? It’ll only take a few minutes.”

It was hard to answer honestly with him looming over you, drill in hand. The ordeal was easier if he injected the right spot – but I’d had a jag from him once in the wrong spot – that, and the size of the needle made it a toss-up AMA - Alberta Doctors’ Digest

which was worse. It was also hard to say: “Yep. I’ll have a local” – because that was admitting cowardice, fleeing from the enemy, being a softie.

The grinding of the drill bit. The searing pain makes your eyes water. Spit out blood and tooth chips. And then the squealing whine of the fine drill that vibrated less but when it found a tender bit, boy: an exquisite lash of pain through the entire jaw radiating throughout the head and down the neck forcing out a shocked gasp. And every so often the hissing of the spittle sucker inserted just in time, sucking up the juices like a kid sucking the dregs of a drink through a straw. This avoided a gallon of saliva cascading down the throat and into the trachea causing death by drowning. I could see the headlines: “BOY DROWNS AT DENTIST’S.” Then squeeze in the silver amalgam. And at last, that moment of relief as he unclips the gown.

“There. That’s it. Wasn’t too bad, was it now?”

Mr. Miller’s disdain of local anesthetics was related to his golf tee time. Local anesthesia slowed him down.

The philosophy in those dark ages over 50 years ago was that dentistry was straightforward. The tooth was either filled or extracted. We even learned how to pull a tooth at Edinburgh Medical School in case we were going to practice in Moose Factory or Jabbalonga or do a locum in Balcarres, Saskatchewan where I was asked to do an extraction in 1975 but declined, sending the annoyed patient to Indianhead (“But Dr. Smith can pull teeth,” he said.)

Let me teach you. You do not start pulling upwards. You take your dental forceps in hand, clamp them over the tooth and press down, hard and firm. Then jiggle the tooth back and forth to break the periodontal ligaments.

And only then do you pull. For resistant cases bring the right knee to rest horizontally on the patient’s chest wall and pull hard. Ignore cries of pain. This information has been more useful to me than the Krebs Cycle.

But omnia mutantur, nihil interit! All things change!

In Edmonton 30 years ago I was introduced to proper local anaesthesia and the rubber dam. Stretched over the tooth, it stops saliva gathering but also stops any opportunity to chat.

Dr. Bothwell had a sign in his office: “Be good to your teeth or they will be false to you.”

“How’re things going at the Cross?” he’d say.

I’d try a nod. “Keep still, now.” “Graagh,” I’d reply.

“I don’t know how you can work there. It must be depressing with everyone dying,” he’d say.

“Graargh,” I’d reply.

What I wanted to say was: “Not as depressing as filling rotten teeth all day, buster. And by the way, it’s not all death.” But by the time the rubber dam was removed we >

> were on to something else. Like balance-billing and how in Canada dentists ran private businesses and were not involved with these contentious issues.

The philosophy now is “every tooth is sacred.” My endodontist in Calgary examined a rotting incisor, probed around, X-rayed from all angles including a Panorex, cocked his head and said to me with a glum, yet compassionate face: “I’m afraid we can’t save that tooth.”

It was like he was telling me I had pancreatic cancer.

“What would you advise?” I asked with suitable anxiety and concern.

“We could try a root canal, but … it’s fractured …” he said solemnly. “We can’t save it.”

He then went on to complain about the cost of parking at Bankers Hall.

“We’ll take it out, give you a flipper and then off to the periodontist for an implant.”

I’ve become impressed with dentistry and the dental business model – although despite asking, I’ve never received a cleaning or examination discount for all my empty spaces. I now rap with the dentists when they have a patient on bisphosphonates who requires an extraction – a risk factor for jaw osteonecrosis, a painful lesion where the tooth socket fails to heal.

Bisphosphonates have become a problem in cancer patients with bone metastases largely because of over-enthusiastic dosing – often at the behest of drug companies who want to sell as much of their stuff as possible. The dosing required to inhibit bone turnover is much lower than recommended.

Dentistry has avoided the dead hand of government control and in Alberta is as good now as anywhere in the world, though expensive. Offices run smoothly and efficiently. Time wasting committees are few.

Dentists have been suggesting implants for me for years.

Now with the mortgage paid off, the kids educated, and my remaining teeth thinning, they saw me coming.

With the Alberta Medical Association (AMA’s) ADIUM Insurance Program plan in place, I succumbed. I have just had four implants – painlessly (except in the hip pocket), skillfully and with no fuss. The first implant was in an abscessed tooth – and it took! The rotten, fractured incisor was extracted, the root drained, antibiotics swallowed and the hole filled with bone chips. Six months later I had a new tooth.

The remaining three are in the left lower mandible, the originals having been joyfully extracted 30 years ago.

An MRI of the mandible to show the course of the mandibular nerve, a review of my dentition, the periodontist droning out measurements of the gingival height like a sailing boat’s leadsman singing out the depths of water in the bay. “Tooth three six distal buccal three, mid one, mesial three.…”

After three months, the implants were unplugged, guide stents put in, impressions taken and abutments and crowns cemented on. And I have $12,000 less to worry about – but don’t forget dentists generally have overhead costs of 60% of revenues.

Dentists run competitive businesses and are used to talking about money with patients without embarrassment. Physicians have been brain-washed to think talking money is shameful. The patient and physician operate in a “folie a deux” under the illusion that everything is free. Dentists in Ontario issue an annual fee guide (they even have a code for “difficult patient” and that does not mean a “complex case” – it means an awkward customer) and insurance companies can choose to go below that guide – if they go too far they lose customers. Alberta’s last guide was issued in 1997 and we have some of the highest fees in the country, sometimes too high. There are fewer dentists and less competition in Alberta than in other provinces and so the market is favorable – but they will have to be careful. As in Ontario, Alberta has a Seniors Plan and a Child Health Benefit Plan for low-income families.

The entrepreneurial physician in Alberta, in contrast, receives no rewards for being unique, inventive or efficient and may get only grief, pain and extra work filling out suggestions, applications and appeals which disappear into the Alberta Health Services (AHS) morass. There really must be circumstances where balance billing is acceptable, where a physician has introduced a technique that enhances efficiency or care standards that a patient is happy to pay for. The problem we have is that high quality of care goes unrewarded whereas quantity rules – a formula for stagnation. As Burns might have said about AHS: “The best laid plans of mice and men gang aft agley5, And leave us nought but grief and pain for promised joy!”

Acknowledgement Thanks to Dr. Feonagh Paterson Howard, dentist, London ON for advice and some stories.

Glossary 1. “lug”: the ear.

2. “racking engine”: the rack (common torture a few years ago, for those wishing to gain several inches in height.)

3. “tones”: tones, noise.

4. “raw”: row, racket.

5. “Gang aft agley”: often go wrong, get cocked-up.

January - February 2014

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January - February 2014

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