Alberta Doctors' Digest Jan/Feb 2015

Alberta Doctors'

DIGEST January-February 2015 | Volume 40 | Number 1

Youth Run Club ambassadors send a clear message The ambassador program is a new addition to the Alberta Medical Association Youth Run Club Alberta Medical Association Board of Directors 2014-15

Emerging Leaders in Health Promotion Grant Program The rewards of reading: A literacy campaign

Thinking differently

Can physicians and patients learn?

Patients First速

We help get students

up and running.

The "We" of YRC includes physician champions.

You're integral to the success of YRC. Step (or jog or run... whatever you prefer!) into a school near you and walk the talk of a physically active, healthy role model.

Get moving with Alberta's children and send them home with messages of activity, good nutrition and healthy lifestyle.

We have the schools, the kids, the ambassadors, the partners, the AMA... We just need you!

It's easy! Many great physician champion resources -- videos, a presentation, tip sheets and more -- are featured on the Alberta Medical Association website.

If you're interested in being a Youth Run Club physician champion, call Vanda Killeen, AMA Public Affairs at 780.482.0675 or email vanda.killeen@albertadoctors.org. www.albertadoctors.org/youth-run-club www.everactive.org/alberta-medical-association-youth-run-club In October 2013, the Alberta Medical Association and Ever Active Schools launched the AMA Youth Run Club, a free, school-based running program to promote physical activity in children and youth. By June 2014, 233 schools and more than 11,000 children and teachers were involved.

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

4 From the Editor 10 Health Law Update 14 Mind Your Own Business 16 Insurance Insights 20 Dr. Gadget

22 31 33 36

PFSP Perspectives Residents' Page In a Different Vein Classified Advertisements

FEATURES

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

6 Youth Run Club ambassadors send a clear message where it’s needed

President-Elect: Carl W. Nohr, MDCM, PhD, FRCSC, FACS

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

12 Alberta Medical Association Board of Directors 2014-15 13 Know someone outstanding? Speak up!

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 13

The ambassador program is a new addition to the Alberta Medical Association (AMA) Youth Run Club

AMA seeks 2015 nominations for our highest awards

17 Calling all applicants! It’s time to check out the 2015 TD Insurance Meloche Monnex/AMA Scholarship

The AMA, in conjunction with TD Insurance Meloche Monnex, is very pleased to be providing $20,000 in scholarship funds for 2015

18 Emerging Leaders in Health Promotion Grant Program 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. © 2015 by the Alberta Medical Association Design by Backstreet Communications

AMA MISSION STATEMENT

The rewards of reading: A literacy campaign

25 What's new on the web?

Websites are never finished. They only improve … or decompose!

26 Thinking differently: Can physicians and patients learn?

The Alberta Medical Association has a System-Wide Efficiencies and Savings Consultation Agreement with Alberta government

28 Diagnosing schizophrenia

What can we learn from a historical perspective?

30 Want to participate in clinical research?

Here are some steps to success

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:

Paula Findlay and Tim Berrett are the AMA Youth Run Club's new ambassadors. ( provided by Marvin Polis) JANUARY - FEBRUARY 2015

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FROM THE EDITOR

Coming of age Dennis W. Jirsch, MD, PhD | EDITOR

T

he Queen now needs a full seven secretaries in order to help her send congratulatory notes to centenarians. At the same time, the global anti-aging industry, currently worth $195 billion, will jump to $275 billion by 2020.1 The fastest growing segment of society, we’re reminded, are folk past 85 or 90 years of age.

Stanford Professor James F. Fries talked about “compression of morbidity” in the 1980s,2 suggesting that we would all one day live longer, healthier lives, with fewer disabilities. The “Boomer” version of this counts on a life stretching into one’s 90s – one that might see 18 holes of golf one morning, perhaps some scuba diving in the afternoon, a gourmet dinner, followed by brandy and spirited, postprandial sex. Later in the evening, there might be a pause in this parade of pleasantries – perhaps a tickle in the throat … then … nothing. Life’s candle would flicker out.

We’ve bought into this alchemy big-time. Our media don’t tire of showing us elegant, graying couples cycling round manicured grounds of posh retirement residences.

Romance persists and thrives, a testament to technology, and there’s no need to lack tumescence in these romantic places should the whim arise. Another nod to technical achievement, there’s no need for troubling dampness – male or female – and, if the commercials are to be believed, lively dancing, accomplished ski turns and a general healthy ruddiness will attend. The financial industry is in step, and a bevy of banks and trusts promise no fiscal missteps on the road to 30 or 40 years of swell retirement.

The path’s so sunny, in fact, to prompt suggestions from government, urging retirement post-65. After all, the best is yet to come.

Not everyone can do this, though. One has to know which anti-oxidant berries to nosh on, which exotic supplements are best. Hey, they’re digging up new

AMA - ALBERTA DOCTORS’ DIGEST

roots in Guinea and along the Amazon all the time, and the carapaces of certain bugs and turtles hold particular promise. Attitude is key. One’s longevity potential can flourish with crystals, shamans, the clanging of bells found in secret valleys, or holding painful body poses for minutes at a time, all done with fingers held just so. Neuroscience helps too. Pursue challenging computer games or three and four-dimensional puzzles.

Even learning new, alien languages can modernize an aging encephalon.

So, is 80 the new 50? Why not? Indeed, why not?

(Reluctantly). The Truth, m’dear. That’s why not.

Certainly, average life expectancy has increased as more survive birth trauma and childhood illnesses. Better food, water, sanitation and vaccinations have helped us get this far, but that’s pretty well the extent of it. Our technological successes put a helpful spin on things here and there, but the recipe for successful aging – as far as we know it – is merely common sense: quit smoking, exercise in moderation, maintain a healthy weight.

We can’t continue to base our

image of old age on those persons blessed with hardiness, position or affluence, and who remain sharp as tacks. We must see our declension for what it is.

Beyond the rosy nonsense of our delusions, the facts are grim.3 Age 65 and up, a third of us have trouble walking; another third struggle with fine motor skills. About 10% will have a diagnosable mental health disorder. Things get worse. Most oldsters who live beyond their mid-80s can expect protracted frailty and disability before they die. Alzheimer’s or other dementia traps a third of us past 85, and there’s a 50/50 chance we’ll end up in a nursing home. >

> Our exits come it seems, not in an instant but over a lengthy, excruciating period of time. Recall 300 years ago that Thomas Hobbes said life is “nasty, brutish and short.” Author Ira Rosofsky has updated Hobbes in his new book on eldercare, Nasty, Brutish and Long.4 I’m not about to “diss” longevity research. Recall the Epic of Gilgamesh and the Mesopotamian King who searched for immortality after the death of his best friend, or the three Chinese emperors in the Tang dynasty who died consuming a potion of lead and mercury. Five hundred years ago, conquistador Ponce de Leon sought the fountain of youth and instead discovered Florida, somewhere near present-day St. Augustine.

Our exits come it seems, not in

an instant but over a lengthy, excruciating period of time.

Hormones have long seemed to be an answer. Early neurologist Dr. Brown-Sequard5 was a strong advocate of the injection of ground-up testicles of guinea pigs and dogs. In the early 20th century physiologist Eugen Steinach6 invented a unilateral vasectomy. Cutting one vas deferens, it was thought, would stop sperm production and bump up hormone production, with unimaginable salutary effect.

Thousands had the operation7 including Sigmund Freud and W.B. Yeats, who wrote extraordinary poetry thereafter and took up with a 27-year-old actress.

The Dublin papers took note and referred to Yeats as “the gland old man.” Many surgeons became extraordinarily wealthy and the operation was so wildly popular that its inventor’s name became a verb: “Have you been Steinached yet?”

More recently, baseball legend Ted Williams has tried another tack and has been frozen in liquid nitrogen,8 though head and corpus are, unfortunately, not in continuity. “Freeze, wait, reanimate” has become the mantra for cryopreservationists, who have nothing if not faith in the future.

Most recently, age research has focused on red wine, starvation diets and genetic manipulation: pretty much the same rigmarole.

Dr. Ezekiel Emanuel, an oncologist, ethicist and National Institutes of Health member, has broken ranks to announce, in an Atlantic essay9, that once he hits 75 he’ll decline nearly all medical treatment – flu shots, colonoscopies, pacemakers, etc. It’s less about cost and more about quality of life, according to Emanuel, who despairs the loss of vigor, autonomy, productivity, “smarts” and ambition that oft accompany senescence.

Age 75 is arbitrary to Emanuel, who argues that a diminished life is not worth prolonging.

Pretty brave stuff from an oncologist and ethicist, I think.

He’s reserved the right to change his mind, but I’m worried that Emanuel, age 57 now, has 18 years to reconsider. In oldsters’ terms he’s a pup or a cub – a newbie.

The neat thing about Emanuel’s essay is that “we all get it,” and have to admire his extraordinary honesty.

As well, we can’t continue to base our image of old age on those persons blessed with hardiness, position or affluence, and who remain sharp as tacks. We must see our declension for what it is.

Early versions of homosapiens, hunter-gatherers, likely prized oldsters for their memories, helpful perhaps in times of flood or famine, but eventually they were left by the wayside. Things may have been better in later agricultural communities with their emphasis on family structure and responsibility, and there were likely greater opportunities for useful employment. The elderly, once again, may have had utility as repositories of memory.

By way of contrast, in our digital world, work and family relationships are global and such memory as exists is not anchored, but in the cloud. The aged are left to rely on the beneficence of strangers and institutions as never before.

Still, who knows what old age is really like? Author Malcolm Cowley has thought much about “the balance sheet of perils and pleasures that come with old age.”10 As he says, “To enter the country of age is a new experience, different from what you supposed it to be.

Nobody, man or woman, knows the country until he has lived in it and has taken out his citizenship papers.”

We’re left somewhere between, “Old age is a shipwreck,” and “Come grow old with me! The best is yet to be.”

In particular, Cowley finds the greatest temptation is simply giving up, something that may be all too easy when the elderly feel functionless and no longer listened to. A sense of purpose is as necessary in late life as it is earlier.

We’re left somewhere between, “Old age is a shipwreck,” and “Come grow old with me! The best is yet to be.”

What is it then? Some combo of chance, pluck or resilience?

We’ll see.

Perhaps.

References available upon request.

JANUARY - FEBRUARY 2015

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COVER FEATURE

Youth Run Club ambassadors send a clear message where it’s needed

As an AMA/Ever Active Schools YRC ambassador and Olympic triathlete, Paula “can’t remember not being involved in sports.”

Paula played soccer, danced (ballet, jazz and tap) for 15 years, started swimming competitively when she was 11-years-old, took up track and field at the age of 14 and began her triathlete career when she was 16. She grew up in Edmonton, skiing and skating through the long winters with her very active family.

“My parents were involved in sports and as kids we were always encouraged to play sports and games, and just be active. Our family has always been on the go and still is!” says Paula.

We weren't all "born running," but AMA Youth Run Club ambassadors Paula Findlay and Tim Berrett are living proof that we can all benefit from physical activity. ( provided by Marvin Polis)

T

he ambassador program is a new addition to the Alberta Medical Association (AMA) Youth Run Club (YRC). As the term “ambassador” implies – “an authorized representative or messenger” – the AMA and its YRC partner, Ever Active Schools, sought ambassadors for the YRC who, as provincial or national athletes or other role models, would stand as shining, inspirational examples of the benefits of physical activity.

For the first year of this program, we were very fortunate to bring on two outstanding athletes and role models: well-known Canadian Women’s Olympic triathlete, Paula Findlay and five-time Olympic race walking competitor, Tim Berrett.

Once an athlete, always an athlete: Olympic women’s triathlete, Paula Findlay If you were to ask 25-year-old Paula Findlay’s mom, she’d probably say Paula was born running, or at the very least, born moving.

AMA - ALBERTA DOCTORS’ DIGEST

Prior to representing Canada

in the women’s triathlon at the London 2012 Olympics, Paula won five world triathlon series events in 2010-11.

The YRC’s ambassador program seeks to enlist the support and advocacy of local athletic role models and mentors, who, with their actions and beliefs, champion youth activity. Last fall, the YRC was very fortunate to acquire Paula as a program ambassador.

With her childhood and youth focus on sports and physical activities, Paula is a natural, credible advocate of youth activity. Her impressive and well-earned accomplishments in the competitive world of women’s triathlon are a huge inspiration to all, particularly to children and youth. Prior to representing Canada in the women’s triathlon at the London 2012 Olympics, Paula won five world triathlon series events in 2010-11.

“It had never really been a goal of mine, to go to the Olympics,” says Paula. “But when I started competing >

> in triathlons in 2006, that’s when I started to think it might be a possibility. This is my career, now,” Paula continues. “Training every day, looking after my body and health, performing at a world-class level, having sponsors, being a role model … I love being a mentor to children with similar goals and dreams.”

7

Having just arrived back in Edmonton after almost a year in Australia, training to qualify for the 2016 Olympics, Paula acknowledges the challenges we face staying active outdoors through our (usually) tough Alberta winters.

“It’s REALLY hard to stay active outside when it’s cold!

But it can be done, by dressing warmly, in layers … and you can always go indoors for your activity.”

But for Paula, probably the most important factor in encouraging youth to be active is found at home. “I think being in a family and a household that encourages an active lifestyle is vital. My active family is really at the core of my abilities and interests,” says Paula.

Paula Findlay shares the stage with some of the students at École Bellevue School in Beaumont AB. ( provided by Ever Active Schools)

Paula was fresh off the plane when the YRC put her to work as an ambassador with a presentation on December 16, 2014 to 300 students at École Bellevue School in Beaumont. The YRC will keep Paula running, but she likes it that way!

Walking the walk … Olympic men’s race walker, Tim Berrett As an AMA/Ever Active Schools YRC ambassador, 49-year-old Olympic race walker Tim Berrett knows how to walk THE walk – the Olympic race walk that is – and he knows how difficult and painful it can be.

“The first time I did a walking race, I was about 13,” explains Tim, who was born and raised in Tunbridge Wells, England. “I ran cross-country with my school, which also had a tradition of race walking. There was a race coming up that went right past my parent’s front door so I decided to try it. It was painful! My shins hurt for several weeks after,” he says.

It’s REALLY hard to stay active outside when it’s cold! But it can be done, by dressing warmly, in layers … and you can always go indoors for your activity.

Tim finished third in that race and had been bitten by race walking bug. The Olympic bug followed shortly thereafter. He continued developing as a race walker throughout his school and university years, supplementing his fitness and training with cross-country

AMA Youth Run Club ambassador Tim Berrett leads several groups of runners at Westglen Elementary School in Edmonton. ( provided by Marvin Polis)

and track running. Tim went on to compete in five successive Olympic Games between 1992 with his last competition at the 2008 Beijing Olympics.

Soccer, rugby, cricket, running and race walking: Tim was always active as a child and youth. This habit and pattern of activity and associated good nutrition and health has continued all through adulthood. Tim has been a worthy competitor throughout his life – and is now a board member of Athletics Alberta and Athletics Canada, an athletics program leader at Edmonton’s Westglen Elementary School and YRC ambassador. In all this, Tim sees the benefits of physical activity for children and the value of programs such as the YRC which “give the kids a reason to be active, outside the school curriculum.”

“It’s important for kids to have the opportunity to be active, whether in or outside of school and in an affordable way,” Tim explains.

In addition to the YRC, Tim has been closely involved with AthletiKids, a track and field-based, non-competitive program for K-6 students at Westglen Elementary School for close to nine years. As part of his AthletiKids program at Westglen, Tim has developed the YRC into a fall cross-country running program. > JANUARY - FEBRUARY 2015

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Prior to representing Canada in the women's triathlon at the London 2012 Olympics, Paula Findlay won five world triathlon series events in 2010-11. ( provided by International Triathlon Union)

> “We also do some other activity initiatives that tie in with the YRC, such as the Westglen Challenge, every spring. We started these runs three years ago,” says Tim. “We challenge the (approximately 290) kids to run/walk 2,000 kilometres collectively, during the last week of May. They can bring their parents and families, as they do their morning (before school) runs and laps around the school field.”

Tim Berrett competed in five successive Olympic Games between 1992 with his last competition at the 2008 Beijing Olympics. He also earned medals at two Commonwealth Games. ( provided by James Aldridge)

Based on the success of the Westglen AthletiKids/ YRC program, Tim is ready to expand the program to other schools.

These programs get kids active, engaged and feeling good about themselves.

It’s important for kids to have the

opportunity to be active, whether in or outside of school and in an affordable way.

“There is so much value to physical activity for adults and kids,” Tim states. The teachers of kids who take part in the AthletiKids/YRC programs at Westglen notice that the children who participate in the activities are more attentive in the morning and all through the day.

For the past several years, in addition to his work with Athletics Canada and other sports management boards, Tim supports the current coach of Canada’s emerging group of world-class race walkers and through mentoring, works to improve athletic performance. He’s also keenly involved in the development of a race walking program in Canada.

“These programs get kids active, engaged and feeling good about themselves. With events such as the Westglen Challenge, we involve parents and families and it creates a real sense of community and a good feeling of safety and support,” says Tim.

AMA - ALBERTA DOCTORS’ DIGEST

Please see the video at www.albertadoctors.org/advocating/ many-hands/ama-youth-run-club to learn more about the AMA YRC ambassador program.

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Paula Findlay's charisma lights up the room as she talks about physical fitness at École Bellevue School in Beaumont AB. ( provided by Ever Active Schools)

One of the ways Tim Berrett keeps active is by running and walking with his dog. ( provided by Marvin Polis)

Paula Findlay (L) and Hayley Degaust, AMA Youth Run Club coordinator (R), get the YRC ambassador program off to a strong start at École Bellevue School in Beaumont AB. ( provided by Ever Active Schools)

We want your feet!

Like to run? Have an interest in healthier kids and healthier communities?

We’re rolling out all kinds of resources to help you get kids running where you live. If you’d like to participate in a school have other suggestions to get kids’ feet moving, we can help.

You don’t need to be a parent of a school-aged kid to participate. Your willingness and interest are all you need.

hayley@everactive.org

Ready to get involved? Drop us a line: runclub@

albertadoctors.org

JANUARY - FEBRUARY 2015

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HEALTH LAW UPDATE

The three P’s: Protection of privacy is paramount Jonathan P. Rossall, QC, LLM | PARTNER,

O

ver the last six months, there has been a spate of reports dealing with the accidental or unauthorized disclosure of patients’ health information. In August of 2014, we heard from the Office of the Information and Privacy Commissioner relating to the theft of a medi-centre consultant’s unencrypted laptop. That laptop contained identifiable information relating to over 100,000 patients.

Last October, a laptop computer containing personal health information was stolen from an office of a doctor working in the department of internal medicine within the Winnipeg Regional Health Authority. Personal health information relating to personal consultations from 322 patients was contained on the computer. Anecdotal stories of health information being misdirected or left available on open computers abound.

The Health Information Act has been in existence for 14 years. Although there have been amendments to the act and developments in the evolution of hardware and software, one theme has remained constant: custodians (including physicians) owe a duty to their patients to protect the patients’ diagnostic, treatment, care and registration information. That duty is found in section 60(1) of the Health Information Act, and essentially places an obligation on a custodian to take reasonable steps to maintain administrative, technical and physical safeguards that will protect the confidentiality of the health information, to protect against any reasonably anticipated threats or hazards to the security or integrity of the health information, or the unauthorized use, disclosure or modification of the health information.

In the November-December 2014 edition of Alberta Doctors’ Digest, the Health Law Update article quoted Justice T.W. Wakeling of the Alberta Court of Queen’s Bench, who said: “(o)penness is not the goal of the Health Information Act. The preservation of the privacy of an individual’s health information is one of the purposes of the Act.”

AMA - ALBERTA DOCTORS’ DIGEST

MCLENNAN ROSS LLP

And so this brings me to a discussion of the Information Sharing Framework (ISF) currently in place in Alberta Health and Covenant Health facilities in Alberta.

The ISF is a model of information sharing whereby physicians, Alberta Health Services (AHS), Covenant Health and affiliates of each, share patient health information relating to health services provided in ambulatory clinics for the benefit of patient care.

This framework was developed jointly by the Alberta Medical Association (AMA) and AHS, in conjunction and consultation with numerous stakeholders including the College of Physicians & Surgeons of Alberta (CPSA), Office of the Information and Privacy Commissioner, Canadian Medical Protective Association (CMPA), Alberta Health and the faculties of medicine.

It is critical for physicians to understand that the final responsibility for the protection of their patient’s information lies with them, as custodians.

The ISF is composed of a number of key agreements: an information sharing agreement dealing with the terms and conditions of sharing; an information management agreement which outlines how AHS, as information manager, physically stores and protects the information and discloses it in accordance with that agreement; and an information exchange protocol which lays out detailed and comprehensive rules regarding the gathering, storage, use and disclosure of health information.

There is a governance structure in place to oversee the day-to-day operations of the ISF. One of the primary purposes of these agreements is to address the duty found in section 60(1) of the Health Information Act – the duty to take reasonable steps to >

> maintain the confidentiality of health information and to protect against reasonably anticipated threats. By signing on to the ISF and agreeing to the terms of the conditions, physicians are demonstrating their understanding of this duty, and their intent to comply with the HIA and the means by which that compliance is to be achieved.

The problem is, a large number of physicians in Calgary and Edmonton are currently using the shared information systems and contributing information without having signed off on the ISF. This presents a number of difficulties.

Physicians who are utilizing the

electronic medical records system in Alberta Health Services ambulatory clinics without having signed off on the Information Sharing Framework documents are in breach of the Health Information Act and their own standards of practice.

First, the CPSA Standards of Practice require a physician sharing patient or health information with others, especially non-physicians, to have an information sharing agreement in place. Second, the Health Information Act requires custodians (i.e., physicians) who are disclosing health information to an information manager (in this case, AHS) to have an information management agreement in place.

Both of these agreements form part of the ISF. Physicians who are utilizing the electronic medical records system in AHS ambulatory clinics without having signed off on the ISF documents are in breach of the Health Information Act and their own Standards of Practice. Work is currently underway to educate physicians on the benefits of the ISF and the need to be accountable and responsible in terms of dealing with patient information.

The AMA, as a party to the ISF, is doing its best to ensure that physicians’ questions are answered and physicians are comfortable in entering into these agreements.

However, it is critical for physicians to understand that the final responsibility for the protection of their patient’s information lies with them, as custodians.

David B. MacNicol, Chartered Accountant* *David B. MacNicol Professional Corporation

Professional Care for your Professional Corporation Financial reporting, taxation and business advisory services 20 years public practice experience Experienced with medical professional corporations Corporate year-end �inancial reporting (Financial statement compilation and review engagements)

Corporate taxation Personal taxation

403 479 8049 | dbmacnicol@shaw.ca | www.dbmcpaca.ca JANUARY - FEBRUARY 2015

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FEATURE

Alberta Medical Association Board of Directors 2014-15

(

provided by Curtis Comeau Photography)

Seated, left to right: Dr. Robin Cox; Dr. Carl Nohr; Dr. Richard Johnston; Dr. Allan Garbutt; Dr. James Pope.

Standing, left to right: Paras Satija, MSA observer; Dr. Kathryn Andrusky; Dr. Jasneet Parmar; Dr. Neil Cooper; Dr. Paul Boucher; Michael Gormley, Executive Director; Dr. Ernst Schuster; Dr. Sarah Bates; Dr. Paul Parks; Dr. Christine Molnar.

Absent: Dr. Anshula Ambasta, PARA observer.

AMA - ALBERTA DOCTORS’ DIGEST

FEATURE

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Know someone outstanding? Speak up!

AMA seeks 2015 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.

In 2014, three physicians were recognized with Medals for Distinguished Service.

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.

• Dr. Donald E.N. Addington, Calgary

Nominations must be submitted by April 30. The awards will be presented at the AMA’s fall 2015 annual general meeting in Edmonton.

In 2014, one individual was recognized with the Medal of Honor.

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 at www.albertadoctors.org.

• Samuel Weiss, PhD, Calgary

• Dr. Steele C. Brewerton, Cardston • Dr. Thomas E. Feasby, Calgary

To read more about the 2014 honorees visit the AMA website at www.albertadoctors.org.

SHORT AND TWEET!

Get the latest AMA news in 140 letters or less Twitter is a great way to stay up to date on news like: • News, events and announcements.

• President’s Letter and other publications.

• Important information from other medical associations.

Find us at:

• Don’t have a Twitter account? Signing up for Twitter is fast, easy and free. Just go to twitter.com. You can open an account in under a minute.

We tweet new items almost every day. Join us!

twitter.com/albertadoctors JANUARY - FEBRUARY 2015

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MIND YOUR OWN BUSINESS

Need to manage change?

Focus on what makes people tick Practice Management Program Staff

C

hange in health care is constant and physicians are often called upon to lead change. New technology, integration of allied health professionals, panel management, new information privacy requirements and new clinical protocols are just a few of the many changes that physicians might face in their practice.

The term “change management” is frequently used, but not always well understood. Change management is often focused on the mechanics of change implementation; activities such as planning, communication or training.

However, without an understanding of the underlying psychology and human factors involved, the success of those change activities can be quite varied.

One model that is easy to remember and helpful to understand the people-side of change has been developed by Prosci Research. Their model is based on the experience of hundreds of organizations across multiple industries and is a respected model used by many Fortune 100 companies. In each of these organizations, they evaluated the factors that were present when a project or significant change was successful and when it failed. From this research they developed a model called ADKAR® that defines the stages of successful change and provides insights on how to lead people through the stages.

are aware of why the change is necessary and what the risks are of not changing. If people are going to apply effort to do things differently, they need compelling reasons for change.

Communication at this stage is less about the details of the change or how to change than on building awareness of the need to change. And unlike a toddler, it’s not sufficient to fall back on “Because I said so.” The change might be driven by a need to improve patient outcomes, to create more timely access, to comply with legislation, to create long-term financial sustainability or to reduce risk of legal action – to name a few.

A number of factors will impact the audience’s receptiveness at this awareness stage. These include: • Their own personal satisfaction or dissatisfaction with the status quo.

• The credibility of the messenger, including their past history and level of earned trust.

• Misinformation or rumors that may have preceded the communication.

• Validity of a direct causal link between the reasons given for change and the change itself.

Desire for the change to occur

Awareness of the change

Once people are aware of the need for change, they still need to find the personal motivation or desire to move to the next stage of change. You cannot assume because an individual is aware of the need for change that desire will automatically follow. This is largely because we are not solely logical beings and emotions, personalities, psychological barriers and biases are part of being human.

Lack of awareness was found to be the number one reason for failure. If you’ve spent any time with a toddler you will be familiar with their favorite question …

“Why?” Well, as adults we don’t really outgrow that.

The foundation of successful change is to ensure people

The key challenge at this stage for those leading change is that there is limited ability to create desire in another person. On the other hand, pushing ahead at this stage will almost certainly increase overt or covert resistance to the change. >

A – Awareness D – Desire K – Knowledge A – Ability R – Reinforcement

AMA - ALBERTA DOCTORS’ DIGEST

> There are numerous and complex factors impacting whether or how quickly an individual moves through this stage. The nature of the change, including the magnitude of the change, the certainty of the outcome, direct impact on the individual and perceived equity, all impact whether awareness is converted to a personal desire to change.

Environmental and personal factors will also impact desire, including: • The organizational culture and track record of unsuccessful past changes.

• The number or magnitude of changes in a short timeframe leading to change fatigue.

• The individual’s life situation including family relationships, age, health and stressors impacting their personal capacity for change.

• The individual’s personality and intrinsic motivation – what makes them tick?

Addressing the varied reasons that may hold people up at this stage requires understanding and tailoring your message to multiple audiences. The focus here is to identify “what’s in it for me?” and to help them overcome the barriers they may have.

This stage may take patience and time to work through.

It can be tempting to take a directive approach and push on with the change. However, this comes at the risk of damaged relationships and a far more costly, time-consuming process. It can result in either change that does not meet the desired outcomes or is not sustained in the long-term.

Knowledge of how to implement the change This stage is all about training and education. When people are in this stage they need detailed information on how to use the new process or tools and clarity about new roles and responsibilities. The time required to move through this stage is dependent on whether the concept is familiar or brand new, each individual’s capacity to learn and access to available resources to acquire the knowledge.

A common error in change management is to start with training and education regardless of where individuals are in the change process. There is an assumption that if we throw more knowledge at people they will eventually accept and adapt to the change. However, training is of limited value if your audience is still grappling with awareness and desire and is not ready to absorb the new information.

Ability to act on acquired knowledge At this stage, it is about translating facts and knowledge acquired in the previous stage into action. A person may have the desire to be a concert pianist and have the knowledge to read music, understand chords and scales and received excellent training – but still may not have the ability (finger dexterity, musicality, dedicated practice time, etc.) to be a concert pianist.

Whether a person has the ability to implement change successfully can be influenced by physical abilities, intellectual capacity, available time and resources, or even psychological barriers.

At this stage, the focus for change leaders is to enable people to acquire the ability through mentors, dedicated time, access to expertise or other supports. In some cases, there will be a need to bring in new resources with the requisite abilities.

Reinforcement of the change There is a natural tendency to slip back into the old way of doing things if steps are not taken to actively reinforce and sustain the change. Some of the tactics to sustain change include providing recognition of successes and effort, follow-up training, ongoing monitoring and evaluation and making adjustments to reap the benefits originally envisioned. For teams that employ PDSA methodology (plan, do, study and act), the study and act are effectively reinforcing change.

Key to application of the ADKAR® model is the recognition that the order is important. Desire can only be developed once there is awareness. Desire must come before knowledge of what to do and ability must follow knowledge so that it can be translated from information to application. Lastly, of course, reinforcement is only relevant once you have successfully implemented change.

Keeping these five stages of the ADKAR® model in mind can be helpful in communicating more effectively, understanding where and how to focus change management activities and, ultimately, implementing sustained change that yields the desired results.

The Practice Management Program is available to assist in a number of areas related to the effective management of your practice. For assistance, please contact Linda Ertman at linda.ertman@albertadoctors.org or phone 780.733.3632.

JANUARY - FEBRUARY 2015

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16

INSURANCE INSIGHTS

Update on improvements – TD Insurance Meloche Monnex Don Warden | SENIOR

MANAGER, TD INSURANCE MELOCHE MONNEX – EDMONTON

D

uring the Alberta Medical Association (AMA) Board of Directors' mid-term contract review of the TD Insurance Meloche Monnex home and automobile insurance program in the spring of 2014, we committed to a number of new processes and procedures that would enhance the level of customer service to AMA members and ensure that we were continuing to provide the high level of care and attention to AMA members that they have come to expect.

In an organization like TD with over 85,000 employees (and TD Insurance with over 4,000), it takes time to ensure that we have it right before we proceed with our clients – in this case AMA members. We thank the AMA and its members for their patience while we worked to make these changes. Following is an update to our promised changes: • We are pleased to announce that as of December 1, 2014, we have a new dedicated telephone line specifically for AMA members. The phone number is 1.844.859.6566 and will be answered: “Welcome to the TD Insurance Meloche Monnex Home and Auto Insurance Program for the Alberta Medical Association.” We encourage members to call this number for all claims, an inquiry about your home or auto insurance, a billing inquiry or any concern whatsoever. Additionally, all calls on this line will be automatically advanced to the front of the queue which should reduce call-wait times.

• A concern that arose during the mid-term contract review was the overall coverage provided to AMA members in the various packages we offer. The concern was that a number of AMA members had insufficient insurance, specifically those that had our basic, bronze, silver or gold level home insurance coverage. The review

AMA - ALBERTA DOCTORS’ DIGEST

suggested that AMA members should generally be covered under our platinum or platinum plus line of insurance to be completely covered. To address this, we put together a team to call all AMA members that do not have platinum or platinum-plus coverage (approximately 2,000), and this project was completed last December.

• The Claims Advice Line is scheduled for implementation in the first quarter of this year. This is a telephone line that AMA members can use to call-in and get advice on a claim without having any negative effect on their claims history. This sounds simple, but actually runs counter to how insurance companies operate, as actuaries know that clients that call-in (whether a claim is made or not) have a propensity to make additional claims. The actuarial department has used this in the past to calculate premium.

We would like to remind AMA members of our MyInsurance website at https://myinsurancesoc.td.com.

This is a website available for our clients that requires an initial registration (policy number required) after which you can log in at any time to access information on both your home and automobile insurance. You can print a temporary pink card, get a quote, view your policy or billing details, change your address, modify your auto coverage, modify or remove a driver or vehicle or ask general questions. Later this year we will be adding a claims component so you can communicate with your adjuster and track the claims process.

We will be adding additional features and services in the coming months. Please watch for updates in future editions of Alberta Doctors’ Digest and MD Scope.

If you are currently not insured with us, we invite you to contact us for a quote using the AMA dedicated telephone line at 1.844.859.6566 or you can obtain an online quote at melochemonnex.com/ama.

FEATURE

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Calling all applicants!

It’s time to check out the 2015 TD Insurance Meloche Monnex/AMA Scholarship

T

he Alberta Medical Association (AMA), in conjunction with TD Insurance Meloche Monnex, is very pleased and excited to announce that TD Insurance Meloche Monnex is providing $20,000 in scholarship funds for 2015. By committee selection, four deserving applicants will each be awarded $5,000 to put toward their additional training in clinical areas of recognized need in Alberta.

This amount has been increased from $5,000 per year to the new $20,000 level in recognition of the value that scholarship recipients bring.

Scholarship applicants must be: • Seeking additional training in a clinical area of recognized need in Alberta.

• An AMA member.

• Enrolled and accepted in a clinical program of at least three months duration in a recognized educational facility.

Scholarship recipients of the last three years: • 2014 Dr. Michael P. Chu, Edmonton (clinical research fellowship in mantle cell lymphoma, Stanford Cancer Center, California) • 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)

If that fits your situation, apply for the TD Insurance Meloche Monnex/ AMA Scholarship by March 31.

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 at www.albertadoctors.org.

JANUARY - FEBRUARY 2015

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FEATURE Emerging Leaders in Health Promotion Grant Program

The rewards of reading: A literacy campaign

T

he circle of life – at least, the circle of a healthy, economically stable and educated life – was the foundation of Darby Ewashina and Krystyna Ediger’s Emerging Leaders in Health Promotion Grant project: “The Rewards of Reading: A Literacy Campaign.”

Beginning in the fall of 2013, the two second-year, University of Calgary medical students and active members of the Student Run Clinic (SRC) – which operates out of the Inn From the Cold homeless shelter in downtown Calgary – introduced their literacy and educational project to children/youth (0-11 years) of SRC patients, who are also residents of the shelter.

With the reading and literacy project’s aim to have a positive effect upon the future health of children at the shelter, Darby and Krystyna strived to connect the dots between health, level of education, socio-economic status, prosperity and life-long learning.

“We know that health status improves with level of education and we recognized a problem in that many of the children at the shelter were often experiencing a disruption in their schooling,” explains Darby.

We know that health status improves with level of education and we

recognized a problem in that many of the children at the shelter were often experiencing a disruption in their schooling.

“We know too that education is closely tied to socio-economic status and that effective education for children and life-long learning for adults is key to health and prosperity,” she continues. “It’s about getting off on the right foot, getting equipped with the right tools and then it’s easier to maintain that positive momentum through life, via better employment, better income and ultimately, better health.”

The premise of the project was to engage with the child and youth SRC patients, while they were attending their clinic appointments. With the reading and clinic spaces housed in one, large room, the project leaders were able to model good reading behavior to the children and their parents/guardians. Efforts were also made to send the children home with books in order to encourage reading with their families, on their own time.

L to R: Second-year (fall 2013) University of Calgary medical students Krystyna Ediger and Darby Ewashina unwrap their new textbooks … nope! They display a few of the books provided for their Rewards of Reading health promotion program by FirstBook Canada’s National Book Grant program. ( provided by Darby Ewashina)

AMA - ALBERTA DOCTORS’ DIGEST

Equipped with books and educational materials acquired through FirstBook Canada’s National Book Grant Program, Darby and Krystyna set up a child care volunteer program with eight University of Calgary Health Sciences students. During their monthly, four-hour shift, the volunteer students would engage the children and youth through reading circles and arts and crafts, with an emphasis on literacy enhancement. >

> Under the guidance of project mentor Dr. Janette A. Hurley, head physician of the SRC and a family medicine practitioner in Calgary for 24 years, Darby and Krystyna trained and worked with the volunteers to establish the reading and craft activities while working with the SRC’s 20 clinicians and four executive members to set-up the program. Through these activities, Darby and Krystyna met the requirement of the Emerging Leaders in Health Promotion Grant Program to “facilitate growth of leadership and advocacy skills in a mentored environment.”

19

“Through the set-up of this whole program, we acted as educators both to our colleagues and to the children at the shelter,” says Krystyna. “We had to lead by example when it came to implementation of the reading circles and other educational projects. As well, we had to communicate effectively with all parties and were often looked to for advice and reassurance while the program was in its early stages.”

With the support and involvement of the SRC’s 20 student clinicians, executive members, three staff physicians and the volunteer Health Sciences students, Darby and Krystyna’s literacy campaign has effectively connected the SRC staff, its patients and their families, meeting the final requirement of the Emerging Leaders in Health Promotion Grant Program to “promote development of the physician’s role as advocate for healthy populations.”

Darby reads to the complete amusement of Rewards of Reading participants Carter (L) and Henry (C). ( provided by Darby Ewashina)

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DR. GADGET

Where’s my CPS? Wesley D. Jackson, MD, CCFP, FCFP

Y

esterday, I noticed a first-year medical student, who was working with me for the day, looking up a medication that we were considering prescribing in the 2012 version of the Compendium of Pharmaceuticals and Specialties (CPS). This book, produced by the Canadian Pharmacists Association (CPhA), was updated yearly and distributed free of charge to all Canadian physicians, allowing for quick access to key information on most pharmaceutical products available in Canada.

First published in 1960, the CPS contained manufacturer and CPhA monographs, product information and pictures, patient information, therapeutic guides, generic and brand name information, and other useful information.

The 2012 blue bound, soft-covered book measured 10 x 12 inches with over 3,000 pages and, as with previous versions distributed for more than 50 years, adorned shelves in most physician offices across the country. The physical size allowed for less chance of loss while providing other innovative uses such as posture improvement and core muscle development through various balancing exercises using the book’s bulk.

This year, the CPS did NOT arrive at my office. Instead, I received an email from the Canadian Medical Association (CMA) inviting me to download a new app free of charge to me through my membership, called RxTx Mobile. This app, available for iOS and Android devices, is CPhA’s mobile application providing offline access to all 3,000 plus pages of the CPS (Rx) as well as drug

AMA - ALBERTA DOCTORS’ DIGEST

choices (Tx), Health Canada Advisories, some medical calculators and other information the publishers felt might be useful to readers. Of particular use to many physicians is the relative cost feature, available for over 2,200 drugs, which was designed to illustrate the comparative costs of therapy for a given condition. The app, updated every two weeks, with a combined value of over $500, is available to all CMA members who are residents and practicing physicians.1

Information that previously was

available only on my shelf at the office, is now almost always with me in my pocket.

The design of RxTx Mobile on both my phone and my tablet is simple and very efficient, allowing me very quick access to monographs, and several therapeutic choices with a good search function for both generic and brand names. Drug choices are particularly helpful for searches such as the most recent treatment for bipolar disorder or the red eye. Through the Health Canada Advisories button, I was interested to learn, among other things, that multiple distributors were selling unlicensed home-use HIV test kits via amazon.ca. The calculators available through RxTx Mobile will not be particularly useful to most physicians and I was unable to locate pictures of medications to identify that “little blue pill.”

The app does contain drug interactions within the monographs, but unfortunately does not include an interaction checker – a tool that I find very useful.

There are other excellent alternative apps available to physicians. The National Physician Survey published in December 2014 suggested that one of the most popular apps in Canada is Epocrates. This app, produced in the United States of America (USA), includes a very well designed interface, a drug-drug interaction tool, medication pictures and several useful medical calculators – among other things. Unfortunately, the >

> interaction check lacks some important details and because it is USA-centric, the app does not include Canadian brand names or drugs available only in Canada.

This year, the Compendium of

Pharmaceuticals and Specialties did NOT arrive at my office. Instead, I received an email from the Canadian Medical Association inviting me to download a new app, free of charge to me through my membership.

Lexicomp, my preferred app in this category, is available to all Canadian physicians after logging on to the CMA website.2 This excellent resource provides drug monographs, an interactions database, laboratory tests, natural products and poisoning and toxicology

information. Lexicomp also includes Canadian drug names. Adverse reactions to medications are clear and often ranked in order of frequency. The current CMA subscription allows for web access only through your mobile device, but a very well-designed app is available for offline use at a cost. Many physicians may already have access to the Lexicomp app through university or primary care network affiliation.

These apps, and others not mentioned here, have greatly improved access to important medication information. Information that previously was available only on my shelf at the office, is now almost always with me in my pocket. No longer will I need to debate that Cialis really is indicated for benign prostatic hypertrophy at the office Christmas party or try to remember all of the side effects of the latest acne therapy at a family gathering. I must admit, however, that my posture and core strength are suffering.

References 1. https://www.cma.ca/En/Pages/cps-mobile-app.aspx.

2. https://www.cma.ca/en/Pages/drug-information.aspx.

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22

PFSP PERSPECTIVES Caring for yourself and your colleagues in the years ahead. How will you make it happen?

Vincent M. Hanlon, MD | ASSESSMENT

A

nother year has just ended. How did you do in 2014 getting through your pile of unread books (or unopened book files on your e-reader)? For me, two volumes in particular from my extensive collection of purchased and unread books encouraged me to think differently about my work as an assessment physician and educator with Physician and Family Support Program (PFSP).

One was The End of Absence – Reclaiming What We’ve Lost in a World of Constant Connection (2014) by Canadian journalist, Michael Harris.1 He explores in an even-handed fashion what it means to live a healthy digital life – who we are and how we behave in our virtual communities. He considers the loss of solitude and time by ourselves, in both our on and off-line lives. Harris suggests, “Ask yourself what might come from all those silences you’ve been filling up.” What is gained and what is lost when we shift away from face-to-face encounters, and invest more of our time and ourselves in web-based connections?

The other was the final book published by cultural critic, Jane Jacobs. In Dark Age Ahead2 she speculates about the future of community. That future may not be pretty.

“For communities to exist, people must encounter one another in person,” says Jacobs. The imperative to build community one personal encounter at a time seems anachronistic in the digital world described by Harris.

For her part, Jacobs outlines the contemporary decline of many supportive, stabilizing and life-enhancing elements of community.

How willing and able are we to be physicians for physicians?

Physicians are individual members of a professional collective. We are the creators and the products of this

AMA - ALBERTA DOCTORS’ DIGEST

PHYSICIAN, PFSP

professional culture. Medical culture is made up of multiple small and large communities, which we name group practices, academic departments, primary care networks, specialty teams and clinics. We live and work within this rich and imperfect culture, and we contribute, sometimes knowingly or sometimes unwittingly, to its salutary growth or toxic dysfunction.

The healthy functioning of a community can be demonstrated in the ways members look after each other. As physicians, how interested and available are we to care for colleagues? I remember physician health researcher and advocate, Dr. Jane B. Lemaire, speaking eloquently to a group of physicians a few years ago about the the nature of support. She differentiated the opportunities we have to support and be supported by colleagues emotionally, informationally and instrumentally.

To foster a healthy medical community, one thing we need to appreciate is the dynamic nature of our identities – most days we are physicians providing care, but there are some days when we morph into patients with our own health problems. An appreciation and acceptance of these complementary identities can facilitate healthier doctor-patient relationships – and specifically, healthy physician-for-physician patient relationships.

National Physician Survey (2014) demographic data With Jane Jacob’s insights on culture and community in mind, I reviewed some of the demographic data contained in the 2014 National Physician Survey.3 The average age of physicians in Canada is close to 50.

Half of male physicians and 30% of female physicians are over 55 (nearly 32,000 in total). Look ahead 15 or 20 years. Although the average age of physician retirement approaches 70 (Pong, 2011),4 we can anticipate large numbers of this 55 plus physician group reducing to part-time, reconfiguring or limiting their practices in other ways, before eventually retiring. >

> What do all those numbers mean?

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This demographic portrait of Canadian physicians suggests two things to me: 1. Numerous physicians have already witnessed the retirement or relocation of their family doctor. The frequency of such occurrences is likely to increase.

2. At the same time, many of these older physicians will be confronting serious illnesses, some for the first time in their lives.

Just like many of their fellow Canadians, physicians may wonder who will be there to look after them. Who will be there to organize our care in the way that we have organized the care of many patients, physicians and non-physicians alike? And how should we view these physicians-for-physicians initiatives? Some consider them a form of preferential treatment; others argue they are a legitimate benefit that arises from mutual concern for members of our physician community.

We can anticipate large numbers of the 55 plus physician group reducing to part-time, reconfiguring or limiting their practices in other ways, before eventually retiring. ( provided by Dr. Vincent M. Hanlon)

The healthy functioning of a

community can be demonstrated in the ways members look after each other.

One of PFSP’s key messages is our belief in the value of physicians caring for colleagues. PFSP maintains a dynamic network of family doctors and psychiatrists who support physicians, residents and medical students with physical and mental health problems. If you have an interest in providing care to members of our medical community and would like to join this network, please contact PFSP at pfsp@albertadoctors.org.

PFSP education sessions PFSP sponsored two education sessions this past autumn, one in Edmonton, the other in Calgary, as part of our P4P initiative: Physicians-for-Physicians.

PFSP assessment physicians, Dr. Lil J. Miedzinski and Dr. Elizabeth M. Monaghan, led these information and orientation sessions. The feedback received was mostly positive. First of all, the physicians valued and enjoyed the opportunity to have a facilitated conversation with peers about the rewards and challenges of looking after a colleague. Participants welcomed the opportunity to discuss setting boundaries, and reviewing generic case studies, especially those with complex care issues.

If you don't have a family doctor, don't delay searching for one and arranging a first appointment. ( provided by Dr. Vincent M. Hanlon)

Family physician, Dr. Margaret Anne T. Churcher, attended the Calgary session and shared with the group her approach in the office to welcoming a physician as a new patient, including clarification of doctor/patient roles and responsibilities.

This year PFSP is sponsoring two other topics related to physicians caring for peers. This past January, Dr. William A. McCay, an Edmonton psychiatrist, spoke to a group of anesthesiologists about caring for colleagues with mental health problems. This session is the result of collaboration between PFSP and Dr. Teresa E.C. Eliasson, a member of the department of anesthesiology and pain medicine at the University of Alberta. Dr. Eliasson coordinates the office of staff wellbeing within her department.

In February, Dr. Jeremy R. Beach occupational health specialist, will speak about the aging physician in the workplace at our PFSP team meeting, and again for family doctors attending the Alberta College of Family Physician’s 60th Annual Scientific Assembly, February 26-28 in Banff. >

JANUARY - FEBRUARY 2015

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> It’s not too late to make a resolution or two If we value our own health and the good health of our colleagues, how shall we best promote and maintain that?

1. If you don’t have a family doctor, don’t delay searching for one and arranging a first appointment.

2. If your family doctor is planning to retire soon, discuss with them about finding a replacement to take over your care. (And don’t forget to thank your doctor for their good care before you see him or her for the last time.)

References 1. Harris M. The End of Absence – Reclaiming What We’ve Lost in a World of Constant Connection. He explores in an even-handed fashion. Toronto: HarperCollins, 2014.

2. Jacobs J. Dark Age Ahead. New York: Vintage, 2004.

3. http://nationalphysiciansurvey.ca/.

4. Pong RW, PhD. Putting Away the Stethoscope for Good?

Toward a New Perspective on Physician Retirement. Ottawa ON: Canadian Institute for Health Information, 2011.

3. In your search, don’t overlook younger colleagues who have a good chance of still being in practice in your later years.

4. Consider joining PFSP’s network of family doctors and psychiatrists who look after colleagues. Contact us at pfsp@albertadoctors.org.

Jane Jacobs gets the last word: “For communities to exist, people must encounter one another in person.”

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FEATURE

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What's new on the web?

W

ebsites are never finished. They only improve … or decompose! With that in mind, the Alberta Medical Association (AMA) is tirelessly working to create new features while refining existing aspects of our website for our members. Here are some highlights from the past few months: • Intra-sectional Relative Value (INRV) lookup tool: The INRV lookup tool helps physicians understand how their pay rates are set and valued by each specialty area. The tool allows users to quickly and easily look up fee codes by activity description or code to receive information on fee-code owners, current rates and relative value rates.

You can find it in the member services > compensation section, or by following this link: www.albertadoctors. org/services/physicians/compensation-billing/ allocation/inrv-lookup.

• Online Membership Guide: In previous years, we have printed and mailed out paper copies of our membership guide. To ensure it is always up-to-date and readily available, we have put the entire guide online. You can get to it from the member services page, or by visiting www.albertadoctors.org/membership-guide.

• 2014-15 Business Plan: What does the AMA want to achieve this year? How will we go about it? Find this year’s business plan online under the Leaders > Governance section.

• Improved login help: Logging in to a website can be a pain. What’s my username again? Which password did I use? To improve members’ experiences, we have identified a number of common problems and improved our login processes and help section to make logging in less of a headache.

That’s just the start. We plan on continuing to improve and hope to see you along for the journey at www.albertadoctors.org.

Have something you like/dislike about our website, a feature request or something you’d like us to focus on? You can always let us know at webmaster@albertadoctors.org – we want to hear from you.

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FEATURE

Thinking differently:

Can physicians and patients learn?

Dr. Aravind Ganesh | NEUROLOGY

RESIDENT PHYSICIAN

T

he Alberta Medical Association (AMA) has a System-Wide Efficiencies and Savings Consultation Agreement with Alberta government.

One of the most significant activities under this agreement is an Alberta-based implementation of Choosing Wisely Canada.

Choosing Wisely is an initiative that began in the United States of America (USA) and has been imported and adapted to the Canadian health care system. Through education and awareness, we seek to encourage informed conversations between physicians and patients about tests and services for which evidence of benefit is weak and that may actually cause harm. When we get talking, we can change behavior. Patients will receive better care, their satisfaction will increase and the system’s resources will also be used most appropriately.

Can physicians and patients learn to work differently together? We think so.

Alberta Doctors’ Digest (ADD) will bring your more information about Choosing Wisely in Alberta in the year ahead. You will receive communication in other ways, too.

With this issue of ADD, we are pleased to bring you an article “The Problem of Reflexive Testing and Procedures” by Calgary-based neurology resident physician Dr. Aravind Ganesh. Your comments and questions are welcome!

Email choosingwisely@albertadoctors.org.

Restoring sense to medicine – How can doctors and patients “Choose Wisely”?

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and thereby make smart and effective choices to ensure high-quality care.

AMA - ALBERTA DOCTORS’ DIGEST

The problem of reflexive testing and procedures “Don’t just do something, stand there!”

No, I didn’t get that wrong. One of my instructors in medical school (who really was a master at turns of phrase) would use this inverted comment to gently chastise us for putting our patients through unnecessary tests or interventions: Before blindly ordering a lab or imaging test or reflexively performing a procedure, stop and think for a moment – consider the patient’s full situation and the implications of what you are about to order. Does it actually make sense in the context of what the patient’s diagnosis is likely to be? Will the test actually help you confirm the diagnosis or decide on a treatment? Will the treatment or intervention actually help improve the patient’s outcome? Don’t just do something. Stand there.

While that may sound really straightforward, in the modern reality of clinical practice, with its frenetic pace and insatiable demands, physicians often find themselves ordering tests and interventions based on impulse rather than evidence. When faced with an intimidating patient load and the associated pile of paperwork, it’s certainly easier to fall back on a routine “habit” of doing a certain set of things when you see a certain type of patient, even if there is zero evidence to support that type of approach (I’m guilty of this myself). For example, it’s common to find physicians who will order a CT scan of the head pretty much every time they see a patient with a headache or a MRI scan of the back whenever they see someone with back pain.

Some of you might be wondering – so what if my doctor orders some things habitually? Sure it may not be intellectually elegant, but no harm done, right? And in our litigious environment where a physician is more likely to be sued for not doing something, doesn’t this practice make sense? After all, when did you hear about a doctor being sued for ordering a brain scan? Few doctors would be surprised, on the other hand, if a patient came in demanding a brain scan for their headaches or a lumbar scan for their back pain. >

> This raises an important myth in modern medicine that dupes physicians, patients and health care systems – that more testing/interventions equals better care. But this couldn’t be further from the truth. The reality is that we physicians are responsible for wasting over $200 billion annually in North America alone on unnecessary testing and interventions, but our patients end up receiving only about 55% of the recommended care as set out by the most basic best-practice guidelines.

This trend for unnecessary testing also influences how physicians interact with their patients – for instance, the bedside assessment, which was the most important part of the patient appointment in the past (and a type of communion between patients and physicians), has been taking more of a backseat in recent years. This is a concerning trend because tests can only take us so far in the diagnostic process – if we aren’t guided by a clear framework of what the patient’s condition could be, based on speaking to them and examining them.

Furthermore, tests and interventions carry their own risks. Consider the concern about long-term cancer risks with the accumulated radiation from unnecessary CT scans, for example, or the risk of heart attacks, other blood clots or pneumonia associated with surgical procedures. Unless the benefits of performing these tests or interventions outweigh the risks, it does not make sense for physicians to order them or for patients to demand them.

The Choosing Wisely Canada campaign I recently met up with Michael A. Gormley, Executive Director of the Alberta Medical Association (AMA) and Dr. William S. Hnydyk, Assistant Executive Director of Professional Affairs, in Edmonton to chat about the Choosing Wisely Canada initiative, which has arisen in response to these concerns about waste and impaired diagnostic reasoning.

The Choosing Wisely campaign began in the USA in 2012, when various specialty societies joined the American Board of Internal Medicine Foundation and Consumer Reports with the aim of helping physicians and patients make smarter choices about tests, treatments and procedures in order to ensure higher quality of care. As part of this campaign, each society developed a list of five tests or procedures that are commonly used inappropriately in that specialty. Now, this same campaign has come to Canada, headed by Dr. Wendy Levinson, chair of the Department of Medicine at the University of Toronto. The campaign is supported by various medical societies across Canada, including the AMA who are championing the initiative in Alberta.

In reviewing the top five lists made by different specialist societies in North America, it’s interesting to note that the majority of them directly relate to diagnostic imaging.

One frequently mentioned point is the problem I mentioned earlier about imaging patients with headaches

who do not have any clear risk factors for structural problems or patients with back pain who do not have any ‘red flags’ for dangerous causes. These were at the top of the list of concerns for both the American College of Radiology and the Canadian Association of Radiologists.

By disseminating this type of information to both patients and doctors, the CWC campaign hopes to facilitate more sensible conversations between Canadians and their physicians about tests and procedures.

Don’t just do something, stand there. Thanks to the Choosing Wisely initiative, it looks like more physicians will be paying attention to that message.

Dr. Aravind Ganesh is a neurology resident-physician and co-founder of the Calgary-based mHealth venture SnapDx. He is also a clinical researcher, public health advocate and a Rhodes scholar, currently working with the University of Oxford’s Centre for Prevention of Stroke and Dementia.

What’s Up Doc? is a biweekly column covering the most interesting doctors and health researchers in Calgary and in our wider global community. If you are working on something that is changing health care, we’d like to hear about it. Send us a tweet at @snap_dx or email aravind@snapdx.co.

Need confidential advice dealing with patient advocacy or intimidation in the workplace? Call the Zone Medical Staff Association (ZMSA) operated

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The PAAL service has been transferred out of Alberta Health Services and is now operated at arm’s length by ZMSAs.

For more information visit albertadoctors.org/paal

JANUARY - FEBRUARY 2015

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FEATURE

Diagnosing schizophrenia:

What can we learn from a historical perspective?

Sarah Erem | STUDENT,

UNIVERSITY OF CALGARY (PRECEPTOR: PROFESSOR DR. FRANK W. STAHNISCH, FACULTY OF MEDICINE, UNIVERSITY OF CALGARY)

Each fall the Alberta Medical Association Representative Forum/annual general meeting features the Dr. Margaret Hutton Lecture Series. Medical students present on various interesting aspects of medical history. To share their excellent research and conclusions, we are carrying the highlights of the lectures in Alberta Doctors’ Digest.

This issue features guest author, Ms Sarah Erem of the University of Calgary.

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cross the range of psychiatric disorders, schizophrenia can be considered both strange and challenging, because of a variety of powerful physiological symptoms and the social stigma attached to it. This mental disorder is poorly portrayed and misunderstood, from the past to the present.

This mental disorder is poorly

portrayed and misunderstood, from the past to the present.

Thomas Szasz (1920-2012), famous psychiatrist, University of Cincinnati, called schizophrenia “the sacred symbol of psychiatry” of the 21st century.1 It is a complex condition that is characterized by heterogeneity in symptomatology. The differences in symptoms, family and personal background, make it extremely difficult to trace the historical origins of the mysterious disorder. It is often suggested that “schizophrenia-like” illnesses had existed in similar ways in the past since “madness” and “lunacy” have been documented in medicine and written annals from the beginning of high civilizations onwards.

The ancient Egyptian2 and Greek texts, the Bible as well as non-Western sources are filled with many examples of irrational and bizarre behaviors.3

AMA - ALBERTA DOCTORS’ DIGEST

However, the medical descriptions of “madness” before the 1800s suggest that conditions occurred throughout a person’s life rather than primarily in young people.4 Additionally, auditory hallucinations that occur in 75% of current patients are extremely rare in cases of “insanity” prior to the 1700s.5 Finally, the first recognizable medical record of schizophrenia did not appear in Europe until the early 1800s.6

Dr. Emil Kraepelin and his dichotomy Dr. Emil Kraepelin (1856-1926) was a leading German medical doctor who had a variety of research interests in psychiatry, pharmacology, genetics and neurology.

His work had a major impact on modern psychiatry and its understanding of mental illness based on natural scientific concepts and experimental observation.7 After obtaining his medical degree in 1881 from the University of Leipzig, he pursued his interests in experimental psychology in the laboratory of Wilhelm Wundt (1832-1920). In 1882, he then worked in the research lab of Wilhelm Heinrich Erb (1840-1921) in Heidelberg, Germany who helped him to shape his neurological understanding of pathology and define his own scientific method for experimentation, which he later applied in his first Psychiatric Classification8 (“Compendium der Psychiatrie”) to differentiation of the concept of endogenous psychosis.9 This, in his opinion, was caused by internal biological conditions, such as organic brain damage, metabolic dysfunctions or hereditary factors, and was regarded as incurable by contemporary psychiatrists and alienists.10 Kraepelin therefore offered to differentiate between “manic depression insanity” (currently: major manic depression – following DSM-V)11 and “dementia praecox” (“schizophrenia”– following DSM-V),12 which he considered to be forms of an inherited neurodegenerative disorder. In contrast, he described manic depression as an episodic disorder, which does not lead to permanently impaired brain function.13 His ample clinical observations at the psychiatric clinic of the University Hospital in Munich led Kraepelin to the >

> hypothesis that specific combinations of symptoms in relation to the course of psychiatric illnesses allow one to identify a particular mental disorder.14 One of the most problematic issues about Kraepelin is his generalization of psychiatric finding specifically to political and ethnical contexts. In addition to that, he has not been known as the most empathetic of doctors, which was not really unusual. The patients in 19th century were rather seen as “study material” for the medical researchers, who valued their clinical observations and lacked in communication with their subjects.15 In the later period of his career, as a convinced champion of social Darwinism, he actively promoted a policy and research agenda in racial hygiene and eugenics, consequently, his influence in the medical field declined largely due to his political view. After this, the diagnosis of psychiatric disorders fell into the hands of psychoanalysts established earlier by the Vienna neurologist and psychiatrist Dr. Sigmund Freud (1856-1939)16 and eventually made its way into the classifications of DSM I and II.17

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"The patient sees figures, spirits, the corpses of their relatives; something is falsely represented to him, all sorts of devil's work, the patient hears abusive language and threats." ( provided by Manic-depressive insanity and paranoia, 1921, p. 22)

Eugen Bleuler and birth of “schizophrenia” In 1908, Eugen Bleuler (1857-1939) at the lecture of German Psychiatric Association (“Deutsche Gesellschaft für Psychiatrie”) in Berlin took “the liberty of employing the word schizophrenia for revising the Kreaepelin’s concept.” In his opinion, breaking up or splitting of psychic functioning was an excellent symptom of the whole group.18 Compared to Kreapelin, Bleuler saw a great value in listening to the patients. While accommodating himself in their environment, he realized that the condition wasn’t a single disease (he referred to a “whole group”) and didn’t always progress to full dementia, nor did it always occur in young people.19 Consequently in his book Dementia Praecox or the Group of Schizophrenias 1911, he divided symptoms into two broad categories: fundamental and accessory. Bleuler believed that fundamental were occurring in schizophrenia only and therefore were pathognomonic. The accessory symptoms, on the other hand, could occur in a variety of different disorders. The second way of description was primary (directly due to an assumed organic deficit) or secondary (developing as a result of the primary disturbance – this included delusions and hallucinations).20

DSM III and revival of Kraepelin’s classification In the 1970s, the medical community began to recognize discrepancies in diagnostics between the USA, which still relied on broad psychoanalytical diagnostics, and the European classification using Kraepelinian “firmly medical.”21 Consequently, the new findings resulted in the revival of the Kraepelin dichotomy as strictly medical in a new DSM III edition in 1980.22 It also did not emphasize cognitive decline and included family studies and

"The group of patients reproduces the expression of mania mood in varied coloring from quiet, cheerfulness and proud self-consciousness to unrestrained cheerfulness." ( provided by Manic-depressive insanity and paranoia, 1921, p. 22)

prevalence rates. With these minor modifications, Kraepelin’s nosology remained fundamentally unchanged and is still used in the current version of DSM V.23 Despite the speculations and criticism, Kraepelin’s dichotomy has survived for so long for three major reasons: lack of laboratory tests based on the neuropathology of the illnesses, lack of robust scientific data and the complexity of forming a new classification system.24 The reason Kraepelin’s ideas have remained influential even in this century is because it is a simple concept which allows psychiatrists to feel confident, despite a complex clinical picture, to arrive at a clear diagnosis, which Kraepelin himself doubted on several occasions: “No experienced diagnostician will deny that there is an alarmingly large number of cases in which, despite the most careful observation, it seems impossible to arrive at a reliable diagnosis.”25 References available upon request.

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FEATURE

Want to participate in clinical research?

Here are some steps to success

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Alberta (i.e., the Health Research Ethics Board of Alberta, or the Health Research Ethics Board at the University of Alberta, or the Conjoint Health Research Ethics Board at the University of Calgary), and must comply with the requirements of the board.

Consent to participate in a study should preferably be obtained in writing. Specific issues related to participation in the research study should be discussed with the research subject or substitute decision-maker and documented in the medical record.

Confidentiality

Legal and ethical framework

The CPSA also has a Standard of Practice on Relationships with Industry, aimed at ensuring physicians avoid potential conflicts of interest and that they maintain their professional autonomy. The standard stipulates, for example, that physicians are to disclose any relationships with industry, they should participate only in ethical and scientifically valid industry-sponsored research, and they should not accept gifts from industry. To further reduce the possibility of conflicts of interest, physicians should review the research protocol carefully to ensure it does not compromise their professional autonomy.

lberta is home to world-class medical research and the physicians who participate in research studies should be aware of their legal, ethical, and professional responsibilities and obligations. Many of these obligations are described in a recent article by the Canadian Medical Protective Association (CMPA), which is available on the association’s website. The regulatory framework in Alberta and the guidance provided by the College of Physicians & Surgeons of Alberta (CPSA) serve to protect the interests of both researchers and research subjects and may be cited in legal actions and regulatory authority (college) complaints related to a research study.

The Canadian Medical Association’s (CMA’s) Code of Ethics provides the ethical framework under which Alberta physicians practice, and it states, “Consider first the well-being of the patient.” This ethical principle applies equally when the patient is involved in a research study.

Other sources of legal obligation include the regulations under the federal Food and Drugs Act, which outlines requirements applicable to all clinical trials involving human subjects in Canada. In addition, the CPSA’s Administration of Practice states that physicians must have their research proposals reviewed and approved by one of the applicable research ethics boards operating in the province of

AMA - ALBERTA DOCTORS’ DIGEST

Consent Research subjects must consent to participating in or receiving treatment considered experimental or part of a research study. Courts have held that the standard of disclosure for consent to participate in research is generally higher than for other medical treatment.

While the information to be disclosed varies based on each study, the CMA Code of Ethics generally requires that, at a minimum, the potential subject be informed “about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of the physician’s participation including any compensation.”

Physician researchers generally owe a duty of confidentiality to research subjects. Alberta’s Health Information Act and regulations establish the rules that must be followed for the collection, use, disclosure and protection of health information in the province. Before identifiable personal health information may be disclosed, the research proposal must have been assessed by a research ethics board, the researcher must agree to comply with conditions stipulated in the Health Information Act, and the researcher must enter into an agreement with the information custodian. More information about researcher obligations concerning confidentiality can be found in the Health Information Act, Guidelines and Practices Manual.

Clinical trial agreements Many of the issues identified here may be addressed in a clinical trial agreement between the study sponsor and participating physicians.

Physicians asked to sign a clinical trial agreement should carefully review its terms to ensure it does not conflict with their legal and professional obligations.

CMPA members are always welcome to contact the CMPA with any medico-legal questions pertaining to their participation in research.

RESIDENTS’ PAGE

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Remove those 3-D glasses; our health is 4-D Dr. Rithesh Ram | FAMILY

MEDICINE RESIDENT PHYSICIAN

I

have been fortunate in my educational career for numerous reasons, including being provided with opportunities to attend meetings, forums, symposiums and conferences.

Beyond the personal development and growth that is an inevitable bonus of being in attendance, once in a while I’ve been invited to something that truly allows a glimpse into the inner sanctum of our health care system.

I attended one such gathering not too long ago in Banff.

health, individual, system and time. Each is made up of its own complexities. For example, health encompasses all aspects that maintain or affect health, and the system includes all aspects that maintain, destroy or improve our system of health. The individual is the one with expectations that time often cannot meet.

At this particular symposium, Chatham House Rules were in effect; therefore, I am free to disseminate information, but without any identities attached. I had never been involved in a symposium under this particular rule, so it was a new experience I looked forward to. The topics included leadership in health care, innovation and patient engagement with potential challenges and improvements a part of each session.

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.

Now a reasonable question to ask: What does this have to do with resident physician involvement and/or engagement in the community?

From the choice of speakers, to the range of attendees, to the conglomeration of sessions, it became apparent that leadership – with regards to the health of our population – is four-dimensional. Consider what the four elements are:

Dr. Rithesh Ram and family believe that keeping Albertans healthy cannot stop at the doors of our medical centers. ( provided by Dr. Rithesh Ram)

At many points within this 4-D analogy, all of the elements could seemingly come together; yet they rarely do. The individual wants faster access that the system does not allow or deem appropriate. The system wants to implement measures that improve preventative health, but the individual is challenged to comply. Health and time will often be in disagreement, with time usually coming out the victor.

Given the inability of these elements to naturally come together, leadership is required to build what would be a statistically significant rapport. Not perfect, but with a margin of error acceptable in almost all aspects of health research. >

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> That is where PARAdime, in its sixth year, enters the battle.

The PARAdime campaign is a resident physician-driven initiative to collect backpacks filled with everyday necessities for various shelters throughout the province.

As one of my colleagues stated in the past, it 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.”

Indeed.

The PARAdime campaign is a resident

physician-driven initiative to collect backpacks filled with everyday necessities for various shelters throughout the province.

And as medical professionals, we have a responsibility to promote health on an individual and communal level within and beyond the system itself.

Initiatives like PARAdime emphasize the connection between health, individual and system. It is timely, as it occurs during the winter season when concerns regarding the health of Albertans are heightened. It also serves as a reminder of how as physicians we can advocate for patient health outside of typical medical venues.

PARAdime reminds me that successful advocacy stems from knowledge of not only how the individual experiences the system, but how the system frames individual experience. Without being engaged beyond our silos of residency, medical schools, operating rooms or clinics; without being informed beyond traditional media, social media, high impact journals or coffee line gossip; without being reflective beyond our best/worst patient encounters, or our best attempt at mindfulness, we will never have any hope of carrying the 4-D health of our population forward into the next century. Hence attending meetings, conferences and symposiums are essential to building professional awareness of the policies that could help or hinder our ability to advocate for patient health and wellness.

As physicians, we are automatically connected to three elements: health, individual and system. The challenge is to invest the time to improve the relationships that already exist.

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Fighting the slings and arrows of outrageous fortune Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

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ah … we’ve all enjoyed the cheap thrill of hearing juicy gossip, eh? But it’s not such fun when you’re on the receiving end.

Back in snowy September 2014, a Hollywood-North newspaper, let’s call it the Hogtown Star, published a shock/horror headline article on the misbehavior of clinical investigators in Canada (myself among them) – at least in the eyes of the US Food and Drug Administration (FDA) and the Hogtown Star.

“Drug Testing Rules Broken by Canadian Researchers,” screamed the headline – with the breathless first sentence: “Top Canadian doctors running clinical trials have risked patient safety, failed to report serious side-effects suffered by their human test subjects and botched the scientific research of the drugs.”

Well, that covers pretty much everything and we may as well go home and hang up the snowshoes. The evidence?

FDA site reviews.

As politicians say when they’re going to obfuscate, “Let me be clear….” Newspapers have every right to investigate whatever they want. I will defend this right to the last lunchtime cocktail. But surely they should also offer a platform for explanations.

The article (by a young investigative reporter) was based on FDA site reviews over the last 26 years on clinical trials of medications being considered for approval in the United States of America (USA) and performed in Canada in the last 31 years. These reviews and associated correspondence are now in the public domain for anyone with the interest and perseverance to read some really boring stuff. The FDA site reviews (as they are meant to) found many errors, inconsistencies and practices that, in a many instances, were not up to current standards.

As a piece of investigative reporting, it was fair enough to bring these less-than-stellar reviews to public attention,

although it should have been noted that FDA reviews of American clinical research are just as scathing. But where the Hogtown Star let Canadians down – and where many of these investigative pieces foment discord – was the newspaper avoiding looking at all sides of the story and their disinterest in giving a platform to us bunglers and botchers to explain ourselves. You’d almost think they were publishing a duff story just to sell their newspaper.

Most depressing of all was the rush of tweets applauding the article: “Thank God for the FDA,” or “Another example of the lack of ethics, morality and professionalism of doctors in this country.…”

They all rushed to judgment. Not one mentioned the possibility that there might be reasonable explanations or extenuating circumstances, and that the FDA is not the great savior of the people and that Health Canada might not be an incompetent body of lazy prats.

The article was a missed opportunity, and at worst, mischievous. It did nothing to promote the needs of patients or research. It may have scared some patients from entering clinical trials. And weirdly, it enhanced the reputation of the FDA.

Newspapers have every right to

investigate whatever they want. I will defend this right to the last lunchtime cocktail. But surely they should also offer a platform for explanations.

I admire many aspects of the USA but these do not include Hershey's chocolate, Twinkies, the Central Intelligence Agency, Jerry Springer or the FDA – which is a huge bureaucracy employing over 14,600 full-timers.

(Health Canada has 2,400 full-timers for the same work volume.) The FDA’s job has evolved into demanding unnecessary tests (especially too frequent X-rays), >

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> conducting intrusive investigations with demands for irrelevant clinical data and finger-wagging lectures from people that have never run a clinical study themselves.

Clinical trials are difficult to do, from idea inception through to agreement from colleagues, funding, ethical issues, privacy considerations, starting-up, accruing with patient informed consent, monitoring, data collecting, analysis and write-up. It’s much easier not to do them.

I’ve found pretty much everything in life was encountered at school by age 12. An FDA review is like the “bad report card problem” from teachers that don’t really like you much. We’ve all had that and one’s first reaction is to try to figure out ways of avoiding the parental review. This never works. Lord Northcliffe, the 19th century editor of the Daily Mail (or perhaps it was W.R. Hearst) said: “News is something somebody wants suppressed. All the rest is advertising.”

So suppression (or hiding behind legal advice to say nothing) is not going to work unless you’re guilty. The next and best approach is to sigh, hand the report card to the parent and try to explain the circumstances.

A major job of the FDA is to discover fraud (of which there is a fair amount in the USA; much less so in Canada). They are trained detectives and do their jobs thoroughly. Among the many hundreds of thousands of observations, they find errors (in the American way, excessively called “violations”). People who understand medical practice, they are not.

Where the Hogtown Star let

Canadians down – and where many of these investigative pieces foment discord – was the newspaper avoiding looking at all sides of the story and their disinterest in giving a platform to us bunglers and botchers to explain ourselves. You’d almost think they were publishing a duff story just to sell their newspaper.

Consent was verbal until around 1986. It was a messy trial to do – the surgeons seeming to know the answer without doing the trial (oophorectomy was OBVIOUSLY better than tamoxifen) so accrual was slow.

This trial resulted in tamoxifen being approved for use in pre-menopausal women with recurrent breast cancer. This has extended many lives with usually a good life quality.

Enter, Mr. Carp (not his real name, but similar), the FDA reviewer, on a wet Monday morning in 1988 in Edmonton. Mr. Carp came in with fedora and trench coat, lapels drawn up like Dick Tracy and flashed his badge. I put out my hand to shake his and he drew away like I had ebola. I then asked if he wanted to go for lunch during the week. He refused with a look as if I’d offered a bribe.

“I’ll see you at the end of the week, dah-cter,” he said.

Friday arrived. I was summoned. He sat with a pile of charts on the opposite side of the table.

“D’ja want the bad noos or the good noos, dah-cter…”

“Er, I’ll take the good news.”

“The good noos is that as far as I can tell, every patient on this trial actually existed.”

“That’s the good news?” I said.

I then spent the next two hours explaining why Mrs. Jones did not have her chest X-ray when she was meant to because she visited her sister in California; why the dose of tamoxifen was doubled or halved seemingly on a whim (our protocol didn’t go into details like that); why in the chart I had dictated that the patient was stable and yet the radiologist had reported that the sclerotic bone disease was progressing (the assessment of bone disease in breast and prostate cancer remains hard with frequent disagreements between radiologist and clinician). And so on. One or two discrepancies were serious, most were minor. Remember, clinical trial assistants were non-existent in those days. Protocols were simple and brief.

Mr. Carp then berated me for a lack of written consent forms for half the patients.

“But we only introduced written consents in 1986,” I said.

In our case, the trial that the Hollywood-North rag was interested in was one we did with a Toronto colleague starting in 1983. It was a trial in metastatic breast cancer, randomizing patients between oophorectomy and tamoxifen with cross-over on disease progression.

In 1983 (before Nelson Mandela was put in jail, and likely before my Hogtown Star interrogator was born) clinical research was a bit of a novelty. Trial protocols were perhaps five pages long, in contrast to the 150-plus pages nowadays anticipating every conceivable scenario.

AMA - ALBERTA DOCTORS’ DIGEST

“I wanna see written consents, dah-cter.”

It was the “past practice should be like the present” fallacy, the silly notion that because practice has evolved, you were responsible for the past and, using a crystal ball, should have behaved like it was the present. It’s the same fallacy the Hogtown Star article fell into – judging trials, not in the context of the times but by current standards. It’s as daft as the handwringing that goes on when talking today, in a time of peace, security and friendship, about Japanese internment camps in Canada >

> and the USA during the war like it’s our fault. Both sides had them (the camps in Japan were much worse than ours). In the context of war, thinking changes, dude.

Thousands of observations with multiple interactions occur in a clinical trial. There are going to be mistakes and errors. This never happens in journalism.

So the article appeared, reputations were shaken.

Letters from physicians and patients explaining the circumstances were sent. None were published. They were onto Rob Ford’s sarcoma.

This increasingly dismal world has become more black and white. When something is controversial, there are only two sides – a right side and a wrong side. Twitter feeds amplify half-baked opinions.

One of the disappointments for me was the lack of support from Alberta Health Services (AHS) “public relations” staff. Not one contacted me to help.

Oh, there had been a flurry of emails from people rushing to the scene, largely to ensure that there was not going to be negative publicity. The “media relations” and legal people in AHS said: “Don’t talk.” This was bad advice.

These folks are paid by administration and are there to protect administrators and “the system.” “Media relations” issued a statement saying that current clinical trials were now run properly without flaws, completely ignoring the fact that today’s practices are a result of actions taken following the kinds of review that the Hogtown Star was pouring scorn on.

They are not there to protect YOU, dude. Thinking they are is like those reckless physicians who decline Canadian Medical Protective Association (CMPA) insurance, fondly imagining the hospital insurance will back them up. To be fair, the Sunnybrook Hospital media people did not give this kind of advice. They actually helped a colleague in distress and emphasized the benefit of facing accusers head on when you have a good case.

As a veteran of the 1993 breast cancer pseudo-scandal when the Chicago Tribune headlines screamed “Breast Cancer Fraud” on a quiet Sunday, I knew the best approach was to stand up and make it clear what actually happened. The way the Chicago Tribune article was written made it look like the actual results of National Surgical Adjuvant Breast and Bowel Project (NSABP) trials, a leading breast cancer trials group in the USA (including the critical breast conservation study B-06), were fraudulent. In this notorious case, what happened was that a surgeon in Montreal had circumvented the patient inclusion criteria of some clinical trials by including patients who didn’t fit the criteria (such as starting their chemotherapy a day or so later than in the protocol). He was into being the top accruer. There was no fudging of any end-results and his actions would have no conceivable biological effect on the results. When this scandal broke, the truth was lost in the accusations flying around.

I called a meeting of all the patients on these early studies and explained what happened. “Is that all?” was the general response. These patients were wiser than the bureaucracy of the National Cancer Institute headed by Dr. Sam Broder (where is he now?) who used the pseudo-scandal to fire Bernard Fisher, Director of the NSABP, a surgeon who did more for breast cancer patients than anyone. Since I have had more FDA reviews than most in Canada, and although I would have liked to have kept my head down, I knew I was going to be targeted.

He was a polite young man with a Scottish surname (though I failed to negotiate much sympathy) and I spent over an hour on the phone with him, hoping to educate him on the history of clinical trials in western medicine.

I’ve done a lot of clinical trials, some good, some not so good. The first trial I participated in was at the Royal Marsden Hospital, London, England in 1973 – a trial in myeloma patients. Professor Tim McElwain thought that high dose IV melphalan with prednisone might be a useful treatment. (He was correct.) The protocol was a hand-written page pinned on the notice board of the doctors’ coffee lounge.

I’ve had several reviews by the FDA over the years – always fraught occasions – fraught because these people are top-class detectives. Their job is to detect scientific fraud – and they’re good at it. What they’re not good at is seeing the big picture as to whether the trial was timely, well thought through and the observations were correct.

They tend to focus on details: when blood counts were done, whether the timing of X-rays was as dictated in the protocol.

My youthful interrogator at the end of my grilling asked me what lessons I’d learned from all this. I gave a trite answer, but on reconsideration, here are the lessons learned: 1. When the past comes back to bite you, bite back. Don’t hide from the press if you have a good case.

2. Do not rely on “media relations” people to help. A good department might help a bit but they are there to serve administration, not you.

3. Being a principal investigator in a clinical trial is a big responsibility. Most of the time things go smoothly but when things go wrong, you are the one holding the baby and responsible for the errors of the whole team.

4. Tell investigative reporters that their career will go further if they look at all sides of a story. A good reporter will consider this and welcome a platform for explaining extenuating circumstances.

JANUARY - FEBRUARY 2015

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CALGARY AND EDMONTON AB

EDMONTON AB

Imagine Health Centres in Calgary and Edmonton have an immediate opening for a psychiatrist certified with the College of Physicians & Surgeons of Alberta (CPSA).

Alberta Health Services is inviting applications for full-time family physician positions within the family care clinic at East Edmonton Health Centre. These positions are open to physicians who wish to establish a new full-time practice within an interdisciplinary setting, supporting a vulnerable, culturally diverse and complex population. Remuneration for these positions will be on a guaranteed/sessional rate.

Imagine Health Centres are dynamic, multidisciplinary clinics with a large array of services including family physicians, specialists and many other allied health professionals such as pharmacists, physiotherapists, psychologists and more. Imagine Health Centres is dedicated to promoting the health of patients utilizing the most up-to-date preventative and screening strategies.

The successful candidate will work closely with our multidisciplinary team to optimize management of our patients with mental health issues.

Collaborate with our large network of family physicians and their referrals to maximize outcomes for your patients.

Opportunities for group therapy and corporate health are available. There are also opportunities to help develop leading programs for mental health at all levels of primary care within our multiple sites located throughout Calgary and Edmonton.

An attractive compensation package will be offered to the successful candidate.

All candidates must be immediately eligible for licensure or already licensed with the CPSA and provide proof of malpractice insurance from the Canadian Medical Protective Association. Compensation is fee-for-service.

All inquiries will be kept strictly confidential and only qualified candidates will be contacted.

Submit your CV to: Joanne Oliver joanne.oliver@imaginehealthcentres.ca

The clinic offers patients access to an interdisciplinary primary care team including family physicians, nurse practitioners, registered nurses, licensed practical nurses, mental health/social workers, dietitians and cultural support workers. The team works closely with community agencies and external partners to provide comprehensive primary care services. Clinic operations are fully computerized with an electronic medical record (EMR). Other co-located programs include public health services, addictions and mental health, adult and children’s home care and region 6 social services.

This is a combined clinical practice and teaching environment and successful candidates will be encouraged to hold clinical appointments in the Department of Family Medicine at the University of Alberta, Faculty of Medicine & Dentistry. Successful candidates will also be expected to become members of the North Edmonton Primary Care Network.

Interested applicants must hold an MD or equivalent, be eligible for a license to practice medicine in Alberta and have completed a Residency in Family Medicine. >

> All qualified candidates are encouraged to apply; however, Canadians and permanent residents will be given priority.

Alberta Health Services hire on the basis of merit. We are committed to the principle of equity in employment.

We welcome diversity and encourage applications from all qualified men and women, including persons with disabilities, members of visible minorities and Aboriginal persons.

The competition will remain open until the position is filled.

To apply please forward a copy of your curriculum vitae and a letter of interest to: Karen DeViller, Site Director East Edmonton Health Centre karen.deviller@albertahealthservices.ca EDMONTON AB HealthPointe Medical Centre is a dynamic multidisciplinary pain, spine and sport medicine clinic in Edmonton. We have a part- or full-time opportunity for a family physician or specialist that has a strong interest and experience in the medication management of chronic pain patients.

The medication management physician will be responsible for seeing consultations within the clinic and should be well versed in pain assessment; it would be an asset to have his/her methadone and suboxone license, but not required.

The successful candidate will work closely within our multidisciplinary team to optimize management of our patients with chronic pain.

Physicians working at HealthPointe enjoy an efficient workflow, paperless electronic medical records and friendly support staff; physicians are able to easily maintain a work/ home life balance with flexible days available.

If you are interested in learning more about our clinic, please contact us.

All inquiries will be kept strictly confidential.

Contact: Roberta Fyffe or Dr. Sean Gonzales T 780.453.5255 staff@healthpointe.com

EDMONTON AB

EDMONTON AB

Busy west Edmonton clinic, close to West Edmonton Mall seeks a family physician interested in part- or full-time work. Flexible hours, good split and working environment.

Two positions are immediately available at the West End Medical Clinic/M. Gaas Professional corporation, located at unit M7, 9509 156 Street, Edmonton AB T5P 4J5.

Full-time family physician/general practitioner positions are available.

The physician who will join us at this busy clinic will provide family practice care to a large population of patients in the west end and provide care to all patients of different age groups, pediatric, geriatric, antenatal and prenatal care.

Contact: bemececontact@gmail.com Attention: Manager EDMONTON AB Urban Medical Clinic in vibrant southeast Edmonton is a new state-of-the-art medical clinic that is rapidly expanding. The clinic uses TELUS PS Suite electronic medical records. Our team currently includes two family physicians and we are part of Edmonton Southside Primary Care Network with a full-time nurse and dietician. We have 8,000 patients registered. The clinic is growing and we are recruiting part- and full-time physicians. Competitive overhead for long term commitments. We have eight examination rooms, one procedure room and one specially designed wheelchair room.

Contact: Dr. Oshean Naidoo onaidoo@telus.net or Dr. Dhanakodi Rengan drengan@telus.net T 780.757.9545 EDMONTON AB Beverly Medical Clinic is a new state-of-the-art medical clinic that is rapidly expanding. Our team currently includes three family physicians, two internists and a pediatrician.

The clinic is growing and needs more dedicated family physicians as one of the physicians is planning on slowing down. Competitive overhead for long term commitments; 75/25% split.

We have 10 examination rooms, one treatment room and one specially designed pediatric room.

Contact: Dr. A. Elfourtia or Dr. Z. Ramadan Beverly Medical Clinic 4243 118 Ave Edmonton AB T5W 1A5 T 780.756.7700 C 780.224.7972

The physician income will be based of fee-for-service payment and the overhead fees are negotiable. The physician must be licensed and eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA). Their qualifications and experience must comply with the CPSA licensure requirements and guidelines. If you are interested please contact us.

Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 F 780.756.3301 westendmedicalclinic@gmail.com EDMONTON AB The Beverly Towne Medical Clinic is a new state-of-art medical clinic that is rapidly expanding. Our team currently includes three family physicians, pediatrician and gynecologist.

The clinic is growing and needs more dedicated specialists and family physicians as one of the physicians is planning on slowing down. The family physician position is permanent, full time and fee-forservice. The physician and clinic will share fee-for-service billings, 70% (physician) and 30% (clinic) for overhead expenses.

For eligibility criteria please visit this link: http://www.cpsa.ab.ca/Services/ Registration_Department/Alberta_ Medical_License.aspx Contact: Dr. A. Elfourtia or Dr. Z. Ramadan Beverly Towne Medical Clinic 11730 34 St Edmonton AB T 780.756.7700 or T 780.224.7972 beverlymedicalclinic@gmail.com > JANUARY - FEBRUARY 2015

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> EDMONTON AND FORT MCMURRAY AB MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic each have 10 examination rooms and Alafia Clinic with four examination rooms are looking for six full-time family physicians. A neurologist, psychiatrist, internist and pediatrician are required at all four clinics.

Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton.

Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray.

The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines.

The physician income will be based on fee-for-service with an average annual income of $300,000 to $450,000 with competitive overhead for long term commitments; 70/30% split. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records (paper free) and member of a primary care network.

Full-time chronic disease management nurse to care for chronic disease patients at Lessard, billing support and attached pharmacy are available at the Lessard and West Oliver locations.

Work with a nice and dedicated staff, nurse available for doctor’s assistance and referrals. Also provide on-site dietician and mental health/ psychology services. Clinic hours are Monday to Friday 8:30 a.m. to 8:30 p.m., Saturday and Sunday 10:30 a.m. to 5 p.m.

AMA - ALBERTA DOCTORS’ DIGEST

Contact: Management Office T 780.757.7999 or T 780.756.3090 F 780.757.7991 lessardclinic@gmail.com RED DEER AB Well-established family practice clinic with four physicians has an opportunity to add a part- or full-time physician. Diverse patient population, electronic medical records and primary care network support. Hospital privileges necessary, obstetrics optional. Excellent support regarding on-call schedule.

Contact: Dr. L. Ligate F 403.346.4207 lora.l@shaw.ca SHERWOOD PARK AB The Nottingham Medical Clinic in Sherwood Park is expanding and we are looking to add part- and full-time family physicians. Currently the clinic has four physicians and is appointment-based. We use Med Access electronic medical records and offer flexible hours, laboratory, X-ray and on-site pharmacy.

Clinic is associated with the Sherwood Park Primary Care Network providing additional benefits.

Contact: T 780.416.3220 sdenson@shaw.ca

PHYSICIAN AND/OR LOCUM WANTED CALGARY AND EDMONTON AB You require balance … you demand the best. Join the fastest growing medical group in Alberta to practice medicine the way it was meant to be.

Imagine Health Centres (IHC) is currently looking for family physicians and specialists to join our dynamic team in either Calgary or Edmonton.

Physicians will enjoy extremely efficient workflows allowing for very attractive remuneration, no hospital on-call, paperless electronic medical records, friendly staff and industryleading fee splits.

Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. Come and be a part of our team which includes physicians, physiotherapists, massage therapists, psychologists, nutritionists and pharmacists.

Imagine Health Centres prides itself in providing the very best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians. There is also an optional and limited time opportunity to participate in ownership of our innovative clinics.

Compensation is fee-for-service.

Current positions available are locum, part- or full-time.

We currently have three Edmonton clinics with a fourth coming soon to Windermere (southwest Edmonton) early this year. The current clinics are near South Edmonton Common, Old Strathcona and West Edmonton.

We currently have one clinic in southeast Calgary and a second clinic opening downtown early this year.

All inquiries will be kept strictly confidential and only qualified candidates will be contacted.

Submit your CV to: Joanne Oliver joanne.oliver@imaginehealthcentres.ca

SPACE AVAILABLE MAPLE RIDGE BC Prime downtown street level large medical office space for lease in Maple Ridge; prime main street exposure with street and lot parking.

Contact: Adrian Keenan Re/Max Lifestyles Realty T 604.312.6488 akeenan@telus.net >

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PRACTICE WANTED CALGARY AB I am a family doctor looking to take over any medical clinic from which the owner is relocating or retiring.

I would also consider buying a medical building.

If you are a family physician or specialist looking for part- or full-time work please contact me.

Contact: Dr. D. Das T 403.585.6840 drddebasish@gmail.com

COURSES CME CRUISES WITH SEA COURSES CRUISES • Accredited for family physicians and specialists • Unbiased and pharma-free • Canada’s first choice in CMEatSEA® since 1995 • Companion cruises FREE EASTERN CARIBBEAN March 14-22 Focus: Primary Care Update Ship: Independence of the Seas

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TAHITI AND TUAMOTUS March 18-28 Focus: Geriatrics, physician health Ship: Paul Gauguin

PANAMA CANAL November 20-30 Focus: CME with Ontario Medical Association Ship: Zuiderdam

HAWAIIAN ISLANDS April 20-May 1 Focus: Primary and palliative care Ship: Celebrity Solstice

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AUSTRALIA AND NEW ZEALAND January 5-19, 2016 Focus: Caring for an aging patient Ship: Celebrity Solstice

SOUTHEAST ASIA HIGHLIGHTS January 31–February 14, 2016 Focus: Internal medicine and primary care Ship: Celebrity Millennium For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

SERVICES DOCUDAVIT MEDICAL SOLUTIONS Retiring, moving or closing your family or general practice, physician’s estate? DOCUdavit Medical Solutions provides free storage for your paper or electronic patient records with no hidden costs. We also provide great rates for closing specialists.

Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com

DISPLAY OR CLASSIFIED ADS TO PLACE OR RENEW, CONTACT:

Daphne C. Andrychuk Communications Assistant, Public Affairs Alberta Medical Association T 780.482.2626, ext. 275 TF 1.800.272.9680, ext. 275 F 780.482.5445 daphne.andrychuk@ albertadoctors.org

JANUARY - FEBRUARY 2015

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