Alberta Doctors' Digest January/February 2016

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Alberta Doctors'

DIGEST January-February 2016 | Volume 41 | Number 1

Crossing borders A physician’s roadmap to helping a patient seek coverage for medical treatment outside of Canada

Alberta Medical Association Board of Directors 2015-16

MD Financial Management a major sponsor of AMA Youth Run Club

Tarrant Scholarship 2015 The future of rural Alberta medicine is in good hands

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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

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

President-Elect: Padraic E. Carr, BMedSc, MD, FRCPC, DABPN

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 12

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor. The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.

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Dr. Gadget PFSP Perspectives Residents' Page In a Different Vein Classified Advertisements

FEATURES

Editor-in-Chief: Marvin Polis

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

From the Editor Health Law Update Mind Your Own Business Letters Insurance Insights

6 Crossing borders A physician’s roadmap to helping a patient seek coverage for medical treatment outside of Canada

1 1 Alberta Medical Association Board of Directors 2015-16 12 Calling for 2016 TD Insurance Meloche Monnex/AMA Scholarship applicants

$20,000 in scholarship funds are available for 2016

20 Lace up!

AMA Youth Run Club 2015-16 season has begun

2 1 MD Financial Management steps up for Youth Run Club and healthy communities 23 AMA seeks 2016 nominations for our highest awards 26 Tarrant Scholarship 2015

The future of rural Alberta medicine is in good hands

28 TD Insurance Meloche Monnex/AMA Scholarship 2015 winners

Strengthening Alberta’s health care future times four!

© 2016 by the Alberta Medical Association Design by Backstreet Communications

To request article references, contact:

AMA MISSION STATEMENT

daphne.andrychuk@albertadoctors.org

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

COVER PHOTO:

Dr. Ruth L. Collins-Nakai offers a physician's roadmap to helping a patient seek coverage for medical treatment outs¡de of Canada. JANUARY – FEBRUARY 2016

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FROM THE EDITOR

Better or worse? Dennis W. Jirsch, MD, PhD | EDITOR

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ome years ago I took advantage of a medical convention in Yellowknife and, afterwards, went fishing in one of the remote northern lakes with a couple of colleagues. After a day of spectacular fishing, the food at the small lakeside lodge was simple but good and, rosy from the wind and the sun, my companions and I settled into armchairs near a log fire. The post-prandial Scotch was good, as well, and plentiful, and we relaxed. No need for a designated driver. At length (and as you might expect!) we became armchair philosophers, as mellow tipplers are apt to do, and in turn we waxed eloquently – or so it seemed – and offered up garrulous assessments of the world-at-large. We had been joined by an old miner who had made his home for decades in a ramshackle cottage nearby. When it was time to listen to our grizzled veteran’s assessment of the world, the weathered oldster stood up before the fire and moved an outstretched hand horizontally, chest high. “I figure,” he said, “that things generally go along like this for quite a long time. But then, after a while, things get worse.” And at the end of the steady horizontal sweep of his arm, his hand arced downward. I thought his assessment of the world was good at the time. I thought it was good the next day and the one after that. I still do. I know that we’re all different. There are those who remain upbeat through mortar fire, pestilence and all manners of tragedy, while others live in a universe where King Solomon’s treasures would be found wanting, where

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all cups are always less than half full. I thought, though, that the old fellow was on to something. Most of our lives are agreeable enough – most of the time – but given the role of chance in our lives, and the dark certainties of morbidity and mortality, I thought the reclusive prospector had gotten it just about right.

A recent newspaper article

asked the question: Is the world getting better or worse? According to the piece, over 70% of respondents felt the world was getting worse …

This vignette is long past but I remember it clearly. And because I remember it so well I have wondered many times at the trait in all of us that wants to figure things out, that wants to see the big picture. I am reminded of the parable, common to many religions and traditions, of the group of blind men examining an elephant. One examines an ear, another a leg, another a tusk or a trunk and so on. When they discuss their findings, they are in general disagreement about the nature of an elephant. Though I’ve heard this story referring to various medical specialists examining a patient, possibly blinkered by each individual’s point-of-view, I think the most compelling feature of the tale may be our need to see “the elephant” in its totality. I can’t find a good English word to describe this and find we have appropriated a German word. Gestalt means seeing the whole picture all at once. In our search for comprehension we’re often looking for a gestalt. >


> A recent newspaper article asked the question: Is the world getting better or worse?1 According to the piece, over 70% of respondents felt the world was getting worse, and the article introduced me to another new word. Declinism describes our predilection to assess the past more favorably than the future. Times past, we like to think, were “the good old days.” Our bias has been explained variously, by suggesting that we become ever more aware of the risks of living, or that we conflate changes in the times with changes in ourselves. As well, our memories are well known to be fallible and today’s memories tend to be dark ones. Think of the news – bad news is the news.

Our memories are well known to be fallible and today’s memories tend to be dark ones. Think of the news – bad news is the news.

We probably overlook good news, especially over time. It can be argued, for instance, that our health has improved, and improved greatly, over the last century.2 At the beginning of the last century, life expectancy, on a global basis, was a mere 32 years; now it is over 70. Infant mortality, again measured world-wide, has similarly improved from 20% of infants dead before their first birthday to less than 4%. Extreme poverty too would seem to be on the wane.3 The number of people living in extreme poverty – set at $1.25 a day in 1990 – has dropped more than half since 1990 when 1.9 billion people lived on under $1.25 a day, compared to 836 million in 2015. Said another way, two-thirds of the world lived in extreme poverty at the beginning of the last century and this has fallen to an estimated 17% of persons in 2012. Though I don’t know what he would have to say about the horrors perpetrated in the Middle East, or the recent terrorist attacks in France, or even the endemic gun violence in the USA, author Steven Pinker in The Better Angels of Our Nature provides a range of evidence supporting his argument that we are, in general, becoming less violent and more altruistic.4 Despite two World Wars and the Holocaust, evidence points to a dramatic reduction in the risk of an individual dying through violence than was the case in previous centuries.

Though there may be some good news, it is certainly not all good. We’ve done nothing much to ameliorate climate change, for example, and our focus a generation ago or so on nuclear disarmament was only temporary. There remain an estimated 16,000 nuclear weapons world-wide.5 We are beset with new problems. Chronic diseases, even in the young, are on the upswing. Depression, anxiety and stress have become our preoccupations, as digitization of work has been accompanied by chronic underemployment and perilous economic times. Perhaps the question of whether we’re worse off or not is one we’re not equipped to answer. Or one we can’t answer without becoming much more specific and individual – as in worse or better for you or for me? In what way? Our pre-history may be at work here and I can imagine a remote time when a cautious hominid precursor had to peer out on the savannahs, noting a mix of sun and shadows, recalling the last glimpse of predators, and the need to come to a momentous decision about whether it was a good time to step out onto the grassland from the safety of the trees.

We probably overlook good news,

especially over time. It can be argued, for instance, that our health has improved, and improved greatly, over the last century.

The conclusion our precursor came to, of course, would be momentary and would not pertain to the specifics of another time or place. We moved off the savannahs and the grasslands, began to use tools, appreciate time’s cyclical benefits and burdens as well as our own uniqueness and that of others. Our cerebral hemispheres grew; we became both braver and more cautious. We began to know the nature of complexity. The labyrinthine world unfolds but remains mysterious and we persist. What was it that my old teacher, internist Dr. Buzz Edwards, used to say regarding complex matters? There are a thousand shades of gray. I can agree. References available upon request.

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COVER FEATURE Crossing borders: A physician’s roadmap to helping a patient seek coverage for medical treatment outside of Canada Ruth L. Collins-Nakai, MD, MBA, FRCPC, FCCS, MACC

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lberta Medical Association and Canadian Medical Association Past President Dr. Ruth L. Collins-Nakai is chair of the Out-of-Country Health Services Appeal Panel. This panel, along with the Out-of-Country Health Services Committee (OOCHSC), operate at arm’s length from Alberta Health and consider appeals, or in the case of the committee, applications for funding of insured medical, oral surgical and/or hospital services that are not available in Canada. “When we have patients whose particular situations lead them to actively consider seeking care out-of-country, it can be a bit daunting to know where to begin to help them,” says Dr. Collins-Nakai. “That includes understanding how and why such coverage is provided – or may not be covered. The committee and the appeal panel felt it might be useful to physicians to provide information on the processes and procedures to access publicly funded out-of-country health services.” Typical applications for funding are for referrals for rare diagnoses that require additional consultation, assessment or treatment, or for conditions where Alberta specialists are requesting further assistance or expertise not available elsewhere in the province or in Canada. In these cases, the Alberta physician making the application has typically consulted widely with other colleagues and specialists in both Alberta and the rest of Canada, and has included this information in the submission made on their patient’s behalf. Such additional information, especially from relevant specialists, is helpful in the determination of funding applications and in meeting the criteria for funding. “There is a process for patients to obtain out-of-country health services and if they wish coverage from the Government of Alberta, it is essential that the regulation be followed,” Dr. Collins-Nakai explains. “Otherwise, it becomes the patient’s choice to obtain the services they want – but at their own expense.”

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Important details follow below. You may find this article a handy reference tool to keep on file. For further information, contact OOCHSC at 780.415.8744.

It is strongly recommended

that Albertans obtain private supplementary (travel) insurance before travelling outside the province or outside Canada, as costs for services can be significantly higher than in Alberta.

Two possible sources of funding Alberta Health provides two sources of funding for Albertans who choose to receive insured medical and hospital treatment outside Canada: reimbursement through the Alberta Health Care Insurance Plan (AHCIP), or an application through the OOCHSC. 1. Coverage under the AHCIP Alberta Health covers only limited physician and hospital costs outside of Canada. Insured physician services received outside Canada are paid at the lesser of the amount claimed, or the rate an Alberta physician would be paid for that service or the most similar service. The services and rates paid to Alberta physicians are listed in the Schedule of Medical Benefits. The rate for in-patient hospital services is $100 (Canadian) per day, not including the day of discharge. The rate for outpatient services is $50 (Canadian) per day, with a limit of one visit per day. These hospital services rates are the maximum that is reimbursed for all services provided to a patient, such as room and board, nursing, laboratory and X-ray services, medical supplies and prescription drugs. >


> Insured hospital services must be provided by a general or auxiliary hospital. Hospital services provided in a private health facility are not eligible for reimbursement. Food, lodging or other travel expenses are not covered. It is strongly recommended that Albertans obtain private supplementary (travel) insurance before travelling outside the province or outside Canada, as costs for services can be significantly higher than in Alberta. 2. Coverage under the OOCHSC The OOCHSC considers applications for funding of insured medical, oral surgical and/or hospital services that are not available in Canada. The OOCHSC operates at arm's length from Alberta Health and, when making funding decisions, is required to follow the legislated criteria outlined in the Out-of-Country Health Services Regulation (Regulation 170/2012). The regulation specifies how and by whom funding requests are made for out-of-country health services, and what is required by the OOCHSC and appeal panel in order to make a decision on the funding request. Physicians should note that there has been a significant change to the original regulations. Applications must be made by Alberta physicians or dentists on behalf of eligible Alberta residents. Patients can no longer make applications themselves. This follows a 2011 motion to that effect by the Alberta Ombudsman (along with several other less significant amendments).

Initial screening and review of applications The OOCHSC chair screens the application to ensure the application is made by a physician or dentist, and contains the required information, including health information, that the chair considers to be required for the proper review by the OOCHSC. Often the chair encounters missing or incomplete information that will create challenges for the committee’s task in reviewing the application. This includes things like insufficient information about how thoroughly options in Alberta have been exhausted, whether or not the services might be available and if available accessed elsewhere in Canada, and whether or not there are extenuating circumstances requiring referral outside of Alberta and/or Canada. In addition, often a referral letter from an Alberta specialist or multiple specialists for out-of-country treatment is not included or the reasons for referring the patient out-of-country treatment are not clearly stated. The OOCHSC chair may conduct any independent investigation that may be considered necessary in order to complete the initial screening of the application. This may include information such as requesting further diagnostic or laboratory reports, information regarding Albertan or Canadian standards of care for the patient’s condition, or additional supporting information regarding the reasons for the out-of-country funding request.

The OOCHSC consists of an employee of Alberta Health, who is also the OOCHSC chair (non-voting) and four Alberta physicians. Quorum is any three members, one of whom must be the chair. All decisions are made by majority vote. In the case of a tie vote, the decision is deemed to be a vote against funding the out-of-country health service request. Once the OOCHSC chair has determined that an application is complete, the OOCHSC has 60 calendar days to assess the application and make a decision. The OOCHSC can approve, deny or defer a decision for the requested out-of-country health services. A deferral occurs during an OOCHSC meeting when its members require further information in order to make an informed decision. The OOCHSC shall decide whether the services referred to in the application are insured services or insured hospital services, and whether to approve payment with respect to the services received or to be received outside of Canada and whether to impose conditions on the payment if approved. The OOCHSC will send a written copy of its decision with reasons to the applicant and the patient on whose behalf the application was made, within 10 days of making its decision, excluding Saturdays, Sundays and holidays.

Conditions for out-of-country health services funding A number of conditions must be met in order to be considered for out-of-country health services funding. • The application must be made by a physician or dentist on behalf of an Alberta patient who is registered with the AHCIP and who has not opted out of the AHCIP. • The services must be medical, oral surgical and/or hospital services and insured under the AHCIP and/or the Hospitalization Benefits Plan. • There must be documentation that the requested services are not available in Canada and the health services available in Canada have been fully utilized. – For the purposes of the regulation, a service is available in Canada if a resident could have obtained the service in Canada within the time period generally accepted as reasonable by the medical or dental profession for any resident with a similar condition. • The services cannot be experimental or applied research. • The services must be medically necessary, according to an Alberta physician or dentist. In other words, there must be a referral from a physician or dentist in Alberta/Canada for the services outside Canada. >

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> • Applications to the OOCHSC for funding of health services that are non-emergent (elective) in nature must be declared complete by the chair of the committee prior to receiving the services. – For the purposes of the regulation, elective services means insured services and insured hospital services that are not provided in an emergency or in other circumstances in which medical care is required without delay. – OOCHSC applications are considered complete when all the required information has been submitted, the chair has notified the applicant in writing, and the application has been scheduled for review at an upcoming meeting. • For emergency health services, an application for funding to the OOCHSC may be made prior to receiving the services or not later than 365 days after the services were received. Submitting an application for funding does not guarantee funding approval. All out-of-country health services funding decisions are based on medical and clinical information considered by the OOCHSC and current legislation.

Completing an application OOCHSC application must include the following documents/information: 1. A letter of referral/support and a completed application form (available online at www.health.alberta.ca/documents/OOCHSCApplication-Form.pdf). The application should include the following information: • The health services/treatment for which funding is requested. • Expected duration of the initial out-of-country health services and the dates on which the health services will be provided.

• Documentation confirming that relevant health services in Alberta and elsewhere in Canada have been fully utilized, OR • Documentation confirming that the health service is not available in Alberta or elsewhere in Canada. – Some examples of services that are not currently available in Canada in 2015 are: proton beam radiotherapy, consultations and assessments for rare diagnoses where Alberta specialists are requesting assistance, treatment programs that are not available in Canada. – If the procedures or facilities are not available in Alberta or Canada, what if any, are the alternative treatment options available in Alberta or Canada. • If the health service is available in Alberta or elsewhere in Canada, an explanation as to why it is not being utilized. – If there are other circumstances or the time period is considered longer than reasonable by the physician, these should be noted at this time.

Applications must be made by Alberta physicians or dentists on behalf of eligible Alberta residents.

3. A recent health history/summary of the patient that is relevant to the health service for which funding is requested, prepared by an Alberta physician or dentist, and which must include:

• The number and frequency of expected out-of-country follow-up visits, if any.

• The clinical diagnosis relevant to the application.

• Address of the out-of-country facility where the health services are to be obtained.

• Any health services previously provided for the condition, when and where they were provided, and the outcome.

• Name and specialty of the out-of-country physician who will provide and/or coordinate the health services. • The arrangements that have been made for follow-up care in Alberta or elsewhere in Canada.

2. The reason for seeking funding for out-of-country health services and a minimum of one of the following to support that reason:

While it is not explicitly stated in the regulation, it is helpful if a second Alberta physician supports the need for the out-of-country services being requested.

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• Copies of existing relevant findings and/or reports from specialists and/or consultants (in the field of medicine or dentistry relevant to the condition for which funding of health services is requested). • Copies of relevant diagnostic and laboratory reports. • If applicable, additional health services considered or explored but not pursued and the reason(s) why. >


> 4. Any other information relevant to the application.

Note: Invoices, receipts or any other information related to the costs of out-of-country services are not included with the application review.

If the application is urgent for medical reasons, the physician or dentist must state this on the application, along with the reasons for the urgency and the time-frame within which it is recommended that the health services/treatment be initiated.

Appeals Appeals to the decisions of the OOCHSC are handled by the OOCHSC Appeal Panel. The appeal panel is also an independent committee that operates at arm’s length from the OOCHSC and Alberta Health. All appeals must be submitted in writing to the Out-of-Country Health Services Appeal Panel within 60 days of the appellant receiving the OOCHSC decision letter. It is important to note that the appeal panel can only review the documentation that was reviewed by the OOCHSC in making its decision, the OOCHSC written decision and the appeal letter. The appeal panel cannot review any new evidence presented in the appeal letter or accompanying documents that were not provided as part of the original OOCHSC application. In addition, the appeal panel cannot hear appeals for claims denied through the AHCIP and which were not heard by the OOCHSC.

If you have questions regarding appeals, call the Out-of-Country Health Services Appeal Panel at 780.638.3899.

Alberta ombudsman While the appeal panel decision is final, the patient, or the physician or dentist on behalf of the patient, may contact the Alberta ombudsman regarding administrative fairness in coming to a decision by either the OOCHSC or the appeal panel. A request to the Alberta ombudsman’s office may result in an investigation into the practices outlined previously. An investigation does not guarantee a rehearing of the case by either the OOCHSC or the appeal panel, depending on whose decision the complaint was made against. If you have questions regarding filing a complaint, call the Alberta ombudsman in Edmonton 780.427.2756, Calgary 403.297.6185 or toll-free at 1.888.455.2756. Editor’s note: Alberta Doctors’ Digest would be glad to know what you think of this article and whether you found it helpful. Email amamail@albertadoctors.org with your comments. We may publish a selection in our next Letter to the Editor section, but we would confirm with you before doing so.

Ann Dawrant

New evidence provided in the appeal letter will be returned to the appellant. New evidence can be provided to the OOCHSC by the originating physician or dentist for consideration as to whether the information is sufficient to warrant reconsideration or a new application to the OOCHSC.

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The appeal panel follows the same guidelines as the OOCHSC in making a decision. The appeal panel may confirm or vary the OOCHSC decision or substitute its decision for the OOCHSC decision.

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Once a decision has been made, the appeal panel will notify the appellant of its decision in writing within 20 days, excluding Saturdays, Sundays and holidays. All appeal panel decisions are final. The appeal panel has six members, four physicians, an ethicist and a member of the general public. One member of the appeal panel is designated as chair and another as vice-chair, both of whom are voting members. A quorum for an appeal panel meeting is three members, two of whom must be physicians and one of whom must be either the ethicist or the member of the general public. All decisions are by majority; a tie vote on a matter is deemed a denial of funding for the out-of-country health services.

“Please call me to experience the dedicated, knowledgeable, and caring service that I provide to all my clients.”

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www.anndawrant.com

• 30 years as a successful residential realtor in west and southwest Edmonton • Born and raised in Buenos Aires and has lived in Edmonton since 1967 • Bilingual in English and Spanish E-mail

anndawrant@shaw.ca

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HEALTH LAW UPDATE

The unrepresented litigant Jonathan P. Rossall, QC, LLM | PARTNER,

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he unrepresented litigant. There are few phrases more likely to send a chill down the spine of a courtroom lawyer. And this is all the more so when the litigant in question is a patient pursuing legal action against his/her former physician(s). Access to justice has been a topic of concern in our legal system for many years, more so in the last decade. Legal costs are spiralling and the ability to retain competent legal counsel has become available only to the very wealthy (or, ironically, in the case of legal aid, to the very poor). The middle class has seen access to justice become, at best, a vehicle driving on the road to insolvency, and at worst, simply a dream. And so we see more and more individuals pursuing their own remedies through the courts. This shift has been recognized in the Alberta courts in a number of ways. Most recently, we have witnessed the increase in the financial limits of the Provincial Court, Civil Division (formerly “Small Claims Court”) to $50,000 which makes the pursuit of many civil proceedings in that venue more palatable. The Provincial Court is much more “user friendly” for unrepresented litigants with many steps, such as mediation and case management geared toward parties representing their own interests. In addition, the Alberta Court of Queen’s Bench (the superior court) has recently re-written its rules – in large part to make them simpler, more plain-language oriented and easier to follow. Nevertheless, there remains an increasing number of individuals pursuing their own actions without the requisite knowledge or guidance. Ironically, while the plaintiffs in these cases may see this as a cost-saving step, the reality is that costs are often enhanced by delays, additional time requirements and needless adjournments to perfect often inadequate presentations of facts or argument. At the outset, the comment was made that this is all exacerbated in the medical/legal forum. Many frequent readers of Alberta Doctors’ Digest will remember previous Health Law Update columns trying to summarize the process of taking a civil action against a physician through the courts. Suffice it to say that it is not an easy process, even for experienced counsel. Expert assistance is a AMA - ALBERTA DOCTORS’ DIGEST

MCLENNAN ROSS LLP

necessity, both in terms of aiding the lawyer to understand difficult and complex medical issues, and in presenting evidence relating to those issues to the court. The court’s expectations of counsel in pursuing and defending such cases is high. When the case is being advanced by an unrepresented plaintiff, those expectations are seldom met and, again, the consequences are often delay, needless adjournments and in the end – increased costs.

Legal costs are spiralling and the ability

to retain competent legal counsel has become available only to the very wealthy (or, ironically, in the case of legal aid, to the very poor).

So what is the answer? Unfortunately, there is no simple solution. In most Canadian jurisdictions, lawyers are permitted to take on civil litigation on a contingency basis – their fee comes in the form of a percentage of the judgment ultimately awarded against the physician or hospital. However, law firms will typically only take on strong cases where there is little risk, and even in those cases most lawyers will expect the disbursements, or expenses to be funded by the client. Those can be significant, especially where experts are being retained. Some provinces in Canada are advocating strongly for tort reform, including “no-fault” funds established to compensate injured patients for injuries suffered in the course of a surgical or medical procedure, much like the model adopted by the Workers’ Compensation Board. In other jurisdictions the courts are seeking to streamline the trial process by limiting the number of experts put before the courts, or encouraging the joint use of experts by the parties. Mandatory mediation is also pursued in many provinces which can lead to settlement in appropriate cases. The bottom line is that legal costs are not likely to go down in the near future. If access to justice is to become achievable, continued creativity and adjustments will be necessary unless our judges are prepared to lower their standards and expectations – an unlikely prospect.


FEATURE Alberta Medical Association Board of Directors 2015-16

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Seated, left to right: Dr. Paul Parks; Dr. Richard Johnston, Immediate Past President; Dr. Carl Nohr, President; Dr. Padraic Carr, President-Elect; Dr. Sarah Bates. Standing, left to right: Dr. Kimberley Kelly; Dr. Kathryn Andrusky; Hamza Riaz, MSA observer; Dr. Neil Cooper; Dr. Jasneet Parmar; Michael Gormley, Executive Director; Dr. Kimberly Williams, PARA observer; Dr. Paul Boucher; Dr. James Pope; Dr. Christine Molnar; Dr. Robin Cox.

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FEATURE

Calling for 2016 TD Insurance Meloche Monnex/AMA Scholarship applicants

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he Alberta Medical Association (AMA), in conjunction with TD Insurance Meloche Monnex, is providing $20,000 in scholarship funds for 2016. 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. If that fits your situation, apply for the TD Insurance Meloche Monnex/Alberta Medical Association Scholarship by March 31. 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.

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. 3119, toll-free 1.800.272.9680, ext. 3119 or visit the AMA website at www.albertadoctors.org.

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

Practitioner advocacy assistance Line (PaaL)

1.866.225.7112

The PAAL is a 24-hour confidential service you can call to share the issue and obtain advice from your ZMSA. All calls are answered by Confidence Line, an independent provider of confidential reporting lines.

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


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MIND YOUR OWN BUSINESS

Performance and employee management A partnership and good practice Practice Management Program Staff

W

hether you are a sole practitioner managing one employee or a member of a large clinic with multiple staff members, managing employee performance is a mandatory part of maintaining a successful and productive business. Failure to consistently and effectively manage performance can be a costly venture with consequences such as lost revenue, office morale, staff turnover, negative publicity in the community and even loss of patients due to customer service issues. An additional cost not often recognized is the stress and strain of simply being the observer of a continuous negative situation that has gone uncorrected or unaddressed. With formal systems and components in place, most workplaces can function effectively, but it is not without work on behalf of both the employer and employee. EMPLOYER RESPONSIBILITY Talk and communicate to your employees. Engage in positive and meaningful interactions. Be honest and operate in good faith.

A key premise to performance management and employee relations is that it is a partnership – a two-way relationship, with the employer (supervisor) and employee having equal responsibilities. In very simple terms, think of it as a scale which weighs the elements that both the employer and employee each have responsibility for, and when one element is either missing or overused, the scale moves out of balance and an issue develops. The following is an illustration of some basic elements of the employeremployee partnership which are essential to maintaining a functional employeremployee relationship.

REQUIREMENT Workplace communication: The exchange of ideas and information, to function and be understood and understand others in the workplace. All work related discussion should be designed to further the goals and directions of the employer’s business.

Ensure one is in place for every employee to clearly define the employer-employee relationship that has been established.

Employment agreement/letter of offer: Have one for every employee which includes basics of:

Ensure updates are completed when any changes are made to the role or responsibilities.

• Position hired for.

Discuss any concerns or issues immediately with the employee.

• Location of employment.

• Start date. • Wage/salary. • Reference to job description, physical demands and competencies.

EMPLOYEE RESPONSIBILITY Talk and communicate to your employer and co-workers. Engage in positive and meaningful interactions. Be honest and operate in good faith. Ensure you agree, understand and follow all term and conditions. Ensure employer provides a new agreement after any changes to the original. Discuss any concerns or issues immediately with the employer.

• Listing of benefits and entitlements such as: – Vacation – Personal days (illness, bereavement, time off with/without pay, etc.)

AMA - ALBERTA DOCTORS’ DIGEST

>


> EMPLOYER RESPONSIBILITY Ensure the job description is accurate and covers all essential job functions, roles and responsibilities, as well as expected level of competency. Employer must review upon initial hire, and ensure there is regular review if there are any questions. Employee should sign off annually. Discuss any concerns or issues immediately with employee. Ensure compensation strategy aligns with physician goals and objectives for the practice. Ensure correct placement of new employees on the pay band, and the accurate movement of existing employees through the pay band. Follow it rigorously – no modifications without communication to staff. Discuss immediately with employee if any concerns or issues arise. Should be a continuous process of informal and formal discussions culminating in a formal annual review. The annual review should contain “no surprises.” Discuss immediately with employee if any concerns or issues arise.

REQUIREMENT Job description: An accurate, written representation of the scope of the role, which addresses: • Tasks, functions and responsibilities. • Clinical and administrative functions and responsibilities. • Qualifications: education and experience required for the role. • Hazardous situations/environments. • Potential physical demands. • Level of competency expected. • Pay grade/band.

Ensure it is reviewed upon initial hire as well as annually, with the document being signed off by the employee.

Ensure you understand it completely and ask for clarification if not. Sign it off annually. Request updates if changes occur to core duties and responsibilities listed in the current description. Discuss any concerns or issues immediately with the employer.

Compensation strategy: A document which lists the: Be aware of it and ensure you understand it. • Philosophy of the employer’s approach to compensation (e.g., “We choose to hire the best and brightest, and will pay 2% over the market median to retain our employees”).

Discuss issues immediately with the employer if there are any concerns or confusion.

• Salary band which identifies the ‘start and end’ of the pay scale and how an employee moves through the scale for every position in the company. • Strategy to review the pay scale to consider annual cost of living adjustments. Must align with the employer’s strategic plan as well as their clinic and compensation philosophy.

Performance evaluation/review process: A process which allows the employer and employee to have a two-way conversation (formal or informal). • Must discuss employee’s performance as compared to the job functions, responsibilities and expectations. • Should be ongoing (on the spot, ad hoc feedback), as well as formalized meetings. • Should be both written and verbal. • Must be signed off by both parties.

Be clear on exactly what you stand for, as well as what you want your employees to value and reflect.

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EMPLOYEE RESPONSIBILITY

Employee code of conduct: A document which outlines the expectations and guiding principles of the employee’s conduct and behaviors. Can also include the employer’s values and define the corporate culture of the organization. Can be as specific as “thou shalt not do ‘x’,” or outline legal and ethical guidelines expected of employees. May reference specific policies that are paramount to how the employer chooses to operate.

Be involved and active – participate! Ask for feedback or clarification whenever there is confusion. Be honest about your performance and provide feedback when requested. Discuss any concerns or issues immediately with the employer. Read it, understand it and sign it. Ensure you support the values of the organization. Any uncertainty of whether or not you conform or believe in the values or ethics of the employer must be raised immediately. >

JANUARY - FEBRUARY 2016


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> The chart on the previous page outlines a few of the basic items required to set the stage to build a functional and productive workplace. As stressed previously, the employer-employee relationship is a partnership that requires full participation and engagement from both sides. Once there is an imbalance or inequity, problems are soon to follow. How do you decide where to start when diagnosing a workplace issue? When Practice Management Program (PMP) consultants are called upon to assist a physician with a staff management issue, we find typically that the problems have been ongoing for months or years in the clinic, and staff and physicians are now at the breaking point. The honest truth is that addressing staff performance issues is not easy or intuitive, is not taught in medical school – and can be exhausting. What do you do when, in your opinion, your employees are “behaving badly?” You believe they are not fulfilling their role responsibilities, are not getting along with co-workers, are not getting their job done, or appear to no longer be interested in doing their job? The automatic reaction is that it is their issue and they are the problem. However, everyone owns a share in every relationship issue, and the employer-employee relationship is no different. The issue needs to be explored with a non-judgmental approach, free of assumptions to determine why the behavior is occurring. When exploring a staff performance or behavior issue, operate on a good faith approach and don’t immediately assume a negative behavior problem exists until you have explored all other options. When investigating the issue, go through the previous chart and evaluate the employer-employee relationship on: 1. Whether or not the components exist – fully, partially or not at all. 2. Whether each of the parties has kept up their end of the relationship – are they fully committed to it? 3. Is there a full understanding by both the employer and employee on how their behavior or actions (or lack thereof) has affected the other party – do they even know an issue exists? Once you have explored the issues, you will need to work with the employee to define a plan to close the gap. It could be as simple as clarifying a job duty they do not understand (clarifying the job description). It could also be a more involved plan where they lack a skill or qualification that you need to train them on, or even the most complex issue, where it involves behavior that violates your code of conduct or ethics. With the previous in mind, the plan you create can be as simple as reviewing the job duties, to arranging training with a more senior co-worker and providing an opportunity to practice the skill, to a formal, written performance/ behavior management plan or warning. Any plan that is created needs to be in writing. It should define the issue, the desired behavior, the desired outcome, the review period and the potential result for

AMA - ALBERTA DOCTORS’ DIGEST

not correcting the issue – which could be ending the employer-employee relationship. As the behavior needs to be measured, monitored, evaluated and reported back upon to the employee, the plan itself may have several iterations before the desired outcome is achieved. It is a cycle, and this is why it is called a process of “progressive discipline.” With the above being said, there are situations where an employee’s behavior would not afford them the benefit of participating in a progressive discipline plan. These actions typically result in immediate dismissal for serious acts or misconduct. Should you believe you have encountered such a situation, it is within your best interests to contact an employment lawyer to obtain an opinion on your best course of action. In all situations of performance management through progressive discipline or potentially terminating an employee, you must record and document everything to ensure an accurate historical record is kept. As illustrated through the above discussion, employee management is not a passive activity, but rather requires constant and consistent engagement by both the employer and employee. If you find yourself requiring assistance in this area, contact the PMP for guidance. 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 780.733.3632.


LETTERS

17

An open letter to the Chief Justice of Canada An Alberta doctor speaks out on physician-assisted death

A

n open letter to the Chief Justice of Canada on Carter vs. Canada (Attorney General), 2015 SCC 5, (2015) 1 S.C.R. 331 with regard to physicianassisted suicide (PAS) otherwise known as physician-assisted death (PAD). Dear Chief Justice: I must draw your attention to the position of the College of Physicians & Surgeons of Alberta (CPSA) as stated by Registrar, Dr. Trevor Theman, in his article, “Caution and respect for patient autonomy frame CPSA advice on physician-assisted death” published in the NovemberDecember 2015 Alberta Doctors’ Digest. (ADD is a publication of the Alberta Medical Association.) Dr. Theman indicated to physicians in Alberta that: “… mature minors seeking PAD should be treated as adults …" This position goes significantly beyond the ruling in Carter vs. Canada which limited PAS/PAD to those over 18 years of age. The evidence from Belgium, the Netherlands and Switzerland shows that it will not be long before some physicians make value judgments about certain handicapped and incompetent patients (young and old) who, in their perception, are living ‘intolerable’ lives. Now they can justify unsolicited assistance to those patients because the CPSA is able to ignore a major criterion for

physician-assisted suicide/death as defined by the Supreme Court of Canada. Dr. Theman also stressed that physicians: “… have an obligation to act in the best interest of the patient … a physician must assist the patient in accessing all options for care.”

guard against any coercion or a hasty, ill-considered decision. It is in society’s best interest that physicians continue to protect those under our care. Yours sincerely, Kevin M. Hay, MB, BCh, BAO, MRCPI, CCFP, FCFP Wainwright AB

This implies that informing the patient of the ‘treatment’ alternatives and how they may access those services is not enough. It suggests to me that doctors will be mandated to refer for assisted suicide – an action which I find morally and professionally repugnant. Evidently we will be disciplined by the college if we refuse to do so, despite your ruling in Carter vs. Canada: “Nothing in this declaration would compel physicians to provide assistance in dying.” (The phrase ‘assistance in dying’ is an unfortunate euphemism for assisted suicide because most of those providing palliative care consider it to be ‘assistance in dying’ by treating the patient’s pain and suffering without intending to cause the patient’s death). I believe the court should insist that assisted suicide/assisted death is performed by a new, well-regulated occupation (or ‘trade’ or ‘profession’). Physicians should remain a prime advocate for our patients and be there to

JANUARY - FEBRUARY 2016


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INSURANCE INSIGHTS

OK, you survived

But what about critical illness insurance to keep your finances healthy?

This article has been provided compliments of Sun Life Financial, underwriter of the AMA Critical Illness Insurance plan.

R

ecovering from a serious illness can come at a significant cost. If it happens to you, how will you pay for it?

Imagine this: You’ve just been diagnosed with cancer. While your doctors say your chances of a cure are good, the weeks and months of treatment and recovery you’ll need can come at a high price. Not the surgery or the hospital stay. Not the radiation treatments. Not even the chemo (if they give it to you in the hospital). Those costs are generally covered by your provincial health insurance. But if you have to take several months or longer off work, if your spouse has to take significant time off to look after you when you get home, if you’ve been prescribed expensive drugs that provincial health insurance doesn’t cover, or you need months of physiotherapy, you may require the additional financial support that critical illness insurance offers before your disability insurance kicks in.

The odds are that you or someone in

your family will experience a serious medical setback at some point – and survive. But while you’re dealing with your illness, your finances could be suffering, too.

Where will the money come from? You could raid your retirement savings plan or other savings, run up your credit cards or even borrow against the value of your home – all of which have the potential to derail your plans for retirement. Our critical illness insurance coverage can help keep your retirement plans on track.

AMA - ALBERTA DOCTORS’ DIGEST

Will you suffer a critical illness? You could. The Canadian Cancer Society says 40% of Canadian women and 45% of Canadian men will develop cancer during their lifetimes, and the Heart and Stroke Foundation estimates there are more than 70,000 heart attacks and 50,000 strokes in Canada each year. There is good news, however. More Canadians than ever are surviving life-altering illnesses. Some more stats: • There are close to one million cancer survivors in Canada today, according to the Princess Margaret Cancer Foundation. • 80% of heart attack victims and 75% of stroke victims admitted to hospital survive, says the Heart and Stroke Foundation. The odds are that you or someone in your family will experience a serious medical setback at some point – and survive. But while you’re dealing with your illness, your finances could be suffering, too. For example, research by the Canadian Breast Cancer Network found that 44% of Canadians with cancer who were surveyed had depleted their savings and retirement funds to cover treatment costs and make up for lost income.

How does critical illness insurance work? If you’re diagnosed with one of the conditions covered under your critical illness insurance policy, after the required waiting period you’ll receive a lump-sum, tax-free* payment once your claim is approved. You can use that money for whatever you want. If you have disability insurance or extended health care coverage, it’s important to understand exactly what those benefits cover, and for how long. It’s a good idea to review your disability policy or health care benefits in comparison with the features of a critical illness insurance plan. >


> Compare: • Your monthly disability insurance benefit. • Elimination periods (i.e., how long you wait before disability benefits are payable). • Deductibles and maximums under your extended health care coverage. Wise financial planning takes into consideration not only building your savings, but also protecting it. An ADIUM Insurance Services insurance advisor can help you to determine how critical illness insurance can support your overall financial plan. For more information and premium rates for critical illness insurance, please contact your ADIUM Insurance Services advisor:

Northern Alberta (Red Deer north) Kelly Guest, EPC, CHS T 780.482.0306 TF 1.800.272.9680, ext. 3306 kelly.guest@albertadoctors.org Southern Alberta Mona Yam, CLU, CFP, CHS, BA, BComm T 403.205.2088 TF 1.866.830.1274, ext. 4088 mona.yam@albertadoctors.org * There are no specific income tax laws for critical illness insurance. Based on current tax laws, our insurance provider, Sun Life Financial, believes any cash benefit from critical illness insurance will not currently be taxed when the policy is owned by and the benefit is payable to an individual. Original source: Do you need critical illness insurance? Written for sunlife.ca. © Sun Life Assurance Company of Canada, 2015

CUMMING SCHOOL OF MEDICINE Office of Continuing Medical Education and Professional Development

Explore our professional development courses and conferences

All inquiries please contact our registration department 403.220.7032

MARCH 5-6, 2016 CCFP Exam Preparation Course

APRIL 16, 2016 General Internal Medicine – PoCUS

cmereg@ucalgary.ca

MARCH 11, 2016 Annual MSK Clinical Pearls Conference

APRIL 22, 2016 Biostatistics Workshop: Basic Terms and Concepts

To register

APRIL 6, 2016 33rd Annual Calgary Therapeutics Course (Pre-Course)

APRIL 29, 2016 Biostatistics Workshop: How to Critically Appraise an Article

APRIL 7-8, 2016 33rd Annual Calgary Therapeutics Course ONLINE WEBCAST also available

cumming.ucalgary.ca/cme

cumming.ucalgary.ca/cme

MAY 5-6, 2016 ACH Paediatric Update Conference JUNE 3, 2016 Women’s Health in Primary Care Conference

JANUARY - FEBRUARY 2016

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20

FEATURE

Lace up!

AMA Youth Run Club 2015-16 season has begun Vanda Killeen | SENIOR

COMMUNICATIONS CONSULTANT, AMA PUBLIC AFFAIRS

L

ast October, in balmy, almostshirt-sleeve weather, the Alberta Medical Association (AMA) Youth Run Club (YRC) kicked off its third year in Calgary and Edmonton. The 2015-16 season YRC launches in Calgary and Edmonton were large, boisterous affairs, led by AMA President Dr. Carl W. Nohr and supported with equal enthusiasm by AMA staff, representatives from YRC partner Ever Active Schools, YRC sponsors the Running Room and Alberta Physiotherapy (see next page for an exciting announcement regarding our newest YRC sponsor!) and new this year, staff from Calgary South Primary Care Network (PCN) and Edmonton North PCN. Calgary’s launch was hosted by Sam Livingston School, a kindergarten-to-grade-four French immersion school in southeast

Shelley Palmer, Lauderdale School staff member and Ebenizer Abrra, student: post-YRC run.

AMA - ALBERTA DOCTORS’ DIGEST

Calgary. The entire student population of 500 participated in the sunny morning one-kilometer fun run, with Calgary South PCN leading the warm-up and providing the kids with reusable PCN logo goodie bags containing water, granola bars and the popular, neon-green YRC sunglasses provided by AMA and Ever Active Schools. Forward a week to Lauderdale School in northwest Edmonton where, under equally sunny skies, Dr. Nohr again led the school’s 170 YRC participants in competitive, joyful laps around the schoolyard goalposts. Challenged by many of the children to race with them, Dr. Nohr carried on with their laps around the field long past the actual end of the event. A good, fresh-air time was had by all at both schools and now the YRC gets down to business with

Dr. Carl W. Nohr, AMA President, shares high-fives with YRC runners at Calgary’s Sam Livingston School.

its fall/winter season. Currently, 177 schools across Alberta host Youth Run Clubs, with over 9,000 young participants running with the clubs and learning (for the benefit of themselves and their families) about nutrition and the other mental and physical aspects of healthy, active lifestyles. While many of the clubs run through the winter (indoors and outside, when weather permits), come April the ranks of YRC always swell as more schools come onboard to incorporate the YRC into their spring/summer extra-curricular fitness programs. YRC’s goal for 2015-16 is to have 350 schools and 20,000 students lacing up their runners for the spring edition of the program. The YRC ended its 2014-15 season with 305 schools and 17,000 participants.

Tim Berrett, YRC Ambassador, gets the Lauderdale School YRC run off to a celebratory start!


FEATURE

21

MD Financial Management steps up for AMA Youth Run Club and healthy communities

“We know that only one in 10 Canadian kids is active enough, and that their current lifestyles are dominated by too much screen time,” MD’s President and CEO Brian Peters explained in bestowing the sponsorship. “By educating Alberta’s children and youth on the benefits of being active, we can help to positively affect the long-term health of tomorrow’s leaders and help them to develop healthy lifestyle habits. MD is pleased to be a part of the Youth Run Club because, quite simply, we are investing in a more healthy and positive future.”

Brian Peters

T

he Alberta Medical Association (AMA) Youth Run Club (YRC) is the association’s flagship initiative for promoting healthy communities. The AMA has made a significant investment to support YRC and we are gratified by the positive results that have been seen so far with 17,000 children engaged. In January we were delighted to welcome MD Financial Management as a major sponsor to help continue with this important and productive initiative.

The AMA’s close relationship with the Canadian Medical Association and its group of companies – including MD Financial Management – makes this partnership, which is based on shared values, a natural and welcomed development. Thank you to MD Financial Management for contributing to a successful and exciting 2016 for the AMA Youth Run Club! For more information, visit: www.mdm.ca https://www.albertadoctors.org/ ama-youth-run-club

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DR. GADGET

A picture is worth a thousand words . . . Wesley D. Jackson, MD, CCFP, FCFP

I

am a visual learner and, as such, believe myself to be a more effective teacher when using visual tools. Unfortunately, one of the talents I was NOT blessed with is the ability to draw, as evidenced by my team’s recent loss in Pictionary when I failed miserably when asked to draw a hot dog. Despite this handicap, over the years I have been trying to explain sometimes complex anatomical relationships to my patients using my crude drawings and verbal pictures including much hand waving and finger pointing, with an occasional sprinkle of medical jargon. Not surprisingly, this form of patient education often resulted in mechanical head-nodding and blank stares, similar to the reaction to my attempt at drawing the hot dog. Fortunately, my patients were generally much kinder to me than my former Pictionary teammates. The expensive anatomical textbooks that helped me in medical school were always available, but not necessarily written to be used as a teaching aid. Their use required leaving the patient and looking for the correct image – consuming valuable time. As the Internet became more accessible in the exam room, Google Images became a very close friend despite its drawbacks, some of which include sometimes inaccurate drawings or pictures and static images. I still go back to this friend if I am in a pinch for time. There are better options now available to review common anatomy, which not only are relatively inexpensive, but also allow for rapid access of high quality, accurate images which can be manipulated in many ways by the user to meet the specific needs of their patient, like the 38-year-old firefighter who didn’t understand why his labral tear was causing shoulder pain. I have also used these apps to help learners understand practical anatomical concepts such as the least harmful approach to a “blind” intra-articular injection.

AMA - ALBERTA DOCTORS’ DIGEST

My favorite anatomy app at the moment is Essential Anatomy 5 by 3D4 Medical (http:// applications.3d4medical.com/essential_anatomy_5/). This easy to use app, available on iOS and Macs and costing about $30, includes highly detailed 3D graphics of all major systems which are highly customizable by the user. It is especially useful to understand musculoskeletal (MSK) problems as it contains significantly more detail in this area (including the glenoid labrum) than “Visible Body – Human” (see below). All images can be annotated and shared in several ways. The company has also produced a new, subscription-based product called Complete Anatomy which promises even more interactivity, including further customization through the addition of specific, patient-centered pathology (http://completeanatomy.3d4medical.com/ support.php). Visible Body – Human (http://www.visiblebody.com/ index.html) is a very close second choice – in fact I actually purchased both programs. While the graphics are not quite as detailed, this app offers more choice in system views and better detail in non-MSK areas such as the urinary and reproductive systems. Included are also several useful animations, with others available at a nominal cost through in-app purchases. This app is available on iOS, Mac OS, PC and Android systems. Other anatomy apps, including several by DrawMD (http://www.drawmd.com) and OrcaHealth (https://orcahealth.com), are less detailed and generally require a subscription for increased functionality. I found them less useful clinically, but they are worth a look. I must admit that I continue to do a lot of hand waving, finger pointing and verbal drawing while educating my patients and learners, but now I have a readily available option to respond to the inevitable and not infrequent blank stares. And I still can’t draw a hot dog.


FEATURE

23

AMA seeks 2016 nominations for our highest awards

The Alberta Medical Association (AMA) is calling for Achievement Award nominations for individuals who have contributed to the improvement of the quality of health care in Alberta. The Medal for Distinguished Service is given to a physician(s) who has made an outstanding personal contribution to medicine and to the people of Alberta, and in the process has contributed to the art and science of medicine while raising the standards of medical practice. The Medal of Honor is awarded to a non-physician(s) who has raised the standards of health care and contributed to the advancement of medical research, medical education, health care organization, health education and/or health promotion to the public.

• Dr. Luanne M. Metz, Calgary • Dr. Eldon A. Shaffer, Calgary

Nominations must be submitted by April 30. The awards will be presented at the AMA’s fall 2016 annual general meeting in Calgary. To request a nomination form for these awards, please contact Janice Meredith, Administrator, Public Affairs, AMA: janice.meredith@albertadoctors.org, 780.482.2626, ext. 3119, toll-free 1.800.272.9680, ext. 3119 or visit the AMA website at www.albertadoctors.org.

In 2015, three physicians were recognized with the Medal for Distinguished Service. • Dr. Norman R.C. Campbell, Calgary

In 2015, two individuals were recognized with the Medal of Honor. • Glen B. Baker, PhD, Edmonton • Alvin Libin, Calgary To read more about the 2015 honorees, visit the AMA website at www.albertadoctors.org.

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JANUARY - FEBRUARY 2016


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PFSP PERSPECTIVES

Shining light on the importance of healthy medical relationships Sara Taylor, BSc, MD, CCFP | EDUCATION

CONSULTANT AND ASSESSMENT PHYSICIAN, PHYSICIAN AND FAMILY SUPPORT PROGRAM

“I

think the most significant work we'll do in our whole life, in our whole world is done within the four walls of our home.” — Stephen R. Covey

The Physician and Family Support Program (PFSP) not only provides support through a 24-hour assistance line, but also education around topics that are relevant to medical students, residents and practicing physicians in Alberta. Some topics, although very important to discuss, are often difficult to offer through education sessions and presentations. One such topic is medical relationships, and for the purposes of this discussion, the focus will be a physician’s relationship with his/her spouse/partner. In 2014, 37% of the 1,337 calls to the PFSP 24-hour assistance line were related to relationship issues. Of these calls, 66% were related to marital concerns and 26% were related to parenting concerns. Previous years reflect a similar pattern where a significant proportion of calls to the line were related to relationship difficulties, particularly with one’s significant other.

Are these statistics surprising? Such issues with medical relationships are neither unique to Alberta nor a new trend.1 This reality becomes important to patients, colleagues and the health care system, as experience indicates that difficulties in home life often translate to difficulties in work life. Unfortunately, certain qualities that make physicians effective, including perfectionism and prioritization of work before all else, often results in difficulties fostering healthy relationships.2

What is the foundation and meaning of a healthy relationship? Any relationship will be tested at times, none more so than with our spouse/partner. How the relationship

AMA - ALBERTA DOCTORS’ DIGEST

responds to those pressures reflects the health and well-being of the relationship. Dr. Michael Myers, a psychiatrist and specialist in physician health, indicates that communicating in a mature and giving way in a relationship or marriage is not innate.2 The reality is that relationships require work. Some of the work involves an attempt to understand the other person’s perspective. This requires identifying their expectations of the relationship through their hopes, needs and values.2 When children enter the relationship, expectations and priorities become even more important. At the core of human nature, we all want to love and be loved, physician or not, so taking time to nurture and foster a healthy relationship is worth the effort.

What are some of the challenges medical relationships face? Medicine is, without question, a profession with a significant amount of stress, both emotional (being exposed to human pain and suffering, excessive cognitive demands) and physical (working long hours, sleep deprivation on-call). Who suffers under such extreme amounts of stress? Not only physicians, but also their families as well. However, the connection a physician has with a spouse/partner is usually the biggest source of support in the face of the challenges and stressors of practicing medicine.2 Despite the importance and value of a physician’s intimate relationships, marital challenges are ubiquitous in the relationships of doctors. A few of the common challenges physicians may impose on the relationship include overwork, a need for control, self-neglect, chemical dependency, depression and more.1 When these difficulties exist, one of the greatest obstacles physicians face in repairing their relationship is their perceived stigma. Because of this stigma, and the culture of medicine, physicians often do not seek help with their relationship or with themselves.1 This has also been one of our greatest obstacles within the education offerings of the PFSP – although many physicians have requested more information and education around healthy medical >


> relationships, they fear the potential judgment in attending such a session.

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The dual physician relationship The dual physician relationship is not that uncommon, as nearly 40% of physicians are likely to marry another physician.3 Although this union has its own unique set of challenges, such as striking a balance between work-life and home-life, it has many benefits as well. I myself have been in a dual physician relationship for the past 21 years, married for 19 of them. Having flourished despite the couples match, having children during residency and compiling medical training debt times two, I am living proof that the shared experience of the medical profession can be a source of great strength. Not surprisingly, a 2002 study looking at dual physician marriages found they have a relatively low divorce rate of 11%.4

Early intervention/prevention in medical relationships One key question to ask yourself: Does your spouse/ partner complain that you do not prioritize them high enough in your life or that you do not share enough of yourself? If you are leaning toward answering ‘yes’, or this question instills defensive feelings, the following are some simple steps you can consider: • Share a kiss before heading out the door in the morning. • Phone once during the work day – just a few minutes, sounding unhurried (even if you are) can make a big difference. • Use one another as a source of support. • Aim to set boundaries between work-life and home-life.

What should I do if my relationship is already in trouble? 1. Communicate concerns with your spouse/partner. Arguing may be a sign of trouble, but verbalizing concerns can often open up dialogue around what is fueling the conflict. Even giving this much needed attention to the relationship can be transformative.

A couple's retreat can really send the message that you are both committed to the relationship.

6. Prioritize self-care, such as seeing your own physician, tending to your own physical and emotional needs and incorporating stress management techniques, such as mindfulness and meditation. Early this year, the PFSP will be publishing an e-book to expand this discussion. It will not only include more information on physician relationships with their spouse/partner, but also relationships with their colleagues and self. We hope that this information will both increase awareness and provide resources to help physicians foster healthy medical relationships as part of their personal wellness. References available upon request.

2. Validate any concerns with information and resources through books, articles, online resources or community programs. 3. Express gratitude and appreciation for your spouse/ partner and all that they do.5 4. Attend a couple's retreat to really send the message that you are both committed to the relationship. 5. Marital therapy is a commonly accessed resource through our program and allows you and your spouse or partner to grow and learn with a trained professional. JANUARY - FEBRUARY 2016


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FEATURE

Tarrant Scholarship 2015

The future of rural Alberta medicine is in good hands Vanda Killeen | SENIOR

COMMUNICATIONS CONSULTANT, AMA PUBLIC AFFAIRS

A

warded to third-year medical students from the University of Calgary (U of C) and the University of Alberta (U of A) who demonstrate a strong interest in studying and developing a career in rural medicine, the 2015 Tarrant Scholarship funded a full year’s tuition and related fees for the winning students. It is bestowed each year by the Alberta Medical Association Section of Rural Medicine. The two most recent worthy recipients are Allyson Cornelis and Renee Deagle. They accepted their 2015 Tarrant Scholarships at a luncheon on September 30, 2015, in Calgary.

Allyson Cornelis, U of A recipient, and Dr. Tobias N.M. Gelber, President, AMA Section of Rural Medicine.

Allyson Cornelis, U of A Born and raised on a farm near Legal, Alberta, Allyson Cornelis grew up participating in many activities, including music, sports and Air Cadets.

AMA - ALBERTA DOCTORS’ DIGEST

Allyson attended the University of Alberta’s Augustana Campus in Camrose for her undergraduate degree. During her studies there, in addition to developing strong connections within the Augustana community and volunteering in Camrose, Allyson joined (and with two colleagues, later led) the Rural Medicine Interest Group. She also attended rural clinical skills weekends and had a one-month placement in Hinton. This school year, Allyson will be participating in the Integrated Community Clerkship program, completing some of her medical training in Bonnyville. Through her volunteer and placement experiences, Allyson appreciates the value of strong social networks and the sense of purpose and achievement that come from being actively involved in communities. Through her medical training and education to date, Allyson has identified continuity of care and strong physician-patient relationships as two of the most important aspects of health care delivery and she intends that these attributes will form the basis of her future medical practice. The other key aspect of Allyson’s future practice is that it’s in rural medicine, as her experiences, interests and values have led, and continue to lead, to the practice of rural medicine as a satisfying and enjoyable career.

Renee Deagle, U of C recipient, and Dr. Tobias N.M. Gelber, President, AMA Section of Rural Medicine.

Renee Deagle, U of C Renee grew up on her family’s ranch, near the Village of Consort, Alberta. While Consort itself is very small, the community provides a hub of services to a large surrounding area. Renee notes that the Consort Hospital and Care Centre provides the majority of health care services from Consort east to the Saskatchewan border. The 4-H beef club, volunteer work at her church, school sports, hockey, serving as her school’s Students Against Drinking and Driving representative, music studies and work as a lifeguard were just a few of Renee’s childhood and teen activities. Many aspects of rural life have left a lasting impression on Renee, including the high value placed on rural medical services. Renee has experienced the tragedies of people not receiving expedient medical >


> attention and she’s also seen friends and their families benefit from getting necessary emergency care in time to save lives. Renee came to her medical studies at the U of C from a career as a practicing nurse in several rural communities, including High River, Daysland, Killam, Grande Prairie, Coronation and Dawson Creek, BC. It was while living in these areas and working in their communities and rural hospitals that Renee realized her passion for rural medicine, including appreciating the close relationships that develop among colleagues and with patients in rural hospitals. In her first year of medical school, Renee completed 30 hours of rural shadowing and was voted a representative for the Rural Medicine Interest Group. Renee has completed three rural medicine electives and has applied to the rural family medicine residency programs across western Canada.

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FEATURE TD Insurance Meloche Monnex/AMA Scholarship 2015 winners Strengthening Alberta’s health care future times four!

T

he $5,000 TD Insurance Meloche Monnex (TDIMM)/Alberta Medical Association (AMA) scholarship is awarded annually to physicians, to support training they are undertaking in a clinical area of particular relevance to Albertans. Previously awarded annually to one physician, the TDIMM/AMA scholarship program was expanded last year to include four awards of $5,000 each. For 2015, the TDIMM/AMA scholarships were awarded to the following recipients, resulting in four times the benefit to health care in Alberta.

Dr. Amanda J. Brisebois, Edmonton A University of Alberta clinical associate professor, an attending physician (internal medicine) at Grey Nuns Community Hospital and Royal Alexandra (palliative care) as well as founder of a non-cancer palliative care service, Dr. Amanda J. Brisebois was awarded a TDIMM/AMA scholarship to participate in a non-cancer palliative care observership at several sites in Melbourne, Australia. Australia is a world Dr. Amanda J. Brisebois leader in providing care to patients with non-cancer chronic illness and the Royal Melbourne specifically has multiple resources for this patient population. In her scholarship application, Dr. Brisebois noted the limited number of physicians in Canada with non-cancer palliative care expertise, particularly in light of the increasing number of Canadians who will die of chronic illnesses – more than from cancer. “Although there is a clear national and provincial push to increase the awareness of the needs of this patient population, there are few clear experts in this area. Patients with severe heart, lung, kidney, hematologic,

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liver and neurologic diseases have significant symptoms in the last years of life. We hope by improving these symptoms, we will improve these patients’ quality of life,” she explained. Dr. Brisebois has already made great strides in this direction, having established a non-cancer palliative care service in the form of an out-patient clinic in Edmonton, a first of its kind in North America.

Dr. William J. Connors, Calgary With specialties in general internal medicine and adult infectious diseases, TDIMM/ AMA scholarship winner Dr. William J. Connors began his two-year masters of public health degree program (with a concentration in infectious diseases) last August at Rollins School of Public Health, Emory University, Atlanta, Georgia. In his scholarship application, Dr. Connors notes that he Dr. William J. Connors aims “to develop the skills to evaluate, design and implement effective public health initiatives so as to better serve those affected by communicable diseases in Alberta, Canada and internationally.” In addition to core course work in research methods and epidemiology, Dr. Connors intends to expand his skills through practicum work and research collaboration with the American Centers for Disease Control, closely associated with Emory University. Specifically, Dr. Connors is focusing his training on retention in HIV care, tuberculosis case management and delivery of communicable disease care to marginalized inner city populations. This training supports Dr. Connors’ belief that public health-oriented medical care for communicable diseases, such as HIV, hepatitis C and tuberculosis is in growing demand in Alberta. >


> After obtaining his MPH degree, Dr. Connors intends to return to Calgary to practice as an academic adult infectious diseases clinician, building a clinical practice based on hospital and community care as well as specialty clinical work in tuberculosis, HIV and hepatitis C. Research will remain a priority for Dr. Connors, as he hopes to continue researching effective communicable disease care delivery models for groups marginalized by our current system.

Dr. Lik Hang Lee, Calgary

Dr. Lik Hang Lee

After a year of clinical fellowship training in gastrointestinal (GI)/ hepatobiliary pathology at Memorial Sloan-Kettering Cancer Centre (MSKCC) in New York City, New York, Dr. Lik Hang Lee will return to Alberta “with a unique and valuable education and skill set” that will enable him to continue his “active role in medical education and research at the University of Calgary.”

Shortly after completing an anatomical pathology residency last June, Dr. Lee caught a plane to New York to begin his fellowship at MSKCC. Intent on acquiring expertise in the subspecialty of GI pathology, Dr. Lee was looking forward to participating in the diagnosis and management of difficult and rare GI cases, particularly GI-related cancers, as he learns directly from world experts in GI pathology. In his TDIMM/AMA scholarship application, Dr. Lee notes that the high volume of cases that go through MSKCC, in combination with the education from the experts, will help him become a “strong pathologist.” Dr. Lee explains that “GI pathology is a specialty that is more and more dependent upon new molecular pathology technologies, computer-aided analyses and diagnostic techniques that are being used at MSKCC but are not yet available in Canada. With valuable experience in these techniques, I aim to introduce them in Alberta to improve patient treatment and care.” Before he completes his fellowship studies in June, Dr. Lee will have conducted clinical and pathological research in collaboration with pathologists, clinicians and prominent researchers at MSKCC. He’ll also be continuing a project

he began there during an earlier elective: improving criteria for the diagnosis of colorectal medullary carcinomas. At MSKCC, Dr. Lee will also be actively involved in teaching and supervising pathology residents, surgical pathology fellows and medical students.

Dr. Jessica C. Wang, Calgary TDIMM/AMA scholarship winner Dr. Jessica C. Wang has just begun 18 months-to-two years of study in critical care medicine with a focus on cardiovascular intensive care and echocardiography at the Alfred Hospital in Melbourne, Australia. Upon completion of her studies and research, Dr. Wang plans to return to Calgary and with her Dr. Jessica C. Wang specialties in internal medicine and critical care medicine, work toward her goal of practicing critical care with a focus on cardiovascular intensive care. In her scholarship application Dr. Wang says, “This is an intensely multi-disciplinary subset of critical care that has been evolving as patients live with more advanced organ failure, are more challenging operative candidates and as technology and accessibility to this type of critical care improves.” Dr. Wang adds that, “Expertise in this area is becoming increasingly important with world-wide interest in the use of mechanical circulatory support (ventricular assist devices and extra-corporeal membrane oxygenation – ECMO) for both cardiac and respiratory failure.” In addition to numerous educational opportunities, Dr. Wang notes that there are active research projects with ECMO and the Alfred Hospital’s intensive care unit has a minimum of $25 million in active research annually along with close ties to the ANZICS Clinical Trials Group. Dr. Wang also hopes to participate in the Alfred Hospital’s ICU echocardiography service, performing both transthoracic and transesophageal studies on critically ill patients. In the absence of a formal “CVICU fellowship,” Dr. Wang is confident that the tailored training regimen she’s about to embark on at Alfred Hospital, with its clinical case-mix, educational infrastructure and research opportunities, will allow her to achieve her training goals.

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RESIDENTS’ PAGE

PARAdime

Alberta’s resident physicians reach out to support the most vulnerable Nicole Delaney, MD | PGY

4, ANATOMICAL PATHOLOGY, UNIVERSITY OF ALBERTA

A

s physicians, we strive to alleviate suffering and promote the health of our patients. Yet in our day-to-day work, many of us identify barriers that prevent our patients from being healthy. One of the most significant barriers encountered is the lack of access to the basic necessities of life – things like a safe place to live, sufficient food to eat or a social network to provide support during difficult times. Those in poverty often face additional challenges when they become ill – taking medication often takes a back seat to finding a place to sleep or food to eat. During residency, much of our training and evaluation is structured around the CanMEDS framework of essential physician competencies provided by the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada. One of these essential competencies is being a health advocate, contributing our expertise and influence as we work with communities and patient populations to improve health. This is not simply a checkbox to complete on an evaluation form. Although we traditionally diagnose and treat disease, doctors know it is equally important to help promote health and well-being in our communities. There’s a direct correlation: helping people to achieve safe housing and strong social networks in turn helps to promote health and wellness in our communities. As health care providers, we are motivated to help people. Sometimes providing that help requires stepping out of our traditional doctor-patient roles and finding different ways to help those in need. And as an additional benefit, if we can help improve the health of some of the most vulnerable, it can relieve some of the stress on an overburdened health care system. For the past seven years, Alberta’s resident physicians have partnered with local community shelters to support some of the most vulnerable through the annual PARAdime campaign. By collecting everyday necessities and donating them to homeless shelters across the province, resident physicians are able to be involved with our local communities and help create positive change.

AMA - ALBERTA DOCTORS’ DIGEST

Although we traditionally

diagnose and treat disease, doctors know it is equally important to help promote health and well-being in our communities.

PARAdime is coordinated by resident physicians through our professional association, the Professional Association of Resident Physicians of Alberta (PARA). We are very pleased to be collecting donations on behalf of local community organizations in six cities and towns across the province. The wonderful community organizations we are partnered with this year are: the Youth Empowerment and Support Services (YESS) in Edmonton, the Calgary Drop-In and Rehabilitation Centre, the Safe Harbour Society in Red Deer, the Rotary House in Grande Prairie, the Wood’s Homes in Lethbridge and the Salvation Army Family Support Services in Medicine Hat. >


> I have had the privilege of assisting in the collection and drop-off of donations at YESS in Edmonton for the past three years. YESS is an inspirational non-profit organization that is dedicated to supporting at-risk youth and offers ongoing support programs as well as emergency assistance. It has been incredibly rewarding to work together with other resident physicians as a group to collect important everyday necessities – such as warm winter clothing, toiletries and non-perishable food – to help make a small but valuable difference in someone’s life. The most gratifying aspect of the entire campaign was to hear from staff at the shelter about the positive impact of our donations. For many at-risk youth, receiving these donations was one of their most positive interactions with doctors and the health care system. We have been told that the youth really looked forward to opening up bags of donated items to see what was inside.

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Dr. Nicole Delaney (L) and Dr. Natalie Logie (R). The PARAdime campaign collects everyday necessities and donates them to homeless shelters across the province.

Regardless of how you choose to help out, I encourage all of you to continue your personal efforts to be a health advocate in your local community. Although we all struggle occasionally to feel like we are truly making a difference, every small action is valuable. In the words of Aesop: “No act of kindness, no matter how small, is ever wasted.”

LOOKING TO SET UP YOUR PRACTICE? WE’RE JUST WHAT THE DOCTOR ORDERED.

If we can help improve the health

of some of the most vulnerable, it can relieve some of the stress on an overburdened health care system.

One of my greatest life lessons is that most people have ongoing challenges in their lives that they often do not share openly with friends and colleagues. Luckily, as doctors, most of us have social and financial supports that help us to cope with adversity. Not everyone is as fortunate to have such advantages when they face challenging life circumstances. It is my sincere hope that our donations help to make life a little easier for some of those going through tough times. For the 2015-16 PARAdime campaign, resident physicians collect donations from late November 2015 until the end of January 2016. Collection boxes for donated items have been set up in hospitals in Calgary, Edmonton, Grande Prairie, Lethbridge, Medicine Hat and Red Deer. We invite all staff and medical students to help us give a helping hand to those in need in your local communities. Although the needs vary by community, we are looking for gently used winter clothing, non-perishable food and toiletries. For more information on how to help out, please visit the PARA website: https://para-ab.ca/ paradime-campaign/.

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IN A DIFFERENT VEIN

Oranges, lemons and muktuk Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

I

was going to rant about current Canadian politics – the Eastern media besotted with the Bonnie Laddie; the breathless hubris that “Canada is Back” (Back in debt? Back in blue berets? Back in the delusion of being loved by the world?); the applause of Ottawa’s worryingly partisan civil service and the strange assertion that Canada has been liberated from a vicious dictatorship (my amiable MP for Calgary South-West) – but it makes me want to gag and cry, "Ruth", as the Aussies say. These blowhards will soon experience the fine Canadian tradition of devouring politicians. Okay, enough boyo. Nine years ago in November, we sailed a rollicking passage from Bermuda to St. Martin with blows of 40 knots plus. One of the crew, Dan, a Newfie, would say (hinting we should reef the sails) “Boy this wind … She’s blowing the arse out of her.” In the cabin one night I was praising the book Scurvy by Stephen Bown, and Dan pipes up: “Boy, I know his father. Contact Stephen. He lives in Canmore.” Alberta sometimes surprises us with artists and writers globally known, less known in their home province. Stephen Bown is one of those – a rattling good Canadian author and biographer of interesting people and interesting times. His novels include The Last Viking, Madness, Betrayal and the Lash, Scurvy and many others, including his latest, White Eskimo. I finally met Stephen last December (see photo). So as an antidote to these horrific, crazy times, let’s look at a couple of Stephen’s books where he’s brought back to life people who brought change, in times just as awful, in a valuable, enduring way and who believed in themselves, persisting despite set-backs. “I first did biology at the University of Alberta, but didn’t think it was for me. I’d always loved history so switched to that but realized I didn’t want to teach history. Maybe I could combine science and historical research to scratch a living doing what I enjoy,” says Stephen.

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Oh, I’d like to do that too, I thought, but then he said he gets about $2 for each sale of a $34 book, so stuff that, I thought. At least he doesn’t need to worry about those taxation plans for the filthy rich hatching all around us. “Writing as a living is not getting easier,” says Stephen. “The book review section in newspapers is shrinking. One review is syndicated to all the papers. My current one in the Calgary Herald is wedged in at the back of the new condos section! In my books I try to entertain as well as inform. There are a few tricks writers use – such as establishing an interesting or tense scene to hook a reader. You then have time to create the background and characters.” For physicians, his acclaimed book Scurvy is a must-read. The characters and problems don’t change much over the centuries. And now with his latest book White Eskimo, I thought it nice to look at two fine characters brought to life by Stephen Bown – one a Scots physician, the other a Danish explorer and anthropologist.

How do you take an observation that

flows against the current of contemporary theories? Four out of five off-the-wall ideas are just that. Crackers.

Scurvy In the stone walls of Edinburgh Medical School was a plaque we moseyed past each day, ignoring it in the dazed way of students with much more important things on our minds. Here we find James Lind, described as The Hippocrates of Naval Medicine. He had a kindly face, a hooked nose and was topped with a powdered wig (see illustration) – an old dude of no great interest and yet he epitomized the huge paradigm shift from the world where a physician was judged by his ability to spout learned tripe on theories of disease doused with Latin, >


> toward a world of science, of clinical observation and hypothesis testing. It was the era of the personal case, the era of “… in my experience.” And Lind, as much as anyone, helped to lead us out of those dark, benighted times – which even today threaten to creep back.

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“After the Seven Year War with France, there was a stunning statistic,” says Stephen. “In 1763 the casualty list for British sailors was incredible – out of 184,899 men rounded up for the war (often using the press gang), 1,512 were killed in action while 133,708 died of disease, mainly scurvy!” There were clues as to how to prevent this carnage, mostly ignored. The explorer, Jacques Cartier and his crew 200 years earlier were plagued by scurvy and as my grand-daughter, Alexandra, told me, the local natives showed him the juice of the white cedar. In 1747, Dr. James Lind, newly appointed ship’s surgeon, boarded HMS Salisbury, a Man o’ War sailing the English Channel. Despite being near land, the ship was soon plagued with scurvy. Lind conducted one of medicine’s first clinical trials. There were some 80 sailors on board suffering from scurvy: swollen, putrid, bleeding gums; loose teeth; blotchy skin rash; old wounds breaking open; extreme weakness and mental lethargy.

You have to take your time,

getting a few supporters who realize you’re not daft. Then try to get support of someone with influence to persuade the masses.

“Imagine how difficult it must have been,” said Stephen. “A sickbay no bigger than this office we’re in now, with a dozen hammocks with moaning men swaying back and forth, and the foul stench of scurvy, recording clinical details with a quill pen. I don’t know how he did it.” “Lind’s trial would have been thrown out by a contemporary ethics committee,” I said. “There was no protocol, no inclusion/exclusion criteria, no stats section, no consent form and no money.” Lind performed what he called “a fair test” of some of the many useless “cures” for scurvy. For readers that like to think in boxes, please see the Consort Diagram, which would be required for publication in The Lancet or New England Journal of Medicine today. The two receiving the oranges and lemon ate them greedily, returning to duty within six days. The remainder died, although the two receiving cider “seemed to get no worse for a while.” Kaplan-Meier curves, a conflict of interest statement and a note of thanks to the study

Dr. Alexander H.G. Paterson (L) offers keen observations for doctors based on several books written by Alberta's Stephen Bown (R).

participants are not reported. Some contemporary university students would no doubt want to tear down Lind’s plaque because of his unethical behavior, but as an exercise in clinical observation and reporting in the stinking, slimy conditions of a cramped navy sickbay amid roiling seas, it is unparalleled. Publication was the key. And the results in time led to the prevention and cure of scurvy, such that we now take Lind’s findings entirely for granted – so much so that huge amounts of ascorbic acid (immediately excreted into the urine) are now uselessly squirted into well people as a “wellness” potion to prevent something. “In those days, publication was not the easy matter it is today and it took him six years,” says Stephen. “Their lordships of the Admiralty in the meantime eagerly promoted the idea of sea water as an anti-scorbutic – of which there was a plentiful supply.” “No doubt Alberta Health Services would have been on side with that,” I said. “But hang on – it sometimes takes me six years to get something published.” Stephen continued: “This trial, this ‘fair test’, was ignored for many years. Captain James Cook followed Lind’s advice on his voyages and had little problem with scurvy, and yet such were the entrenched interests, unenlightened fiscal tightness and disregard for human life, that Cook’s experience was ignored. From the time of Lind’s experiment, it took 48 years before the Admiralty routinely issued lemon juice as an antiscorbutic – largely as a result of the lobbying of Sir Gilbert Blane, an aristocratic physician who had the ear of their lordships.” >

JANUARY - FEBRUARY 2016


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> It’s a nasty tale of physicians promoting their cures with no concern for conflicts of interest (the Irish physician Macbride shamelessly promoted “malt of wort” and for a while this useless remedy was the Admiralty’s antiscorbutic of choice). How do you take an observation that flows against the current of contemporary theories? Four out of five off-the-wall ideas are just that. Crackers. So you have to take your time, getting a few supporters who realize you’re not daft. Then try to get support of someone with influence to persuade the masses. Lind did that but it took time. You’re up against vested interests, budgets and lazy thinking. We need not be so critical and snooty, either. It took a similar time, for example, for the surgical community to accept the early observations of George Crile of the Cleveland Clinic and Bernard Fisher in Pittsburgh in the early 1960s that breast conservation surgery and radiation gives the same survival as a radical or simple mastectomy (NB: surgeons prefer “total mastectomy” to “simple mastectomy” since there can be misunderstanding as to whether “simple” refers to the procedure or the operator).

… those are the qualities that

make a truly great person in my eyes: keen observation of the reality of life and courage to face the spears and arrows of conventional wisdom, yet faith in their observations while willing to entertain the objections of others.

And the peptic ulcer and Helicobacter pylori story – obvious now, but I remember dear old Dr. Mclean Ross, surgeon, in Edinburgh saying as we did our third vagotomy and pyloroplasty for gastric ulcer that week, shaking his head: “Aye, oh dear, dear … These type A personalities …” And with the surging onslaught of the tyranny of Twitter with its flocks of sheep and the flakiness of Facebook with auto-links to “How I lost 50 pounds in two weeks” and “Secret cures your doctor does not want you to know,” we can expect the asinine arrogance of the personal anecdote to survive and flourish for a good while yet.

White Eskimo If you like boisterous parties, Knud Rasmussen was your man. At stuffy meetings in Copenhagen, he was apt to leap up and grab the microphone, delivering an impromptu speech that brought a boring gathering to AMA - ALBERTA DOCTORS’ DIGEST

Dr. James Lind performed what he called "a fair test" of some of the many useless "cures" for scurvy.

life. He shared with James Lind the virtue of humility but was quite a different character: popular, energetic, brazen at times, loving a party yet driven and striving for academic approval. He was always modest about his own achievements, emphasizing the contributions of others. But like Lind, he had faith in his observations. Danish, one-eighth Inuit, he lived in the early 20th century between two starkly different worlds: the fierce climate, topography and poverty of Greenland and the cosmopolitan world of Copenhagen. He had that magical energy and ability to rally people around him to greater effort in the face of despair, hardship, starvation and danger – amazingly without ever enrolling in a “You Too Can Be A Leader" course. On his expeditions, rations of meat and muktuk (whale blubber – I’ve tried it and you can have it) depended on hunting and if there was no hunting, well … tough luck, suck it up. It’s what being a real leader is about. He was a master of survival in the grimmest of Arctic conditions. And he had that ability to connect with all people, but especially the shy Inuit. I think we’ve forgotten how grim life was up there 80 years ago. As an old Inuit said to Rasmussen: “Oh, you strangers always see us happy and free of care. But if you knew the horrors we often have to live through, you would understand why we are so fond of laughing. There is not one amongst us but has experienced a winter of bad hunting when many starved to death in front of our eyes.” Stephen Bown describes an Inuit birth during a sled run: “… blowing snow and biting winds … they could find no shelter in the open landscape … the dogs were blown off their feet by gusts … they tried to build an igloo but the snow was too dry so they overturned sleds to make a barrier against the ferocious gale … As she could not undress in the freezing cold, they slit a small opening in her pants and held her in a crouching position until the baby emerged. The new mother quickly snatched the child inside her coat, wrapped some skins around him and soon had him warm and snug.” And of the primal nature of Inuit life in the 1920s with starvation forays in search of meat, he writes: “One dog on the trail gave birth to nine puppies, whereupon the others rushed in and ate eight of the pups; the mother then devoured the ninth herself.” >


> This is the first biography in English of Knud Rasmussen, the first explorer to lead a team of dogsleds across the high Arctic, a winding trek from Greenland to Alaska. He showed that the Alaskan, Canadian and Greenlander Inuit were one people sharing a language and culture, even though few had been in contact with each other for centuries. During his Arctic expeditions he recorded the songs, poetry and stories of the Inuit which were in danger of dying. In contrast to the Danish government’s policy of “protecting” the Inuit from “civilizing influences,” he recognized that contact with the outside

world was inevitable and that a gradual process might allow these hardy people to best adapt. The outside world was steadily encroaching the Inuit. And, colleagues, those are the qualities that make a truly great person in my eyes: keen observation of the reality of life and courage to face the spears and arrows of conventional wisdom, yet faith in their observations while willing to entertain the objections of others. And the fortitude to persist.

Consort Diagram for The Lancet of “A Clinical Trial of Currently Used Anti-Scorbutics in the British Navy.” Dr. James Lind 1747.

ENROLLMENT

Assessed for eligibility n = 80 ordinary/able sailors and officers with definite symptoms of the scurvy.

Excluded (n = 64) Not meeting inclusion criteria (n = 0) Refused to participate (n = 2 flogged, died.) Still fit for service (n = 60) Other reasons (n = 2. Inappropriate to randomize gentlemen with better diet.)

ALLOCATION

Allocated to intervention (n = 12) Gp 1 (n = 2) : 1 quart cider daily. Gp 2 (n = 2) : 25 drops oil of vitriol t.i.d. Gp 3 (n = 2) : 2 spoons vinegar t.i.d. Gp 4 (n = 2) : nutmeg paste, garlic and barley t.i.d. Gp 5 (n = 2) : half pint of sea water daily. Gp 6 (n = 2) : 2 oranges and 1 lemon daily for 6 days. Did not receive allocated intervention (n = 0) (give reasons: No choice.)

Allocated to Control Group. (n = 4) Received standard allocated intervention of hammock rest, salted beef, ship’s biscuit and 3 pints beer daily (n = 3) Did not receive allocated intervention (n = 1) (went mad, died before start of study)

FOLLOW UP

Lost to follow up (n = 0) Discontinued intervention (n = 12) (reasons: 10 died; Gp 6 : ran out of oranges and lemons after 6 days.)

Lost to follow up (n = 0) Discontinued intervention (n = 3) (reasons: 3 died.) Did not receive intervention: 1. Died

ANALYSIS

Randomized (n = 16) Method: Chance. 1 case (answering back) Captain insisted allocation to Gp 5

Analyzed (n = 12) Excluded from analysis (n = 0)

Analyzed (n = 4) Excluded from analysis (n = 0)

JANUARY - FEBRUARY 2016

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CLASSIFIED ADVERTISEMENTS

PHYSICIAN WANTED AIRDRIE AB A well-established clinic in Airdrie is seeking family physicians and pediatricians to join our team. We are a collaborative group of physicians who believe in quality patientcentered care and the medical home model. As a member of the Highland Primary Care Network, we have multidisciplinary team members and proactive office encounter technicians on site. We are currently completing AIM and maximizing our electronic medical record capabilities. We are home to four family physicians, one gynecologist and a visiting internal medicine specialist. We offer flexible scheduling and a competitive split. Airdrie is a young and vibrant community of 60,000 and is one of the most rapidly growing cities in the country. Consultant and primary care pediatricians are welcomed as we have a young population with over 1,200 deliveries per year. Airdrie is home to a busy urgent care facility that welcomes qualified community family physicians. Physicians licensed to practice in Alberta, including new graduates are welcome. Contact: Dr. Tammy McKnight T 587.969.7647 drtammymcknight@gmail.com CALGARY AB Westbrook Medical Clinic in southwest Calgary is recruiting four full-time psychiatrists and four full-time family physicians. We have been serving a diversified community of children, adults and seniors for 30 years. We have four full-time family physicians, one full-time psychiatrist, one part-time nurse, one behavior therapist, four experienced medical receptionists and a full-time office manager. Office is computerized but will accommodate physicians AMA - ALBERTA DOCTORS’ DIGEST

who are computer shy. Calgary is a short distance from the famous Rocky Mountains where there are exceptional skiing areas and great hiking trails. Calgary has an active social and cultural scene; good housing and schools available. I am familiar with the permanent residency process to Canada. I don’t have a website but I am happy to speak with you by phone. Email me a suitable time and we can connect via whatsapp. Contact: Dr. Shashi Lota, Medical Director or Roseli, Clinic Manager T 403.246.0877 shashi.lota@hotmail.com CALGARY AB Crescent Medical Centre is a paperless, modern, fully equipped clinic in southwest Calgary. We are currently recruiting permanent partor full-time family physicians and specialists at negotiable terms. We offer full staff support, low overhead, friendly and professional environment. The clinic is a member of Calgary West Central Primary Care Network and committed to provide timely, comprehensive and continuous care of high standards, based on current best evidence. The candidates must hold a license by the College of Physicians & Surgeons of Alberta. Contact: Dr. Saad Yasin Crescent Medical Centre 923 37 St SW Calgary AB T3C 1S4 T 587.318.1608 F 403.727.6772 crescentmedcentre@gmail.com www.crescentmed.ca CALGARY AB Pain specialist Dr. Neville Reddy is looking to recruit physicians (general practitioners and specialists) to join his team of dedicated health care professionals. Innovations Health Clinic has two locations (southeast

and southwest), favorable 30% expenses offered. Contact: Dr. Neville Reddy, MB ChB, FRCPC (Anesthesia) T 403.240.4259 C 403.689.4259 nreddy@innovationshealth.ca innovationshealth.ca CALGARY AND EDMONTON AB Retiring? Semi-retiring? Want someone to take over your panel? Imagine Health Centres (IHC) is growing and welcomes semi-retired and/or retired physicians who want to ensure continuity of care for their patients. Come work part-time, full-time or allow us to introduce ourselves to your patients. Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. IHC prides itself in providing the best support for family physicians and their families in and out of the clinic. Health benefits plan and full financial/tax/accounting advisory services are available to all IHC physicians. Do you want your patients to be cared by a team that collaborates with other health care professionals for enhanced patient care? Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB Villa Caritas, Edmonton’s acute psychogeriatric hospital, 16515 88 Avenue in Edmonton, is recruiting a general practitioner to share the general medical care of 150 patients. This is a minimum 0.4 position to start on April 1. Remuneration is fee-for-service. Contact: Medical Director Villa Caritas 16515 88 Avenue Edmonton AB T5R 0A4 sandra.demaries@covenanthealth.ca >


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EDMONTON AB Immediate opening for family physicians; new graduates welcome. Join a group of established physicians who will be happy to encourage and mentor new physicians. Very challenging clinical medicine. Busy northeast clinic in a well-equipped, modern professional building. No capital investment or management responsibilities. High income, medical teaching facility and part of the North Edmonton Primary Care Network. Contact: Thomas Bray T 780.476.6744 tombray@telusplanet.net EDMONTON AB Family physician, pediatrician or internal medicine specialist needed part- or full-time for well-established south side practice. Stable patient population for more than 40 years, new and modern office with dedicated staff. Pharmacy and medicentre in the same mall location. Excellent opportunity for all types of practice. Contact: T 780.435.3648 (doctor line only) F 780.435.3691 EDMONTON AB Two positions are immediately available at the West End Medical Clinic/M. Gaas Professional Corporation at unit M7, 9509 156 Street, Edmonton AB T5P 4J5. We are also looking for specialists; internist, pediatrician, gynecologist and orthopedic surgeon to join our busy clinic. 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 patients of different age groups including pediatric, geriatric, antenatal and prenatal care.

Physician income will be based on 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. We offer flexible work schedules, so the physician can adopt his/her work schedule. We also will pay up to $5,000 to the physician for moving and relocation costs.

Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 F 780.756.3301 westendmedicalclinic@gmail.com EDMONTON AB Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC) want you. To meet the growing needs, we have a practice opportunity for family physicians at PMC and MMMC. Both clinics are in south Edmonton. PMC and MMMC are high-patient volume clinics with friendly reliable staff for billing, referrals, etc., as well as an on-site manager. Enjoy working in a modern environment with full electronic medical records. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatric). Both clinics have on-site pharmacy, ECG machine, lung function testing and offer a large array of specialist services including: ENT, endocrinologist, general surgeon, internist, orthopedic surgeon, pediatrician and respirologist. PMC and MMMC are members of the Edmonton Southside Primary Care Network which allow patients to have access to an on-site dietitian and mental health/psychology/psychiatry health services. Overhead is negotiable, flexible working hours and both clinics are open seven-days-a-week. Contact: Harjit Toor T 587.754.5600 F 587.754.8822 manager@parsonsmedicalcentre.ca EDMONTON AB Family medical clinic in west Edmonton is seeking part- and/or full-time family physicians. We offer flexible hours, low overhead (negotiable), fully computerized clinic using Mediplan electronic medical records. The clinic is associated with Edmonton West Primary Care Network. Contact: Dr. Patocka T 780.487.7532 foodprex@telus.net EDMONTON AB Imagine Health Centres (IHC) is expanding and looking for the best to join us immediately! Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. IHC prides itself in providing the 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. We currently have openings for the following at our west end, Windermere or Park Centre locations in Edmonton: Part- and full-time family physicians, neurologist, internal medicine specialist and gynecologist. Do you want to be part of a team that collaborates with other health care professionals for enhanced patient care? Do you want to make a difference in your patients care and take a proactive instead of a reactive approach to health care? Compensation is fee-for-service and inquiries are kept strictly confidential. Only qualified candidates will be contacted. Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB To meet the growing need, we have a practice opportunity for gynecologists to join the Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC). The PMC and MMMC are in south Edmonton and have high patient volume. You will enjoy working in a modern environment with complete electronic medical records, gynecology equipment, supplies and sterilizer. There are a minimum of two examination rooms per physician, dedicated work/private office for physicians. Friendly and reliable staff for billing, referrals, etc., and onsite manager. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatrics).Both clinics have a pharmacy onsite, ECG machine and lung function testing. Overhead is negotiable, flexible working hours and both clinics are open sevendays-a-week. Terms of employment and wages; this position is permanent, part-time/ full-time fee-for-service with anticipated annual income of more than $300,000. Anticipated start date is as soon as possible. Contact: Harjit Toor Parsons Medical Centre 105-625 Parsons Rd Edmonton AB T6X 0N9 T 587.754.5600 manager@parsonsmedicalcentre.ca > JANUARY - FEBRUARY 2016

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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. Benefits and incentives of being part of our clinics include the convenience to work at any of our locations, part- or full-time available, attached to a primary care network, nurse for physician’s patients provide one-on-one, on-site diabetic management care and comprehensive medical follow-up visits. Therapists at our clinics provide one-on-one consults. Seminars and dinner workshops credit go toward their licence. Flexible hours, vast patient circumference looking for family doctors, continuing care and learning opportunities for accredited doctors. Full-time chronic disease management nurse to care for chronic

AMA - ALBERTA DOCTORS’ DIGEST

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. Contact: Management Office T 780.757.7999 or T 780.756.3090 F 780.757.7991 mdgroupclinic@gmail.com lessardclinic@gmail.com SHERWOOD PARK AB Synergy Medical Clinic is seeking the services of a physician interested in accepting new patients and taking patients for a physician retiring early this year. The successful candidate must commit to building a patient panel and providing on-going comprehensive care to his/her cohort of patients. The clinic is located in Sherwood Park at the Synergy Wellness Centre and is part of the Sherwood Park-Strathcona County Primary Care Network. We offer physicians a collegial and collaborative environment where one can provide care to a wide range of patients. Physicians are supported by a tremendous team and the clinic uses Wolf electronic medical records for enhanced patient care. Physician compensation is based on fee-for-service payment. The interested 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. Relocation reimbursement is available for interested out-of-province physicians. Contact: Mel Snihurowych Chief Administrative Officer T 780.400.3303 msnihurowych@ synergymedicalclinic.ca www.synergymedical.ca

PHYSICIAN AND/OR LOCUM WANTED SHERWOOD PARK AB The Sherwood Park Primary Care Network is looking for several physicians to cover a variety of locum periods in a variety of Sherwood Park offices. Practice hours vary widely. Majority of practices run electronic medical records. Fee splits are negotiated with practice owners. Some practices are looking for permanent associates. Contact: Dave Ludwick T 780.410.8001 davel@sherwoodparkpcn.com SHERWOOD PARK AB Dr. Patti Farrell & Associates is a new busy modern family practice clinic with electronic medical records and require locum coverage periods throughout 2016. Fee split is negotiable. Current clinic hours are Monday to Friday 8 a.m. to 4 p.m. are negotiable. Dr. Farrell is a lone practitioner (efficient clinic design built for two doctors) looking for a permanent clinic associate. Contact: C 780.499.8388 terrypurich@me.com

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WEST COAST WAYFARER June 13-19 Focus: Internal medicine and infectious diseases Ship: Crystal Serenity BALTIC AND NORTHERN CAPITALS June 19-July 1 Focus: Cardiology, neurology and gastroenterology Ship: Celebrity Silhouette GREECE AND TURKEY July 9-16 Focus: ER medicine: Novice to expert Ship: Celebrity Equinox ICELAND AND NORWAY July 16-28 Focus: Neurology, cardiology and psychiatry Ship: Holland America Zuiderdam MEDITERRANEAN August 7-21 Focus: Psychiatry and endocrinology Ship: Navigator of the Seas September 24-October 8 Focus: Guide to healthy heart living Ship: Celebrity Silhouette ALASKA GLACIERS August 14-21 Focus: Renaissance in primary care Ship: Celebrity Infinity JAPAN AND KOREA September 18-29 Focus: Endocrinology and dermatology Ship: Celebrity Millennium HAWAII October 15-22 Focus: Family medicine (University at Sea) Ship: NCL Pride of America DUBAI AND UNITED ARAB EMIRATES October 24-November 3 Focus: Exploring the world of medicine Ship: Azamara Journey TRANS-ATLANTIC BARCELONA TO BARBADOS November 5-21 Focus: Mental health in the workplace Ship: Silver Spirit

BAHAMAS SANDALS RESORT November 6-13 Focus: Bringing best evidence to MDs Resort: Emerald Bay, Exuma Island TAHITI AND MARQUESAS November 19-December 3 Focus: Endocrinology and dermatology Ship: Paul Gauguin SOUTHERN CARIBBEAN December 21-January 2, 2017 Focus: Clinical pearls in primary care Ship: Celebrity Eclipse SOUTH AMERICA January 22-February 5, 2017 Focus: 4th Annual McGill CME Conference Ship: Celebrity Infinity AUSTRALIA AND NEW ZEALAND February 5-7, 2017 Focus: Optimizing patient care Ship: Celebrity Solstice BAHA AND SEA OF CORTEZ February 9-21, 2017 Focus: CME with BC Medical Journal Ship: Azamara Quest RHINE AND DANUBE RIVER September 1-16, 2017 Focus: Clinical update in medicine Ship: Avalon For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

service and information security management. Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com PHYSICIAN RECRUITMENT SERVICE Global Medics Canada have been successfully placing family physicians in roles across Canada for the last six years and are currently working with many Canadian and CFPC eligible physicians from the United Kingdom, Ireland and Australia looking for short, medium, long term and permanent roles in Alberta. Company and service overview plus many fantastic references available on request. We can help you recruit the perfect family physician for your clinic in the most efficient and hassle free way possible. No money is due upfront and no exclusivity is required. Our placement fee is only payable once the (recruited) physician has arrived and started work for you. If you’re interested or just keen for further information, please contact us: Contact: Phil Martin Business Manager T 250.307.4352 phil@globalmedics.com

DISPLAY OR CLASSIFIED ADS

SERVICES DOCUDAVIT MEDICAL SOLUTIONS

TO PLACE OR RENEW, CONTACT:

Retiring, moving or closing your practice? Physician’s estate? DOCUdavit Medical Solutions provides free paper or electronic patient record storage with no hidden costs. We also provide great rates for closing specialists.

Daphne C. Andrychuk

DOCUdavit Solutions has achieved ISO 9001:2008 and ISO 27001:2013 certification validating our commitment to quality management, customer

Communications Assistant, Public Affairs Alberta Medical Association T  780.482.2626, ext. 3116 TF  1.800.272.9680, ext. 3116 F  780.482.5445 daphne.andrychuk@ albertadoctors.org

JANUARY - FEBRUARY 2016

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