Alberta Doctors' Digest July/August 2015 by Alberta Medical Association

Alberta Doctors'

DIGEST July-August 2015 | Volume 40 | Number 4

Aging, seniors and caregivers A special issue about one of the most important themes in health care today What are our seniors worth? Dr. Jasneet K. Parmar explores the value of seniors in our society

A coalition, a conference and a conversation Groundbreaking Alberta Medical Association research on seniors' issues at the Alberta Seniors Care Coalition Conference

Want to know the real reason for caregiver burnout? A blogger and author talks candidly about the toll of caregiving

Patients First速

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

President-Elect: Carl W. Nohr, MDCM, PhD, FRCSC, FACS Immediate Past President: Allan S. Garbutt, PhD, MD, CCFP 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 September-October issue deadline: August 14

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor. The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association. © 2015 by the Alberta Medical Association Design by Backstreet Communications

From the Editor Health Law Update Mind Your Own Business Insurance Insights Dr. Gadget

28 35 38 39

PFSP Perspectives In a Different Vein Letters Classified Advertisements

FEATURES

Editor-in-Chief: Marvin Polis President: Richard G.R. Johnston, MD, MBA, FRCPC

5 10 12 16 26

7 What are our seniors worth?

A “care of the elderly” physician reflects on the value that society draws from this remarkable patient population

9 Want to know the real reason for caregiver burnout?

Blogger and author Bobbi Junior talks candidly about the extreme toll of caregiving on families and loved ones

19 Our health care system must support the triumph of aging

Canadian Medical Association president calls for a National Seniors’ Strategy

20 High drama!

Alberta physician dodges the enemy, goes on to a remarkable career

22 A coalition, a conference and a conversation

Seniors’ care is the common denominator for important Alberta Medical Association activities

32 The Physician Learning Program is celebrating a big birthday

What can this five-year-old do for you?

34 What’s new on the web? Times, they are a-changing …

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

COVER PHOTO:

Dr. Jasneet K. Parmar reflects on care of the elderly in our special issue on aging. ( provided by Curtis Comeau Photography) JULY - AUGUST 2015

A SPECIAL ISSUE ON AGING

Dear reader Marvin Polis | EDITOR-IN-CHIEF

atching others become older. Getting older ourselves. Working for the elderly in our health care system. Fighting negative stigma. Asking hard questions â&#x20AC;&#x201C; about your patients or your own practice. Remembering to laugh. These are just a few of the themes we explore in this special issue of Alberta Doctors' Digest. There is no simple answer to the deceptively simple question: What does aging mean in Alberta today? I hope you will enjoy the thoughts of our guest writers and our columnists who kindly turned their contributions toward this theme. I would be glad to hear from you about the issue. Email me care of amamail@albertadoctors.org. And be sure to view my intriguing video interview with blogger/author Bobbi Junior on this important topic of aging and being a caregiver in Alberta. Visit https://youtu.be/jo5FWWN7TCk. Marvin Polis Editor-in-Chief

AMA - ALBERTA DOCTORSâ&#x20AC;&#x2122; DIGEST

FROM THE EDITOR

Changing things Dennis W. Jirsch, MD, PhD | EDITOR

“The mistakes are all there, waiting to be made.” - S.A. Tartakower, Russian chess master, speaking of the chess board at the beginning of a game.

e’re off and running with a new political regime at the helm of the province. Many of us are hopeful of developments that will benefit patients and staff alike. In the past two decades we’ve seen non-stop change with dramatic devolution of the system into 17 regions in 1995, rejigging into nine regions in 2003 and then an about-face reversal with total centralization and the formation of Alberta Health Services (AHS) in 2008.

Some think, against this background

of organizational tumult, that further change (to Alberta’s health care system) could be as radical as anything we’ve seen so far.

It’s been a rocky road throughout, requiring revamping of organizational charts, letterheads and signage every couple of years, but rolling personnel changes have provided a dark game of “musical chairs” as jobs disappear and reappear. It’s difficult to find much in the way of recent improvement. Since the advent of AHS, a number of chief and senior executives have come and gone, and in a bizarre political move, the AHS board and board chair were fired two years ago over issues of executive pay. As if this turbulence weren’t enough, there have been a series of management fads throughout the constituent organizations and AHS over the years, with intermittent focus on: accountability; patient-focused care; care maps;

quality improvement; business process engineering and so on. Each of them held sway for a time, but were eventually superseded. Some think, against this background of organizational tumult, that further change could be as radical as anything we’ve seen so far. Dr. Thomas W. Noseworthy, well known for his numerous roles in health care throughout the province over many years, has urged in a recent editorial, “Let’s make the system work, not change it.”1 Tom is arguing, I think, that the system, such as it is, has had about as much change as it can handle. There’s a kind of organizational post-traumatic stress disorder at work. Many workers’ experiences have left them distrustful and disengaged; they’re tired and hunkered down as they brace for further change. The system has held up to the extent it has because health care is inherently local and decentralized, involving a patient, his or her issues and the necessary resources. Much that is external to this may be well meaning but amounts to interference and greater complexity. I’m reminded of former US President Ronald Reagan’s nine most terrifying words in the English language, “I’m from the government and I’m here to help.” It might still apply if “AHS” replaced the word “government” in the president’s phrase. I concur that some degree of constancy, of permanence, to health care structure and function is desirable. One can’t include all change, however, since it is axiomatic that if nothing is changed then nothing will change. Perhaps it is attitudinal change I’m looking for, with more involvement of patients and their families and with professionals, however AHS is configured. Then too, I’d like to see any board structures that are reinvented populated with typical citizens, rather than party faithful or business bigwigs. In the early months of the new regime, I expect there will be all sorts of “dog and pony shows” as ministerial types, bureaucrats and the professions mingle. Each will argue for special status or more resources. There may be special circumstances, but I don’t think a big slug > JULY - AUGUST 2015

> of money is in the offing, even given a left-of-center government. Many remember a year in the mid-90s when former Alberta Premier Ralph Klein pulled out about a fifth of health care dollars. General dismay followed, with public uproar, and in subsequent years health budgets generally prospered in a relative sense. Arguably though, much of the new and restored funding was spent higgledy piggledy and without an overall plan. The amount the province spends on health care is approaching 40% of its total budget and is perceived as a monster that must be reined in. Going forward, as they say, it will still likely be all about money. Dr. Noseworthy has been key in the development of Strategic Clinical Networks in AHS that look to optimize clinical activity. Perhaps Tom is referring to these in his editorial when he suggests, “There are early signs and a reasonable possibility that Alberta could become the best health system in Canada.”

There may be special circumstances, but I don’t think a big

slug of money is in the offing, even given a left-of-center government.

I’d like to hear a lot more about possible successes, however preliminary. We all would. Benchmarking will evidently be a major tool in the efficiency drive. The term comes from the chiseled horizontal marks that surveyors make as reference points, but has come to refer to the process of comparing one’s business (health care) processes to others that are more efficient and effective. The effort aims to reduce variation from what is considered optimal and is conceptually related to earlier initiatives involving care algorithms or care maps. Care maps were an interesting exercise and may have changed some care, but they were all too often amalgams of common practice rather than best practice, and seldom revisited from a quality improvement perspective. If the main impetus for benchmarking is saving money, precisely what is being measured, and on what basis, becomes extraordinarily important. Benchmark activities that are not germane to the common patient experiences of poor access, or inordinate delay, won’t help the organization move forward. AHS should focus on communication activities. We readily hear about large events, as when a building opens, or when an organizational nabob departs or when ERs or ORs are clogged. In contrast, glossy

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magazines and newsletters depict a world that is only sunny. There’s a gap here, and an appetite for news that is more relevant, more candid. Some years ago, New Zealand, serious about its health budget woes, invited a popular radio announcer to discuss health care issues on radio, not once, but on a continuing basis. I was on a mini-sabbatical with the kiwi health ministry for several weeks and was surprised to overhear at bus stops informed, sophisticated discussion from people. “Well, we can’t have everything,” was a common refrain. However we do it, we need a much more informed citizenry if, collectively, we are going to make better choices in health care.

I’m glad that some of the new

MLAs and ministers we have are young and inexperienced. They are perhaps more likely to question what our system needs and where it should be going.

I’m glad that some of the new MLAs and ministers we have are young and inexperienced. They are perhaps more likely to question what our system needs and where it should be going. I’m not at all uncomfortable with their “lack of experience,” since expertise should reside with the bureaucrats in the system. Perhaps they’ll see that there are areas demanding urgent attention, and will for the foreseeable future. I’m thinking of the dilemma of chronic illness, with the grim circumstances of mental health care and eldercare as prime examples. While emptying out mental hospitals and accruing to notions that the elderly can “age in place” may be good things budgetarily, they do not address the reality of numbers of folk who need institutional care and don’t receive it. The elderly represent the “pig in the python” of a swelling population. Much has been achieved with home care, I admit, but it is an insufficient modality to deal with life’s inevitable conclusion. Blinkered inattention has led to the awful reality and the true crisis of “bed blockers” in acute care facilities and can only be dealt with if it is seen for the stain that it is. So there are some big changes I’d like to see. I’d agree with Dr. Noseworthy, though, that we need to work within the structures at hand. We need to move on. Reference 1. http://www.edmontonjournal.com/opinion/Opinion+Quit+ tinkering+with+structure/11094009/story.html.

COVER FEATURE

What are our seniors worth?

A “care of the elderly” physician reflects on the value that society draws from this remarkable patient population Jasneet K. Parmar, MBBS, DiP COE

have served as a “care of the elderly” physician for 23 years, looking after the frail elderly with devotion and advocating for them at every opportunity. Yet contemplating that group today, I can see that I didn’t really understand the essence of who they were and are. I didn’t see the full extent of their value and contributions until I actively looked for it. I would like to share some of what I have learned. I can say with confidence that seniors will never look the same after you read this!

I can say with confidence that seniors will never look the same after you read this!

A force to reckon with Having a skewed view from a slim segment of seniors that I have cared for, imagine my surprise when I learned that 93% of seniors are living in the community.3 Most Canadian seniors are able to look after themselves and spend as much time on household chores as those aged 15 to 64.1 Over 6 million Canadians are 65 and older, representing 15.6% of Canada’s population, and by 2030 they will number 9.5 million or 23% of the population. A large majority of seniors remain active later in life: 80% in social activities; 36% in volunteer work and 13% in the work force.7

The shadow workforce The myth that seniors are solely recipients of care was shattered when I learned that the majority are involved

in providing some sort of assistance to someone they know and that they perform more of this work than younger individuals. This applies to seniors over the age of 75 as well. Seniors aged 65 and older are most likely to spend the longest hours providing care, with 23% of senior caregivers providing 20 or more hours a week.4 For some, it is a large part of their lives, amounting to the equivalent of a full-time job in time.1 This is crystal clear to me as my 78-year-old mother is a full-time caregiver of my 87-year-old father; and my father-in-law at 89 years provides full-time care to my 87-year-old mother-in–law. Our society is full of examples of seniors as caregivers – they are the shadow workforce of the health care system. In 2007, of 2.7 million Canadian family caregivers over 45 who were helping seniors, 75% were between 45 and 65, and 24% were over 65.3 In 2012, there were over 8 million caregivers of all ages in Canada with 56% over 45 years of age.4 The work of the middle aged and older caregivers in Canada was estimated at $25-26 billion annually in 2009, while these citizens incurred $80 million annually in out-of-pocket costs.2 There is insurmountable evidence that our health and continuing care sectors would collapse without this unpaid labor.

The heart of volunteerism Our society places tremendous value on the contributions of volunteers. Seniors play an impressive role in this domain, making up to 45% of the unpaid assistance provided to both formal and informal sectors. Seniors spend twice the amount of time volunteering as younger cohorts.1 The value of this volunteer work corresponded to 549,000 full-time-equivalent jobs and over $5 billion annually in 2001.1 In 2012, baby boomers and senior adults contributed more than 1 billion volunteer hours.7 Seniors are actively sought after by non-profit and community organizations as volunteers, and it is predicted that the future cohorts of seniors – attaining more education, better health and socio-economic status – hold tremendous potential being engaged in productive activities. >

JULY - AUGUST 2015

> Anchoring families in turbulent times Seniors are also a significant source of financial assistance and parental supports for struggling families. The aggregate net worth of Canadians over 55 stood over $1.3 trillion in 1999.1 Most private intergenerational transfers go from old to young and this wealth will be inherited by children and grandchildren of these seniors. In Canada, up to 35% of grandparents who share homes with children and grandchildren are the financial providers and over one-in-10 grandparents are the primary caregivers to the grandchildren.1 The numbers of grandparents assuming the role of parenting is on the rise due to alcohol abuse, divorce, incarceration and teen pregnancies.

The World Economic Forum Report points out that society has an

opportunity to reap a “longevity dividend” in which older people continue to make substantial contributions for unprecedented long periods of time.

Political capital and clout

The face of Canadian society has already changed and the 21st century will be characterized by active aging.

A sought-after labor sector Retirement is not an automatic event these days. More often it is a process that occurs over several years. More than one-fifth of recently retired seniors return to work; the rate of seniors returning to work is exceeding the growth rate of the seniors’ population itself.1 Substantial numbers of seniors are engaged in the equivalent of at least half-time employment. The participation rates of seniors in the Canadian labor force have more than doubled from 6% in 2000 to 13% in 2013.7 Seeing seniors as a solution to labor-market shortages, employers are supporting seniors and their caregivers in part-time and flexible arrangements. Older people are believed to have accumulated social, process and organizational skills that are particularly useful to service economies.5

A growing target market The business world – retail, travel and financial sectors particularly – certainly can spot value when they see it. Seniors have become an important target market with the recognition of the relationship between age and wealth accumulation. As the proportion of seniors in the total population grows, and their financial situation continues to improve, their role as consumers becomes important. The population aged 50 and above has accumulated most of the discretionary funds and the upcoming cohort of baby boomers is a prime example of having captured the attention of market researchers and advertisers.

As taxpayers, Canadian seniors pay less tax on average; however, the proportion of income paid in taxes does not differ much across age groups and seniors with higher incomes pay as much income tax as the younger working population.1 “Generational altruism” is described as the older taxpayers paying for infrastructure and services for which they may never gain personal benefit.5 Canadians take a greater interest in politics as they grow older. Seniors’ social capital in the form of votes, political activism and advocacy brings wisdom and experience to all walks of life. They provide time, skills and money to civic activities. It is projected that, as the population ages, more seniors will hold office as the larger portion of the electorate will be their peers. The impact of seniors as voters is going to become increasingly important when those over 65 will comprise 25% of the voters in 2030.1 The social capital of older adults is yet to be fully realized and ensuring conditions that lead to healthy aging means more engaged, healthy and productive members of our society.

The longevity dividend The World Health Organization states that “an aging population is a triumph of modern society.” The face of Canadian society has already changed and the 21st century will be characterized by active aging.6 The World Economic Forum Report points out that society has an opportunity to reap a “longevity dividend” in which older people continue to make substantial contributions for unprecedented long periods of time.5 Acknowledging the participation, roles and valuable contributions of seniors in our society will help us reduce the stereotyping of seniors and acknowledge the negative bias in our health care system. The increasingly valuable and diverse contributions to society obligate our respect and understanding. We should nurture the meaningful involvement of our seniors – and celebrate their inherent and immeasurable value. References available upon request.

AMA - ALBERTA DOCTORS’ DIGEST

FEATURE

Want to know the real reason for caregiver burnout? Bobbi Junior

Blogger and author of The Reluctant Caregiver, Edmonton’s Bobbi Junior talks candidly about the extreme toll of caregiving on families and loved ones.

t wasn’t that Martha didn’t want to care for Carl anymore (not their ( provided by Lorna Lillo Photography) real names). The fact was, she no longer could. Overwhelmed as Carl’s health issues increased, Martha, 72, recognized she was no longer an effective caregiver for her 78-year-old husband. Carl deserved better. If I kill myself, Martha decided, they’ll have to appoint someone to take care of him. It’s the only option left. Diane Akerman, in her work with a suicide hotline, points out that choice is a signature of our species. We choose to live, sometimes we choose to die. But most of the time we make choices just to prove choice is possible. What happens to choice in a caregiver/care recipient relationship? The caregiver has greater capacity than does the recipient, so both act on the belief that the caregiver should share that capacity with the recipient, allowing the recipient the ability to continue to make choices. While manageable in the short term, this is not sustainable over time. Ongoing giving must be done out of our abundance. As with Martha and Carl, a point may come where all choice has been given to the recipient. The family caregiver no longer has the ability to assess whether no is an appropriate response. The caregiver is now as vulnerable as the one she cares for, perhaps even more so. After Carl’s next check-up, the doctor left Carl to dress and asked Martha to join him in his office, where they could speak privately. “You look like tired,” the physician remarked. “Have you thought of getting some respite?” “Carl would never go for it. He gets more confused if I’m not there.” “What about home care?”

“Someone does his bath. I don’t want more people coming into the house.” “Did you follow up with the O.T. appointment I suggested?” “There isn’t time to call.” Martha raised a barrier for every option suggested. The doctor recognized that while it appeared Martha was being difficult, in truth, she had lost the ability to choose and initiate anything other than what was already in place. For Carl’s part, his health concerns were constant and increasing, putting him into survival mode. Neither he nor Martha had the emotional resources to consider Martha’s needs. “What would you like to do, then?” the doctor asked Martha. Tears now flowed and she admitted her plan. “The only way he’ll allow someone else to take care of him is if I’m gone,” she said. “I think I need to die.” “Do you mean suicide?” “Unless you can think of a better answer.” A better answer was found. Through his primary care network, the physician contacted a social worker who met with Martha alone so she could speak freely. Together they identified that Martha was coordinating 11 service providers to meet Carl’s needs. In addition to caring for her husband, Martha was running a small business! The solution was surprisingly simple. Monthly case conferences with the area’s licensed practical nurse, home care and a geriatric counsellor were organized by the social worker. Appropriate services were identified and put in place. With supports provided, rather than needing to be sought by Martha, the couple’s situation stabilized. After three months, meetings were moved to an as-needed basis. Carl’s health continued to decline, but Martha was no longer at risk. Carl was able to remain at home another three years, moving to a nursing home shortly before his passing. In the end, Martha told the doctor she felt she had provided well for her husband’s last years, a report that felt like success to the entire team. Editor's note: Be sure to view our intriguing video interview with Bobbi Junior on caregiver burnout. Visit https://youtu.be/jo5FWWN7TCk. JULY - AUGUST 2015

HEALTH LAW UPDATE

Organ transplants:

Owners, ethics and an aging population Jonathan P. Rossall, QC, LLM, and Mustafa Farooq | MCLENNAN

n Shakespeare’s immortal play King Lear, the aging king remarks, “(N)othing will come of nothing,” in response to his daughter’s refusal to praise him. It is a remarkably ominous line that lets us, the audience, know that our refusal to acknowledge a problem is to some extent the problem itself. The failure of our medical community to understand the problem with our organ donation model faced with an aging population can be seen in the recent incident involving the National Hockey League Ottawa Senators’ owner Eugene Melnyk. He went public with the fact that he had been battling Stage 4 colon cancer and needed a live liver organ transplant because of his particular blood type. In response, more than 2,000 people called in, more than 400 people applied to donate and 12 candidates actually underwent screening. Eventually, after only six days, Melnyk’s life was saved because one of those people participated in a liver transplant. The situation, while having a happy ending (that speaks well to the generosity of everyday Canadians), also demonstrates the problem that faces us. As our population ages, and as organ transplant technology progresses, demand for organs will continue to rise. On the other side, however, the supply of organs is not proportionally increasing. This requires us to examine how Canada’s health care system currently deals with organ transplant procedures, and what, if anything, needs to change. It is quite clear that aging will have a direct effect on the need for an effective organ donor and transplant system. As a study from the Urban Futures Institute suggests, “… declining birth and death rates and an aging population … combined with the rapidly growing need for transplants and projected organ donation rates will lead to an ever-widening shortfall between the need for, and supply of, organs for transplantation”.1 Indeed, in 2012, 230 Canadians with end-stage organ failure died while on a transplant wait list.2

AMA - ALBERTA DOCTORS’ DIGEST

ROSS LLP

After a significant public push, in 2014 Alberta Health Services (AHS) finally made available to Albertans the Organ and Tissue Donation Registry. According to AHS sources, this “… will allow Albertans to sign up online and specify their wishes when it comes to organ and tissue donation. For instance, donors can consent to donating all their organs and tissues for transplantation, or only selected organs”.3 Note, however, that this registry only conveys the donor’s intent, and is not legally binding in the sense that it does not overrule documents like an advanced directive. While things like the Organ and Tissue Donation Registry are admirable in efforts to do better outreach to Albertans about organ donation, there is still significant work to be done to meet the challenges of an aging population.

It is clear that as our population ages,

an important conversation needs to happen among health care providers about organ transplantation.

An example of a specific and major policy decision is found in the Expanded Criteria Donor (ECD) designation. For kidney donations, for instance, it has been demonstrated in numerous studies that older donors, especially 65 years and older, have a higher rate of graft failure than younger donors.4 With the ECD criteria, older donors who consent to the process are paired with the older patients, or can choose to wait on the donor list. Younger patients, especially children, are given priority access to younger donor organs. This ECD protocol is common in most Canadian organ transplant practices, according to the Canadian Council for Donation and Transplantation. Essentially, the protocol confirms that we are making an ethical policy decision that older recipients may be less deserving of a >

> better chance of recovery than younger patients would be when receiving better organs. Thus, while no official cap exists that cuts off older patients from being on the transplant list, the protocol allows for older patients to receive differential treatment than that of younger patients. Reverting to our recent example: if Eugene Melnyk hadn’t been the owner of the Ottawa Senators, not only might he have been waiting for a very long time to receive an organ, but when he did have the opportunity, it may have been to take a “less-than-ideal” organ. Thus, when elderly patients are required to have a transplant, they may face an extremely difficult choice: remain on the waiting list, or have access to a less-than-ideal older organ.

patients over a certain age. Other countries, like Israel, are currently considering a cutoff age for certain organ transplants. While there are an increasing number of innovative approaches to dealing with organ transplant issues, like the Highly Sensitized Patient program and the Organ and Tissue Donation Registry, it is clear that as our population ages, an important conversation needs to happen among health care providers about organ transplantation. This conversation needs to include a discussion of innovative methods to increase supply (like presumed consent to donate and opt-out measures, or providing state compensation to organ donors) and a means of helping senior patients deal with the risks associated with organ transplantation. If we do not have these important conversations, however, “nothing will come of nothing.”

While things like the Organ and

Tissue Donation Registry are admirable in efforts to do better outreach to Albertans about organ donation, there is still significant work to be done on meeting the challenges of an aging population.

The choices posed by the above protocol, among other considerations, force us to ask whether we should have a cap on the age of recipients. Studies show that after graft loss, patients over 65 are seven times more likely to die than younger to middle-age transplant recipients.5 Thus, we might ask ourselves if a protocol should be established that rules out organ transplantation in elderly

References 1. Baxter D, Smerdon J. “Donation Matters: Demographics and Organ Transplants in Canada, 2000 to 2040” (June 2000). Available from: http://www.lhsc.on.ca/Patients_Families_ Visitors/MOTP/Organ_and_Tissue_Donation/Report46.pdf. 2. Canadian Institute for Health Information, “Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2003 to 2012.” Available from: https://secure.cihi.ca/free_products/2014_CORR_ Annual_Report_EN.pdf. 3. Ibrahim HN et al. “Predictors of graft failure and death in elderly kidney transplant recipients” (2013) 96:12 Transplantation 1089. 4. Weiss-Salz et al. “Negative impact of 'old-to-old' donations on success of cadaveric renal transplants” (2005) 19:3 Clinical Transplant 372. 5. Port et al. “Long-term survival in renal transplant recipients with graft function” (2000) 57 Kidney International 307.

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JULY - AUGUST 2015

MIND YOUR OWN BUSINESS Considering winding down or closing your practice? A few simple planning steps and considerations will help keep you on track Practice Management Program Staff

o you remember how much time and energy went into starting your practice? If you are at the point in your life when you are considering winding down your practice or closing it altogether, give yourself plenty of time to make arrangements that best cater to the needs of you, your patients and your staff. With good planning, communication and attention to detail, you will be free to set your own schedule, pursue another passion or start a new adventure! You’ve worked hard to get to this point and regardless of the reason for this pivotal decision, there are a few key considerations and requirements that you must tackle: 1. Notifying and caring for your patients. 2. Managing your medical records. 3. Accommodating your staff. If you’re unsure where to begin, we recommend picking a closing date. Whether you are in a shared practice or a solo practice, or if you lease premises, then plan on closing at the end of the lease period to save on penalty fees. If you are in a shared practice with a practice agreement in place, make sure you refer to the notification period agreed upon. Don’t forget you are required to notify the College of Physicians & Surgeons of Alberta (CPSA) in advance of closing or leaving your practice in Alberta. The college will want information describing: • How the transfer of patient care will be managed. • The location and disposition of patient records and how they will be accessed. • A forwarding mailing address and contact information for you. • All unused triplicate prescription forms.1

Notifying and caring for your patients Your first and foremost concern when dissolving your practice should be the welfare of your patients. There’s nothing more aggravating than a last-minute adjustment, so be prudent and give your patients plenty of time to AMA - ALBERTA DOCTORS’ DIGEST

prepare for this big transition. You can post a notice on your office door or add a personal touch with a letter or phone call to individual patients. If another physician is taking over your office or patient panel, a letter of introduction seems appropriate. Patients can feel the stress of having to find another physician. Having built relationships with them, you will feel obligated to do what you can to help the transition of care. Providing your patients with a list of available physicians in the clinic or area is a start, but also consider connecting with local physicians to discuss their openness to take on some of your patients and consider referring more complex patients with ongoing or immediate needs to other physicians early. Of course, having an accurate and up-to-date patient panel will make these tasks much easier and enable you to diligently manage the transition of patient care! Key points to remember • 90 days documented notification for all the patients you have seen in the last two years is the standard of practice of the college. • Recommend that no new patients are seen after your announcement. • Refer patients who require continual follow-up early to ensure their medical needs are met. • Notify your patients that their medical records will be kept in secure storage until notified in writing about transferring them to another provider if a copy is requested. • It is critical for you to maintain access to a complete set of “original” patient medical records.

Managing your medical records The storage of medical records is a big concern for a number of physicians, and rightfully so – the retention and management of these records is crucial. The college guidelines state that if you are “unable to provide ongoing management of patient medical records, either personally or through a colleague, your medical records should be put into commercial storage for custody, transfer as necessary and destruction when that is appropriate.” >

> If you do not have an adequate electronic record-keeping system, records should be printed and managed as hard copies stamped with original and the electronic versions destroyed appropriately. Things get more complicated when you are practicing as part of a shared-care model. We recommend that your practice agreement contain a clause outlining a procedure for archiving medical records. However, if your clinic does not assign patients to any particular physician, the medical records belong to the clinic, so don’t take them with you! Retention period and storage requirements • Retain records for 10 years following the last date of service or two years past the patient’s 18th birthday, whichever is longer.2 • Take reasonable steps to ensure against any reasonably anticipated threat or hazard to the security or integrity of health information during storage. • Ensure you have the ability to find records in response to requests (a retrieval system). • Confirm individual electronic records are uniquely identified with data preserved, authenticated with version control and have access controls in place. • Ensure you have control over disposition or destruction of the medical records. Following the retention period required under the Health Information Act (HIA) and the CPSA, make sure to securely dispose of documents. Physically destroying hardware and medical records can be difficult. To do so securely requires professional expertise. As custodians of patient health information, physicians are legally obligated to safeguard that information under the HIA. Secure destruction techniques are an essential step in the life cycle of patient records. You must plan records management processes and activities to take place on a scheduled basis. It is the custodian’s responsibility to securely dispose of patient records after the necessary retention period. First steps to securely dispose of patient records following retention period 1. List all hardware that contains personal health information. 2. Review the list of options and organizations that provide destruction services found at National Association for Information Destruction. www.naidonline.org/ncan/en/consumer/members.html 3. The custodian must enter into an Information Management Agreement (IMA) with an information manager (e.g., storage facility or destruction service) and ask for a certificate of destruction. 4. Schedule the destruction and reconcile the destruction certificates against your hardware list. Keep this information on file. 5. Moving forward, develop a strategy for destroying records on a regular schedule based upon the legal retention requirements.

Accommodating your staff

Your departure is probably very stressful and emotional for your employees as well, so give them plenty of notice. Careful consideration needs to be given to the needs of your staff. The sooner you can provide them with information, the better. However, they will have many questions and it is better if you are able to answer some of them immediately to reduce the stress of the unknown. Tips in accommodating your staff • Ensure they are well informed before you start notifying your patients. • Help them develop responses to questions patients may have. • Patients will likely ask personal questions so prepare your staff by letting them know what information you are willing to share. • Consider writing a letter of reference for your hardworking and valued employees to help them find alternative arrangements. • Consider rewarding your employees with an incentive or bonus if they remain with you until your practice formally closes its door. Don’t forget to negotiate retention incentives or bonuses with your staff. They won’t be able to read your mind and most certainly will be looking for a new job once you make your announcement. In fact, you may need some staff to stay on after the closure to complete the transfer of medical records, reconcile billings, etc.

A few other considerations • Maintain the phone number with a recorded message notifying patients of the closure for up to three months after you close. • Issue a record of employment for all staff within five days of their last day worked. • Contact the Canadian Revenue Agency to cancel employee payroll and your GST account, if applicable. • Retain business records such as accounting and employment records. • Take care of other notifications, e.g., utilities, janitorial services, other contractors. • Consider maintaining your Alberta Medical Association (AMA) membership so you can still vote, serve on committees, receive publications, access ADIUM home and auto insurance, and continue to receive corporate rates from member companies – all at reduced dues. So far we’ve asked you to consider a number of important stakeholders, but please consider yourself and your family. Even if this transition goes smoothly, you and your family are almost guaranteed to have higher stress levels at some point. Effective communication between you and your loved ones, getting plenty of sleep and eating properly will help you come out on top. (If you >

JULY - AUGUST 2015

> need help, the Physician and Family Support Program is there for you – 1.877.767.4637.) This goes without saying, but the best is yet to come. So enjoy your well-earned years of relaxation! If you’re not ready for complete relaxation, consider keeping your hand in the mix by becoming a locum with the freedom to make your own schedule and temporarily fill in for other physicians as needed or between golf games!

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• CPSA guidelines and policies can be found at: www.cpsa.ab.ca. • The Office of the Information and Privacy Commissioner is the regulatory body for the HIA and the Personal Information Protection Act: www.oipc.ab.ca. • The Government of Alberta HIA – guidelines and practices manual: www.health.alberta.ca/documents/ HIA-Guidelines-Practices-Manual.pdf. • The AMA has developed IMA templates at: www.albertadoctors.org. References available upon request.

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

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AMA - ALBERTA DOCTORS’ DIGEST

AA_

150

YEARS!

AMA congratulates Sun Life Financial on its 150th anniversary. Weâ&#x20AC;&#x2122;re proud to call this long-standing Canadian company a partner for over 20 years. We look forward to continuing our partnership with a company that understands the unique insurance needs of physicians.

Congratulations Sun Life Financial!

JULY - AUGUST 2015

AA_AMA_150_Years_v4.indd 1

15-06-18 9:05 AM

INSURANCE INSIGHTS

What do physicians really think about ADIUM Insurance Services?

Here’s what we found out on our 2015 satisfaction survey J. Glenn McAthey, CFP, CLU, CHS | DIRECTOR,

he Alberta Medical Association (AMA’s) ADIUM Insurance Services Inc. conducts a survey every three years to measure member satisfaction with the insurance programs, the services provided, and to help guide us on future plans to improve the products and services we offer. Thank you to all members who responded to our survey!

Who responded? A statistically valid response rate of 11% was received from members who are insured under at least one of the AMA’s group insurance plans. • Specialists (43%), family physicians (41%), post-graduate residents (9%), medical students (4%) and unidentified (3%). • Male (60%), female (40%). • 75% of respondents practice in an urban setting. • 31% of respondents are in practice longer than 25 years.

I am satisfied with the service provided by ADIUM’s staff when I purchase or renew my coverage: 2012

2015

Agree or strongly agree

67%

89%

Neutral

31%

10%

Disagree or strongly disagree

AMA insurance plans enhance the value of my membership: 2012

2015

Yes

84%

87%

16%

13%

I am aware of the insurance planning tools on the AMA website: 2012

2015

Yes

61%

75%

39%

25%

I have used the insurance planning tools on the AMA website:

Comparative statements to 2012 survey

2012

2015

Yes

21%

91%

79%

I find the premium rates and coverage competitive: 2012

2015

Agree or strongly agree

68%

74%

Neutral

29%

24%

Disagree or strongly disagree

AMA - ALBERTA DOCTORS’ DIGEST

ADIUM INSURANCE SERVICES INC.

> I was satisfied with the claims service received by Sun Life (disability):

Verbatim comments

• The verbatim comments received were largely very positive:

2012

2015

Agree or strongly agree

59%

79%

- “I trust ADIUM with what they have to offer.”

Neutral

34%

12%

- “First class support over many years. Thanks.”

Disagree or strongly disagree

- “Very enjoyable experience.” - “Would recommend the service to others.”

I was satisfied with the claims service received by ADIUM (disability): 2012

2015

Agree or strongly agree

69%

85%

Neutral

29%

12%

Disagree or strongly disagree

New statements for 2015 survey The ADIUM insurance advisor I dealt with was: Agree or strongly agree

Neutral Disagree

Professional

94%

Knowledgeable

93%

Trustworthy

88%

10%

AMA Health Benefits Trust Fund: • I was satisfied with the performance of Alberta Blue Cross in the processing of my Core Plan claims: Agree or strongly agree

78%

Neutral

14%

Disagree or strongly disagree

• I was satisfied with the performance of ADIUM in the processing of my Cost-Plus Plan claims: Agree or strongly agree

87%

Neutral

Disagree or strongly disagree

In an effort to save postage, time and trees, I would prefer to receive/access insurance premium invoices and insurance certificates electronically: Agree or strongly agree Neutral Disagree Via email

78%

10%

12%

On my personal AMA website portal

27%

20%

53%

Via an ADIUM mobile app

12%

21%

67%

• There were isolated expressions of unhappiness with the service received which we will reflect on and learn from: - “Didn’t like the four phone call transfers to find someone who could finally help me. • There were many comments about the limited coverage provided under the AMA Health Benefits Trust Fund “Core Plan” through Alberta Blue Cross. (There is a rationale for the design of the Core Plan but this feedback will be shared with our trustees. Watch for a future article on this topic as well as communication to participants in this plan.)

Summary of findings • We are extremely pleased that members find our premium rates and coverage to be competitive. Besides priding ourselves on prompt and professional service delivered objectively, our group plans have to add value to what’s available in the marketplace. We will continue to work with our insurers to make our plans even better in the future. • Members have a variety of preferences for how they want to receive advice from their ADIUM insurance advisor. For this reason, we will continue to make our advisors available when it’s convenient for our members, whether it’s by email, phone or a scheduled face-to-face or telephone appointment. • The high level of satisfaction with our insurance advice and administrative services is something we intend to maintain and even improve upon in the future. • We will continue to use technology to improve access to your insurance information and to improve our operational efficiency. ADIUM will be transitioning to a paperless office over the next year and will be communicating to you on our progress. Congratulations to Dr. Justin Wong, family medicine resident from Calgary, on winning our Apple iPad mini draw prize. If you are not insured under any of our insurance programs, I invite you to contact our office for an insurance review and if warranted, how one or more of our products may be of value to you. Finally, thank you again to the members who took the time to provide their feedback to us. It will help us better serve you in the future.

JULY - AUGUST 2015

Because so much depends on you.

AMA - ALBERTA DOCTORS’ DIGEST

AMA ADIUM INSURANCE DIGEST FULL PAGE AD.indd 1

2015-05-14 9:52 AM

9:52 AM

FEATURE

Our health care system must support the triumph of aging CMA president calls for a National Seniors’ Strategy Chris Simpson, MD, FRCPC, FACC, FHRS | PRESIDENT,

s a cardiologist at Kingston General Hospital in Ontario, I work primarily in an acute care environment, treating patients with arrhythmias. I see everyone from children with genetic arrhythmias that predispose them to sudden death, all the way through to elderly patients with end-stage heart disease. My best days are when I’m with my patients. But, being in this acute care environment every day, I’m also witness to the many occasions our system fails to provide Canadians with the support they need and deserve.

Our goal is to have a strategy that

recognizes the triumph that is aging well.

CANADIAN MEDICAL ASSOCIATION

These patients fall. They develop hospital-acquired infections. They are isolated and get depressed. Their muscles waste away and they lose their ability to get around. But until we’re able to transfer them to a more appropriate care environment, they simply have to lie in a hospital bed, waiting, counting down the days, weeks, months – sometimes years – until supports are put in place to allow them to get care in the community or at home. There are simply not enough of these services to go around. There have been positive changes thanks to the visionary leaders of the senior or elder-friendly hospital movement, but we simply must do more to get our elders out of hospitals. The Canadian Medical Association (CMA) and our 83,000 members across the country believe that we need a national strategy to ensure our seniors are getting the care they need, when and where they need it. We need to find ways to provide care as early as possible to prevent avoidable loss of function and independence; to avoid preventable deterioration that results in expensive, avoidable hospitalizations – expensive to seniors and expensive to the health care system alike.

This strikes me particularly hard with our elders. When they arrive at the emergency department, they’re often alone, usually scared. Maybe it’s late at night and they couldn’t reach their family doc, or the next appointment with their specialist was a few weeks away, or more. I know that they face a wait time that’s unfortunately longer than it should be, and will only serve to worsen their condition.

Our goal is to have a strategy that recognizes the triumph that is aging well. We need a strategy that’s built around the needs of individuals and their families. One that puts the patient at the center and captures all elements of care: from health promotion and illness prevention, through hospital care, home and long-term care and the availability of palliative care. Living well should be the ultimate goal.

Once we’ve examined the patient, if anything gives us room for concern, we’ll have them admitted. And this is where things can go from bad to worse because our acute care hospitals were not designed to care for seniors.

To drive action on this critical issue in the public, the CMA recently launched a new website www.DemandAPlan.ca, where Canadians can add their voices to the call for a national seniors’ strategy. By joining our voices we can ensure that our political leaders act to transform our health care system. Thousands have signed on in support and we hope you will too. With a federal election looming, now is our chance to put the issue of developing a national seniors’ strategy on the political agenda.

We know that in order to provide quality care to seniors with complex, chronic conditions, they should not be on a hospital ward if realistic, appropriate and safe options exist in the community. Hospitals are dangerous places for our senior patients.

JULY - AUGUST 2015

FEATURE

High drama!

Alberta physician dodges the enemy, goes on to a remarkable career J. Robert Lampard, MD

the Oath of Allegiance and marching to the nearest armory for roll calls and drills. But that isn’t what happened to Dr. Hepburn. He was studying in Berlin at the outbreak of WWI on August 4, 1914, and because he held a British passport he was placed under house arrest by August 14, 1914. Dr. Hepburn’s medical life began when he met Dr. William A. Wilson (Dr. Donald R. Wilson’s father) on an Edmonton street in 1904. Wilson encouraged the 19-year-old to make medicine his career choice. After earning a teaching certificate and saving money for two years in Assiniboine, he entered McGill, graduating in 1910. Two and a half years of postgraduate training followed, during which Hepburn switched his interest from obstetrics and gynecology to neurosurgery – influenced by the rising reputation of Dr. Harvey Cushing.

To date, only eight end-of-life WWI

Dr. Howard H. Hepburn made a daring military enlistment during WWI. ( provided by the Hepburn family)

o date, only eight end-of-life World War I (WWI) memoirs of Alberta physicians have been uncovered. None rival the remarkable 10-day enlistment story of neurosurgeon Dr. Howard H. Hepburn (1885-1972). It was so daring that documents relating to it were harbored in the family safety deposit box for decades, for fear of recrimination to those involved. Through the foresight of his son, Dr. Allan Hepburn, also a neurosurgeon, the events were shared in a brief biography of his father written in 1997. It deserves a wider audience. Normally, enlistment involved walking down to the nearest recruiting station, proving one’s age and identity, signing the accession statement, repeating

AMA - ALBERTA DOCTORS’ DIGEST

memoirs of Alberta physicians have been uncovered. None rival the remarkable 10-day enlistment story of neurosurgeon Dr. Howard H. Hepburn.

Seeking adventure, he followed contemporary Dr. Allan C. Rankin to Siam by accepting the chief surgeon position at the Bangkok Police Hospital. There he treated many head injuries, often caused from cutting down smelly durian fruit in the orchards. In practice, he was a court physician to the King of Siam. During his two years, he acquired numerous Siam artifacts – vases, bowls, soapstone carvings, ceremonial swords, knives, sabres and scabbards – which he sent back to Canada. With his contract over, he sailed for England and then traveled to Berlin to meet classmate >

> Dr. Ambrose Lockwood. The two registered for studies in neurology/neurosurgery and thoracic surgery. When war was declared, the two students were interned as enemy aliens. Concealing their passports and insisting they were Americans who were non-belligerents, they relaxed the attentiveness of their guard. With the help of their Jewish-German professor of neurosurgery, the two were able to exit into a boisterous recruiting parade as it passed by. When it reached the railway station, they slipped into the line-up to catch the last train out of Berlin heading for Amsterdam. But armed inspectors were checking the identity of those in the queue. Fortunately, Hepburn happened to lean on an adjacent shed door, which suddenly opened. They found themselves in the station master’s kitchen. In his poor German, Hepburn asked for a glass of water. Then the two exited through the opposite door onto the rail platform and boarded the train. Without tickets, they had to elude the collectors the whole way. Once, their train paused for a troop train that came off an abandoned spur line and headed for Belgium.

The good Lord sent the general

surgeon a bad case every once in a while to keep him humble, and sent the neurosurgeon a good case periodically to keep him sane.

In Amsterdam, they walked to the British embassy and found it was being evacuated. Joining the departing staff, they boarded a submarine for England. After debriefing the British Intelligence Service about the troop train, they enlisted in the Royal Army Medical Corps – the first Canadians to do so. Assigned to the #12 Stationary Hospital at Chaltham, they found it was already embarking for Le Havre. They arrived in France 10 days after escaping from Berlin. Their first action was retreating from Mons, Belgium, back to the French coast, where Dr. Hepburn was transferred to the #3 Stationary Hospital. Over the next year, Dr. Hepburn introduced many innovative techniques: using boiled sea water secured each morning for IVs, putting five pairs of gloves on and removing one each time he saw a new patient, and using paraffin-lined glass cylinders for vein-to-vein transfusions of O-negative blood. Promoted to captain, he was transferred to the #10 General Hospital, followed by the #47 Field Ambulance, the 9th Black Watch as its Regimental Medical Officer and, in 1917, the #71 Artillery Unit. When he was moved to the #24 General Hospital, Hepburn was promoted to major and placed in charge

of surgery. Then he was made an acting lieutenant colonel of the 1,800-bed hospital, before moving it to Dunkirk, France. He transferred back to England exactly five years after he had arrived. The king awarded him a military cross and the government gave him three participatory WWI medals. His time on the continent had been eventful. Shrapnel from an artillery shell injured his left bicep. He was gassed with phosgene. A hepatic amoebic cyst he had acquired in Siam began giving him trouble. Many years later it would rupture into his colon, with relief that it was not cancer. In his spare time he published numerous articles on warfare injuries. He also kept a frontal sinus shell injury X-ray, which in 1917 produced a pneumoencephalogram that outlined the brain. This was a year before it was described in the literature. Immediately after the war, Dr. Hepburn used his leaves and free time to study surgery in Edinburgh, earning his FRCS (Edin) (1919) and FACS (1920). He would become a charter member and receive an FRCSC (1930). After demobilizing in Montreal, he spent a few weeks with Dr. Adson at the Mayo Clinic, before visiting his mother in Edmonton after her hip fracture. It became a life-long trip. In Edmonton, he joined the militia as a major (1920), while his friend and now dean, Dr. Allan Rankin made him a lecturer in 1921. His instructorship in surgery (1922) was elevated to an associate surgeon position (1930), and the first director of the division of neurosurgery (1934). In 1930 he created the “Edmonton Tongs” that placed a cervical fracture in traction. During WWII he was appointed the chairman of the difficult Medical Procurement and Assignment Board for District 13 (Alberta). He was also made the director of the Mewburn Pavilion when it opened. In 1949, he became the professor and head of surgery, until 1950 when he reached 65 and was succeeded by Dr. Walter C. Mackenzie. Retiring from surgical practice in 1951, he was appointed the senior medical officer of the Workers’ Compensation Board until 1963 (age 78). Well respected by his colleagues, he was elected president of the Edmonton Academy of Medicine, the Alberta Medical Association and the Medical Council of Canada. After his death in 1972, the Dr. H.H. Hepburn Memorial Prize in Surgery was endowed to honor the final year student. The Dr. H.H. Hepburn Memorial Neurosurgical Conference Room at the Walter C. Mackenzie Health Sciences Centre was dedicated by Dr. Charles Drake in 1983 with the following words: “The good Lord sent the general surgeon a bad case every once in a while to keep him humble, and sent the neurosurgeon a good case periodically to keep him sane.”

JULY - AUGUST 2015

FEATURE A coalition, a conference and a conversation

Seniors’ care is the common denominator for important AMA activities

The coalition and conference

n April 25 in Edmonton, the Alberta Seniors’ Care Coalition (ASCC) hosted a conference to explore innovative approaches to seniors’ care. The Alberta Medical Association (AMA) is a member of the coalition, which was initiated by the Alberta College of Family Physicians and also involves Alberta Health, Alberta Health Services (AHS), the AHS Seniors’ Strategic Clinical Network and Covenant Health. The April conference, themed “Working Together for Seniors’ Care,” was a multidisciplinary professional development event. The goal was to provide relevant, practice-based learning sessions with a focus on seniors’ health, innovative models of service delivery, dementia, palliative and end-of-life care. As part of our contribution to the coalition and conference, the AMA, partnering with Alberta-based vendor ThinkHQ Public Affairs, conducted public opinion research on Albertans’ attitudes toward aging, being a senior and caregiving. This material was the focus of a joint AMA/Canadian Medical Association (CMA) session at the ASCC conference. While CMA President Dr. Chris Simpson presented on national findings gathered by the CMA, Alberta-specific survey data was presented by ThinkHQ Public Affairs President Marc Henry.

Here’s what the AMA found in the special survey on health care and aging in Alberta: • Albertans are not too worried that they’ll be treated differently when they are seniors than younger Albertans would be. We asked if seniors are treated better, worse or about the same as everyone else.

How do we treat senior citizens? By the government 7%

8% 8%

14% 29%

37% 42%

In the workplace

55%

In society overall

9% 7%

Highlights from the survey of 2,000 Albertans appear over the next two pages. 42%

Better

AMA - ALBERTA DOCTORS’ DIGEST

As patients in the health care system

42%

About the Same

6% 10% 36% 48%

Worse

Unsure >

> • They’re a little bit worried about getting older. The top three things on peoples’ minds: Staying healthy/ health issues and concerns; having enough money/ affording things; finding access to proper care/ doctors/government support.

Albertans' concerns with getting older and aging

• For the survey, we defined “caregiving” as unpaid care or support for an aging family member, relative or friend who has a physical or mental disability, is chronically ill or is becoming frail. Almost 20% (one-in-five) are providing support like this today.

Caregiving for seniors in Alberta 2%

1% 2% 5% 5% 7%

19%

28%

8% 17%

79% 27%

Staying healthy/health issues and concerns Having enough money/affording things Finding access to proper care/ doctors/government support Needing/availability of assisted living Losing independence/having to move from home Being treated poorly/loss of dignity Being a burden/needing help from others Other mentions Don't know/nothing in particular

• They don’t feel informed about what is available to support seniors in the health care system; more than half of people over the age of 55 feel uninformed.

Albertans' knowledge of senior supports in the health care system

13%

I receive care from a family member or friend I participate in providing care for an aging family member or friend Neither

Only 16% believe they are unlikely to provide such support at some point in their lives.

Caregiving for seniors in Alberta

19%

40%

16%

21% 41% 36%

Not at all informed Not very informed Somewhat well informed Very well informed

Not at all likely Not very likely Somewhat likely Very likely Unsure

JULY - AUGUST 2015

> On average, caregivers provide 12 hours of support in a typical week.

The conversation There was another purpose for the public opinion research that the AMA conducted. The results were primarily intended to start a conversation with Albertans about health care through the new AMA-hosted website: albertapatients.ca.

Weekly caregiving time commitment

The albertapatients.ca site launched June 12. In a letter to members, AMA President Dr. Richard G.R. Johnston wrote: “As an organization, the AMA has not had the ability to interact with large numbers of Albertans or give them a way to help us understand their thoughts and concerns regarding health care delivery. This is a great opportunity for the AMA, because when we know what matters to our patients, we can have meaningful conversations, share the information and play an active role in creating a patient- and family-centered health care system.”

22% 34% 19% 25%

The website is an online forum for Albertans to come together and participate in conversations about health care. To join, visitors must register to create an account, confirm their membership by email and complete a member profile. All of this takes only a few minutes.

1 hour or less 2-5 hours 6-12 hours over 12 hours

What do caregivers do? Many things!

Once they have joined, people will have the opportunity to:

Range of supports provided by caregivers Note: more than one response was permitted.

• Participate in surveys about different aspects of health care.

69% 60% 57% 44% 39% 35% 35% 14% 3% 5%

Errands/shopping Companionship/supervision Provide transportation General day-to-day household tasks (laundry, cleaning, etc.) Medical management (medications, doctor visits, etc.) Financial management Meal preparation Personal assistance (getting dressed, going to the washroom, bathing, etc.) Other Prefer not to say

• Take quick polls and see instant results. • Join discussion forums about topics that interest them. • Receive invitations for special surveys or discussions that relate to the interests expressed in their profiles.

These interesting findings suggest a need for further discussion to seek ways to improve our care for aging Albertans in healthy and supportive communities. The AMA is committed to making this happen, as discussed in the next section of this article.

AMA - ALBERTA DOCTORS’ DIGEST

The topics that will be discussed on albertapatients.ca will flow directly from what Albertans tell us they want to talk about. Since the launch period is still underway at the time of this issue of Alberta Doctors’ Digest, the focus has been issues of aging in Alberta, seniors’ care and the experience of being a caregiver – based on the 80 research findings addressed in this article. In the months ahead we will be sharing the results of the activity on albertapatients.ca through this magazine and in other venues. Stay tuned!

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JULY - AUGUST 2015

DR. GADGET

I’m not 87 yet … Wesley D. Jackson, MD, CCFP, FCFP

ne day last weekend, shortly after 7 a.m., I received a notification on my smartwatch that my 86-year-old (“I’m not 87 yet”) father left his house. I picked up my phone and was able to track him as he drove alone to a nearby lake. After about 30 minutes, thinking it would be safe to touch base, I called his cell phone and ... no answer!

After we learned that my fiercely

independent father would frequently go hunting and fishing alone, and after a close call, we convinced him to get a phone equipped with GPS technology.

A few minutes later my cell phone rang; he called me back to tell me he couldn’t answer my call as he was busy landing a 20-pound fish (a pike, for those who may be interested). He then used the same phone to take a picture of the fish, which uploaded automatically to the cloud and was displayed on my device a few minutes later. We were then able to swap fish stories while I chided him gently again about going to the lake alone. My father was in his 40s when the first personal computer was invented and in his 60s when the Internet became a necessity of life for many of his children and grandchildren. He, like many others in

AMA - ALBERTA DOCTORS’ DIGEST

his generation, had lived his entire life very happily and successfully without the benefit of YouTube or Google and could not see any reason to learn and use these complicated tools. He was certainly enticed by the devices that his descendants used, but websites, passwords, modems, routers, Internet service providers, email and many other complications associated with progress provided significant roadblocks to his adoption of modern technology. A little more than 12 years ago, shortly after my mother died, we convinced my father to carry a small, simple-to-use cell phone programmed with a quick dial so that he could contact us “in case of emergency.” He quickly warmed to this technology and carried the phone wherever he went. Two years ago, after we learned that my fiercely independent father would frequently go hunting and fishing alone, and after a close call, we convinced him to get a phone equipped with Global Positioning System (GPS) technology, which would allow us to track him and vice versa. As a bonus, this phone also allowed for video calling, bringing him closer despite the almost 300 kilometer distance between us. The same device provided reading material, Twitter and solitaire, making it worthwhile to keep charged and with him at all times. My father’s experience is not uncommon among his peers and demonstrates that good technology should “fade into the background” for users as great devices simplify and enrich our lives. New portable devices are powerful computers containing many different sensors available for use in multiple scenarios, while continuing to appeal to the older generation. As my father’s case has proven, mobile devices not only improve emotional health through increased quality of communication, but activity can also be monitored and encouraged, promoting improved physical health and well-being. Apps and sensors are >

> now available to monitor blood pressure, pulse, blood glucose, weight and movement, with other options such as blood oxygen levels on the horizon.

Already an app has been developed to study the relationship between activity and the progression of Parkinson's disease. This app was designed to give the device user immediate feedback while sending real-time data to researchers located anywhere in the world. Several other research tools utilizing the power of portable devices are either currently available or are being developed.

As my father’s case has proven, mobile devices not only improve emotional health through increased quality of communication, but activity can also be monitored and encouraged, promoting improved physical health and well-being.

Today's seniors are passively contributing to the development of new diagnostic, research and management tools that will contribute to improved well-being for all. Progress in this area can only accelerate as the younger generation becomes actively involved in further development and use of relevant portable and wearable technology.

Dr. Jackson's 86-year-old father lands a big one while safely keeping in touch with his family using GPS. ( provided by Dr. Wesley D. Jackson)

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

For now, I think I’ll go fishing with my dad....

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CANADA’S HEALTHCARE LANDLORD JULY - AUGUST 2015

PFSP PERSPECTIVES

Caution: Tsunami approaching

Approximately 45% of the national physician workforce is headed for the door

Vincent M. Hanlon, MD | ASSESSMENT

ost careers in medicine have a beginning, middle and an end. Even those superstar colleagues we might consider the Serena Williams or Roger Federer of our clinic or group will retire one day. About 32,000 Canadian physicians are currently over the age of 55.1 That’s approximately 45% of the national physician workforce. More of our colleagues will be retiring in the next few years. Many are now talking carefully about ways to bring down the curtain on a life in medicine. These conversations are all around us.

About 32,000 Canadian

physicians are currently over the age of 55. That’s approximately 45% of the national physician workforce.

One of my colleagues recently retired, full-stop, after working for more than 20 years in the same department. He said he’ll miss many of his patients and co-workers, but not the night shifts. Another colleague in the later stage of her career was recently diagnosed with Parkinson’s disease. Her end-of-career planning is now taking her in an unexpected direction.

AMA - ALBERTA DOCTORS’ DIGEST

PHYSICIAN, PHYSICIAN AND FAMILY SUPPORT PROGRAM (PFSP)

A retired surgeon told me how he felt compelled to retire in 2014 because his weekly OR block was conditional upon him being part of his specialty call rota. His surgical group and hospital were unable or unwilling to accommodate his desire to get off the call list (after more than three decades of taking call) but continue doing some surgery. I spoke with an academic physician whose retirement from his large practice group was, in his words, “badly handled.” He had developed a degree of cognitive impairment. His “contact with officialdom was excellent” regarding the investigation and management of his health issue. He was referring to his multiple conversations with the College of Physicians & Surgeons of Alberta, Canadian Medical Protective Association, and the psychiatrist and psychologist he’d seen in consultations coordinated by the Physician and Family Support Program (PFSP). It was the abrupt end to his career as it was orchestrated by his own department that left him feeling bruised and somewhat bitter. It was not his imagined endgame. He felt that even if he wasn’t able to carry on in a clinical role, he could have continued to contribute as an experienced teacher.

Health challenges and fitness to work These conversations about the desire or need to work differently later in our careers can also be heard at some of our professional development events. At the Alberta College of Family Physicians 60th Annual Scientific Assembly in Banff this past February, University of Alberta occupational medicine physician Dr. Jeremy Beach presented a case-based interactive session on The Aging Physician – Health Challenges and Fitness to Work. It was in a room full of mostly middle-aged and older physicians. Levels of engagement by participants were high and the discussion was lively. >

> Issues of physician health, fitness to practice, individual retirement preferences, desired workloads and departmental resource planning are difficult to reconcile to everyone’s satisfaction. The stakeholders are diverse – older and mid-career physicians, newly-minted colleagues with expectations for clinical positions and academic appointments, nurses and other members of the health care team including residents and medical students, department heads, zone medical directors, hospital administrators and, last but not least, patients. Arriving at the terminus of your occupational journey can be a disappointment rather than a celebration, especially if you have to get off the train before your anticipated stop. Our relationship with work is complex. Add the disruption of an unexpected illness or injury in late career and such a transition can be overwhelming.

Is there a new role ahead for you as a teacher or mentor? ( provided by Dr. Vincent M. Hanlon)

Arriving at the terminus of your

occupational journey can be a disappointment rather than a celebration, especially if you have to get off the train before your anticipated stop. Our relationship with work is complex.

What does the literature have to say? According to Betty Onyura et al, in a 2015 article entitled "Reimagining the Self at Late-Career Transitions: How Identity Threat Influences Academic Physicians’ Retirement Considerations": "An occupation often defines a person’s status, establishes a social network, provides an area in which competence can be demonstrated and praised, offers specific goals to be attained, and provides structure and meaning to a person’s day."2 The study participants were 21 Canadian academic physicians (15 male and six female) whose average age was 63. Through focus groups and semi-structured interviews, the researchers identified a number of perceived identity threats for individuals facing late-career transitions. These included apprehensions about self-esteem after retirement, practice continuity and clinical competence, as well as a loss of meaning and belonging.

Flexibility and adaptation are increasingly necessary at all stages of the career path. ( provided by Dr. Vincent M. Hanlon)

Members of the Department of Medicine at the University of Calgary (U of C) have also been involved in a related piece of late-career research. U of C internist and physician health researcher Dr. Jane Lemaire spoke about this project, entitled The Senior Physician Initiative (SPI), at the International Conference on Physician Health in September 2014 in London, UK.3 The main objective of the SPI committee of the U of C’s Department of Medicine was “to identify and advance career opportunities for senior physicians that will benefit the members, the department, patients and trainees.” >

JULY - AUGUST 2015

PFSP involvement

PFSP recognizes late-career transitions as an issue of crucial importance for an increasing number of our colleagues. We are hearing from them on PFSP’s 24-hour assistance line. We continue to coordinate services based on an occupational health model for those individuals with a complex mix of health, workplace and personal issues requiring timely assessment and treatment. Health promotion activities remain a priority, while we consider some new education initiatives to assist members in making successful career transitions.

Does aging represent a full-stop or fork in the road for your career? ( provided by Dr. Vincent M. Hanlon)

> The research included focus group work with 15 senior physicians and structured interviews with nine division chiefs all within the Department of Medicine (at the time 99 of 290 department members were aged 55 or older). Suggestions were elicited regarding clinical content of inpatient and outpatient work done by senior physicians, their work environments and schedules, and models of remuneration. Potential benefits and problems were identified. The objective of this research work was not about creating part-time, pre-retirement dream jobs for aging doctors. According to Dr. Lemaire, the SPI provided opportunities for reflection and dialogue, which increased awareness and literacy about this potentially divisive issue within the Department of Medicine. Importantly, it drew attention to the need for flexibility and adaptations in the career paths of senior physicians. The study generated some recommendations: 1. Reduced on-call service expectations for senior physicians should be based on principles of mutual agreement, collegiality and flexibility. 2. The Department of Medicine and the health region should collaborate to produce innovative practice opportunities for senior physicians. Affirmative initiatives for senior physicians should not compromise other physicians. Flexibility and adaptation are increasingly necessary at all stages of the career path. The medical profession is grappling with specialist and generalist over and under supply. These human resource phenomena are leading to previously unimaginable physician underemployment and unemployment. The shifting landscapes of geography and population demographics and rapid technological change further complicate matters. AMA - ALBERTA DOCTORS’ DIGEST

Researchers identified a number

of perceived identity threats for individuals facing late-career transitions. These included apprehensions about self-esteem after retirement, practice continuity and clinical competence, as well as a loss of meaning and belonging.

Forewarned is forearmed I asked the aforementioned senior physician with cognitive impairment what advice he would offer to colleagues based on his experience of an unhappy transition into retirement. 1. Root out agism – in our workplaces and in ourselves. 2. Look after the supportive relationships in your life, i.e., your spouse. These are the people who walk with you during the most difficult times in your life. 3. Make sure the fitness to work assessment, e.g., neuropsychological testing, is relevant to the work you actually do. 4. Establish clear goals with your care team regarding treatment and return to work (if that is a possibility). 5. Don’t be afraid to seek out the same kind of timely and expert help for yourself as you want for your own patients. As an afterthought, he also recommended that we be kind to the residents we are teaching because they may turn up, years later, doing our late-career fitness to work assessments – which is what happened in his case. It takes a decade or more of education and training to become a physician. How much time should we spend >

> figuring out how to make a healthy transition from our life in medicine to the next important stage of life?

“MCI takes care of everything so I can take care of my patients.”

References 1. Canadian Medical Association. Basic Physician Facts. 2014. Accessed 2015-06-15. 2. Onyura B, Bohnen J, Wasylenki D, Jarvis A, Biblon B, Hyland R, Silver I, Leslie K. Reimagining the Self at Late-Career Transitions: How Identity Threat Influences Academic Physicians’ Retirement Considerations. Academic Medicine. 2015;90:794-801.

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3. Lemaire JB, Wallace JE, Conly J, Powell C, Lewkonia R. The Senior Physician Initiative. Presented at the AMA CMA BMA International Conference on Physician Health, September 2014.

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403 479 8049 | dbmacnicol@shaw.ca | www.dbmcpaca.ca JULY - AUGUST 2015

FEATURE The Physician Learning Program is celebrating a big birthday

What can this five-year-old do for you?

o meet the benchmarks for its age group, a typical five-year-old must be able to show concern and sympathy for others, use the future tense and know one’s address and phone number. As we celebrate our five-year anniversary, the Physician Learning Program (PLP) is proud to say that we have met those benchmarks and many more. As we grow, our concern and future planning extends to helping Alberta physicians better understand their practices.

We make professional development easier “The Physician Learning Program offers a simple, effective, interesting way of providing self-audit and accumulating continuing professional development points and improving your patient care,” says recent Alberta Medical Association (AMA) Medal for Distinguished Service recipient, Dr. Donald E.N. Addington. Dr. Addington reached out to PLP with an idea for a project which examined the current prescribing practices of typical and atypical antipsychotics in schizophrenia compared to evidence-based guidelines. This project has resulted in a more indepth look at best practices for many psychiatrists in Calgary. But this is just one example of a project facilitated by PLP. Over the past five years, we have worked with many physician groups in the province, including: • Anesthesiology

• Diagnostic imaging

• Emergency

• Family medicine

• Hospitalists

• Neurology

• Oncology

• Orthopedics

• Pediatrics

• Psychiatry

• Surgery

• Urology

Through our work with these various groups, we have been able to better understand the needs of Alberta physicians and how data can enhance continuing professional development.

AMA - ALBERTA DOCTORS’ DIGEST

Our bariatric surgery project saw Edmonton-based surgeons working with PLP to demystify the treatment options for obesity, with a special interest in removing the stigma around bariatric surgery. This project culminated in the creation of an educational video for physicians which has been viewed more than 3,000 times on YouTube. These are just a couple of examples of the ways in which the Physician Learning Program has been able to help some of your peers. Either by joining one of our currently existing projects, or suggesting a new project with answers yet to be resolved, we welcome your interest and participation.

We make your life easier “As family physicians, we spend a lot of our day deciding which drugs to choose, how to manage our patients, how to reach these many, many targets that are being put in front of us. PLP is just one way of making life a little easier for us,” explains Dr. Tina Nicholson, participant in the Clinical Queries, Prescribing Practices project. There are many factors that may influence how you make choices in your practice. PLP is expertly positioned to work with you to see how you measure up against these changing targets. We work with a variety of groups, including Choosing Wisely Canada, Health Quality Council of Alberta, Toward Optimized Practice and the Canadian Primary Care Sentinel Surveillance Network to bring you the most up-to-date information affecting your practice. We specialize in working with physicians to analyze your data. Our partnerships with these groups allow us to be ahead of the curve when tailoring projects to your needs. PLP works closely with physicians to analyze and interpret your data, and supports this work using feedback sessions with your peers. By working with PLP, you can better understand your practice while allowing us to do the heavy lifting.

We aim to help you improve patient care “This gave a real snapshot of what is actually occurring in our hospital with our patients, not sort of reading a study that was maybe published in Denmark or France or Australia … it just adds and makes the patient experience >

> better,” said Dr. Jonathan McMann, participant in our Pediatric Anesthesia project. With our experience and expertise, the PLP team can access and analyze data for physicians that they may find difficult to both access and navigate. We work closely with Alberta Health and Alberta Health Services (AHS) to ensure our data is both accurate and complete. Thus far, we have been able to use data from the following sources: • Inpatient admission, discharge, transfer, service, diagnosis and procedure interventions. • Calgary acute care hospital electronic medical records (Sunrise Clinical Manager). • Diagnostic codes and health services completed by fee for service. • Laboratory tests: clinical chemistry, toxicology, hematology, serology, urinalysis and immunology. • Diagnostic imaging completed at AHS facilities. • Dispensed pharmaceuticals at community pharmacies. • Vital Statistics through Birth Registry, Death Registry, Stillbirth Registry. With access to most of the important administrative health databases, PLP can truly help you understand your practice using evidence-based analysis. With this new understanding, you will be equipped with the tools to make even better choices in your practice for your patients.

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

WHY PLP?

The PLP is a physician benefit program created by a partnership between the Alberta Medical Association (AMA), Alberta Health and Alberta Health Services (AHS). We work with physicians, by request, to identify clinical questions of interest that can be answered using existing administrative data. PLP data reports assist with self-reflection. PLP-facilitated feedback sessions ensure that you get maximum value from your PLP experience. All data is confidential, accurate and personalized to the needs of each individual physician within the context of each project. Our projects are all eligible for Continuing Professional Development (CPD) credits from the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. To learn more about the PLP experience, visit our website at www.albertaplp.ca and view the video on our homepage.

A novel approach to continuing professional development We all scan journals, talk to colleagues and attend rounds to stay current in practice. If we come across something we don’t know, we take steps to update our knowledge (perceived gap). However, we don’t know what we don’t know (unperceived gap), which is problematic because we normally can’t seek to remedy that.

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 unique, award-winning Physician Learning Program launched five years ago attempts to uncover unperceived gaps in knowledge in our everyday practice. It does so by data analyzing your practice (with your consent) using available databases and confidentially providing you with your practice profile in comparison to that of your peer group, allowing you to reflect on differences with your peers and whether some of these may be significant enough to warrant modification of your practice. We also help with analysis and interpretation. Having completed successful pilot projects with physician groups since its inception (see main article), we are now preparing to offer this program to more Alberta physicians.

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

More information: http://www.royalcollege.ca/ portal/page/portal/rc/resources/publications/ dialogue/vol15_6/alberta_plp

Practitioner advocacy assistance Line (PaaL)

1.866.225.7112

For more information visit albertadoctors.org/paal



Tzu-Kuang (T.K.) Lee, MB, BS, FRCPC Chair, Steering Committee, Physician Learning Program

JULY - AUGUST 2015

FEATURE

What's new on the web? Times, they are a-changing … Leopold McGinnis | MANAGER,

WEBSITE, ALBERTA MEDICAL ASSOCIATION

nd so is the Alberta Medical Association (AMA) website! In our tireless quest to make your surfing experience fruitful and painless, we are constantly making content and feature additions to the albertadoctors.org website. In case you missed them, here are a few of our latest enhancements: • AMA Fee Navigator: Successfully navigating the fee schedule is about as easy as winning a carnival ring toss! Our new Fee Navigator takes the AMA mini-fee schedule you’ve relied on for years to the next level. It’s online, searchable, robust, easy to access and free. There’s not enough room here to extol its many virtues, so give it a try today: www.albertadoctors.org/feenav. • Do it yourself! Submitting paper forms is not only fashionably passé, but slow and tedious. Online claims submission and processing makes forms exciting again! Well, maybe not, but now you can submit and view your claims on your time and have them processed much more quickly. Both Continuing Medical Education and insurance claims can now be made through the AMA website. Responses have been VERY positive so far, so try these features out, if you haven’t, and keep an eye out for more self-serve options to come.

More self-serve options! Due to popular demand (and use!), we will be creating more self-serve features for members. New self-serve options will make using and monitoring the AMA services you rely on easier and more convenient. Look for more news about these in MD Scope or your email inbox in the not-too-distant future. Have something you like/dislike about our website, a feature request or something you’d like us to focus on? You can always let us know at webmaster@albertadoctors.org – we want to hear from you!

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• News for Docs: It’s hard to keep up with political and medical affairs news. We can help! News for Docs provides subscribers with a daily cross section of provincial and national news on politics and medical affairs. To sign up, visit: www.albertadoctors.org/ media-publications/publications/news-for-docs. • Mega Menu: Getting lost on the AMA website is now harder, thanks to the new Mega Menu. The Mega Menu appears when you hover over one of the site’s main tabs, giving you a quick snapshot of what you can find in that section.

What’s next? In the coming months we hope to make some of our web content easier to find and more logically grouped. We’ll be rearranging (and even deleting) some things, so if you have any trouble be sure to consult the search box and Mega Menu.

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IN A DIFFERENT VEIN

Aging – enjoy it! Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

“I met a man whose name was Time; And he said ‘I must be going’; But just how long ago that was I have no way of knowing...”

Jokes (my antidote to timor mortis) abound: aging jokes, prostate jokes, dementia jokes, sexual fading jokes, viagra jokes – don’t rage – laugh at the dying of the light. Golf balls are harder to follow even though not hit as far – like the older golfer who was having trouble with his eyesight.

- October Song, The Incredible String Band, 1965.

hat autocrat of the breakfast table, Oliver Wendell Holmes, was still working as a judge in New England at the age of 82. One morning he was standing with a crony on the steps of the Courts of Justice when a pretty young secretary skipped up the steps. “Oh, to be 10 years younger,” sighed Judge Holmes. An optimist? Yes. An age-denier/sceptic ignoring the dying of the light? Perhaps. But I like it. Sure, the muscles and joints ache after sitting in a chair too long and a night out till 3 a.m. is no longer so attractive, but I still like it. One of the redeeming features of aging – and there aren’t a lot – is that your brain becomes a more finely tuned organ for detecting bullshit than in younger years (if you can keep it agile). It’s more sensitive than an airport drug-sniffer dog. It may work more slowly on calculations, recalling names and language agility, but for spotting dudes intent on throwing the brown stuff around, it improves with age. There are a few other redeeming features of aging: kidnappers (except in the Southern Philippines) are not that interested in you; in a hostage situation if you play your cards right and shake your pill container, you will be released first; you can discuss diseases and operations at a party without getting bored; you have a chance of boarding first at a crowded aircraft gate; you can speak your mind and question the value of much neo-technology; you can sing along to elevator music or to the car radio and to hell with what anyone thinks; and your joints are better than Environment Canada at predicting the weather.

One of the redeeming features of

aging – and there aren’t a lot – is that your brain becomes a more finely tuned organ for detecting bullshit than in younger years (if you can keep it agile).

The golf pro says to the old golfer: “Take Charlie with you as your caddie. He’s 80 but has eyes like an eagle.” The old golfer asks Charlie: “Are you sure you can follow the ball?” “Like an eagle,” Charlie, the caddie, says. The old golfer (after taking his prophylactic ibuprofen) hits a good one off the tee. “See it Charlie?” the golfer asks. “Sure.” They walk up the fairway – 100 yards, 200, then 250. The golfer begins to have doubts. “Are you sure you saw it, Charlie?” “Yup … I saw it … but, darn it, I’ve forgotten where it landed.” And then the declining sex life … like playing pool with a piece of rope for a pool cue. But there’s Viagra – where jokes abound among elderly males: >

JULY - AUGUST 2015

> The doc prescribes Viagra for the old man. “The dose is important,” the doc says. “So make sure you follow all my instructions. Monday take half a pill, then skip a day. Wednesday, one pill, then skip a day. Friday try another pill, then skip Saturday and Sunday.” A week later the doc meets the wife in the street. “How’s Willie doing?” “He died,” she says. “It must have been all that skipping.” As I leave Shakespeare’s stage five, full of wise saws and modern instances and approach the sixth stage of life, the stage of pantaloons, piping voice and spindle shanks, dreading the seventh and final – sans teeth (thank you modern implant dentistry – that should not be a problem) sans eyes, sans taste, sans everything – there is a slight laziness creeping in. There’s always a good reason not to do something. The treatment for that is exposing yourself to new experiences … and always, laugh at the dying of the light. Maintaining physical and mental health is a requirement, a job – no longer an option. After 60, exercise becomes a ritual, a need to fight off the decay invading you from all sides: viruses, bacteria, yeasts, fungi, wasps, chemicals, ticks, mosquitoes, cupcakes, Cadbury’s fruit and nut bars, email fraudsters, psychos, kids, tax inspectors, Alberta Health Services – all trying to hasten your decay.

The rationale for the white coat demise is that bacteria flourish on the white coat but not on the assorted grubby golf shirts and jeans now worn by younger physicians. This has apparently led to the banishing of C. difficile and Methicillin-resistant Staphylococcus aureus (MRSA).

The skin ages, with blotches and rough areas and senile keratoses popping up. I never used sunblock as a young man. Blazing sun? Bring it on – you got a tan and looked healthy. Well look at them – those California beach beauties. The Beach Boys don’t sing about them now, those wrinkled crones, skin hanging on them like a rumpled shirt. The shoulders stoop, steps become shorter, the sparkle in the eyes fades, the sclerae become sallow and hearing goes: “What was that you said?” You think less about sex and more about death – there’s a link there, a constant. The world (now “the planet” – a Star Trek term implying that we’re in the Milky Way looking down on the earth from Romulus) has changed. I got to thinking about the huge societal and medical

AMA - ALBERTA DOCTORS’ DIGEST

changes of the last 50 years … and the challenges of adapting to change: “You must have seen many changes, Mr. McGregor, in your lifetime?” says the young man. “I have. And I’ve been against them all.” Here’s a new world/planet scene: the line-up at a Toronto Starbucks. Girl in jogging gear standing behind me with her multi-racial friends: “I have to get an Apple. My Blackberry won’t text back. I can’t go on like this. It’s terrible.” I can’t resist and turn round and say to her. “That must be awful. How do you manage?” She laughs. “OK, OK – first world problem.” I get to the narrow ordering area between glass cages of bakeries and order a breakfast sandwich and a banana slice with icing. “First name?” I look blank. “Huh? Oh, Alexander. Hi, what’s yours?” “Trevor.” He is amused. “We’ll call you when it’s ready.” I get my banana slice – but without icing – and I am really miffed. Here’s an old world/planet scene: “Coffee? Only tea here, son. There’s a non-smoking section over there and we’re out of kippers today.” Want more examples of social change? When I was 13, a serial murderer called Peter Anthony Thomas Manuel was hanged in Duke Street Prison, Glasgow, Scotland. He lived over the hill from us and had terrorized our neighborhood. Down the road, one family, including the son who was my age, had been found dead. The parents shot in the head sleeping in their bed and the son was in the corridor as if running away. I had difficulty sleeping in our big cold house with its creaking stairs. At his trial, dapperly dressed in a suit and red tie and aping legal skills, he’d dismissed his defence lawyer. The jury found him guilty of five murders and “not proven” for three others. The Judge, Lord Cameron, ironically congratulated Manuel on the conduct of his defence as he placed the black cap on his wigged head pronouncing Manuel to be hanged by the neck until dead. “Aye, he’s a changed man,” said Baillie Johnson who visited him to tell him his appeal had failed. “Gone is the debonair cockiness we saw at the trial. He just stared at me and said nothing.” On the morning of his 8 a.m. hanging, at school we counted the seconds down. “He’s goin’ up the gallow >

> steps. The hangman’s puttin’ the noose knot behind his left ear. Now the black hood. Now...” There was a light, almost merry feeling of relief that morning to be rid of the little rat. We don’t hang murderers any more. The risk of hanging an innocent person outweighs the eye-for-an-eye argument and the possible preventative benefit of capital punishment. And we don’t call people “traitors” any more. Going to a foreign country to fight and kill your own country’s troops used to be called treason, and you faced the death penalty. It is now “radicalization” and you are a “foreign fighter”; on return, you might go to jail and are a cause for “concern” and “de-radicalization.” Social change marches on. Getting pregnant outside marriage is an inconvenience (or even a celebration) rather than a disaster or a major embarrassment. Tattoos of an iguana on your back and studs through your nose or tongue are a fashion statement and a sexual stimulant rather than a clinical clue that you were once in the navy or jail. And then there are the huge medical changes. Medical textbooks have been superseded by “guidelines.” Patient verbal consent for pretty much anything you suggested used to be fine; now a fecal specimen for research requires a legal document. Appearing on the ward without a white coat meant it was lost or being washed. Now no recognizable regalia tagging you as a physician is a la mode. You can sneak onto the ward disguised as a member of the public and be undisturbed. Likewise, nursing staff (once in smart crisp uniforms) can blend into the background to avoid the annoyance of being called to the bedside by some client/customer/significant other. The rationale for the white coat demise is that bacteria flourish on the white coat but not on the assorted grubby golf shirts and jeans now worn by younger physicians. This has apparently led to the banishing of C. difficile and Methicillin-resistant Staphylococcus aureus (MRSA). Stethoscopes slung around the neck like a sommelier with his tasting cup (instead of properly in the coat pocket) apparently do not collect neck microbes. Dancer and Duerdon have challenged the whole bacteriological house of cards that white coats and dirty ties caused rising MRSA and C. difficle levels in hospitals. In a must-read article in the Journal of the Royal College of Physicians of Edinburgh they suggest that the evidence from bacteriology is seriously flawed and that the demise of the white coat has done more harm than good.1 For myself, I had always assumed the white coat was actually to keep the patients’ blood, sweat, pus and fleas off myself and not the other way round.

It’s now hard for patients to determine who is doing what on the wards. It’s one of their biggest complaints: “Who’s my doctor?” The ward of the 21st century fills me with anxiety with its emphasis on technology and downgrading of clinical skills. But there’s the enjoyment of reminiscence. An old friend, Dr. Roy Humble, a retired anesthetist in Edmonton, has published an excellent book While You Sleep.2 This is an autobiography of an active life with the bonus for medical readers of fascinating medical situations managed the best way possible under difficult circumstances – lessons (for those of us used to easy specialist access) that the best doctors are often those who have practiced in challenging environments. He describes the vast changes experienced during his career ranging through anesthesia, surgery, obstetrics, pediatrics, general medicine and even psychiatry. Some examples include operations conducted with the light from a laryngoscope; managing exsanguination from an unexpected placenta praevia; unusual presentations of malaria, a death resulting from misdiagnosis avoidable by simple history taking. A lively chapter on the history of the art and science of anesthesia completes the book.

Stethoscopes slung around the neck like a sommelier with his tasting cup (instead of properly in the coat pocket) apparently do not collect neck microbes.

Roy writes: “If anyone of my vintage looks back at the methods they used in the past, they would be amused by what they did 10 years ago, alarmed by what they did 20 years ago, and astonished by what they did 30 years ago.” Roy tells of his training in Glasgow (where a student was required to administer 10 anesthetics). I didn’t do that, but at least I squeezed a bag while the anesthetist went out for a smoke, and to qualify I had to fumble the delivery of eight slippery babies. Now our poor students make a lifetime choice early in their careers missing the >

JULY - AUGUST 2015

> benefits of a rounded medical education. Total trust in the doctor has evolved into a partnership – and that’s a nice thing. Smoking at rounds has become a nicotine gum chew.

For myself, I had always assumed the

white coat was actually to keep the patients’ blood, sweat, pus and fleas off myself and not the other way round.

When you think about aging, you think more about where you came from, like the homing salmon, some biological need to return to a spawning ground. I was four years old when I jumped off the garden wall of our house in Gullane and fell on the ground, my head lying in the smell of fresh cut grass and I thought “I will remember this moment forever,” and I have. The memory keeps returning, for 65 years. Life expectancy is another big change – healthier lifestyles and better medical care so that threescore years and 10 is no longer the expectation but is now closer to fourscore years. Will this be an advance? Is a

pleasure worth giving up so you can spend three extra years in a geriatric ward? Or worse, a psycho-geriatric ward? The minutes are winging their way, not always with pleasure, but with a sense of familiarity. You’re a dog in a familiar kennel – and though this is one way to cope – it may be a false creek. Take up new hobbies. It’s my greatest fear – not cancer, certainly not a heart attack – but losing my marbles – that loss of control, becoming feeble. What sustains you in the aging life? Love of family, friends and a continuing fascination with life itself? Dismiss the fear: “Timor mortis conturbat me.” Keep interested and keep laughing – the best defence mechanism. Do something new and different. And remember Ulysses: “Old age hath yet his honour and his toil. Some work of noble note may yet be done, not unbecoming men that strove with gods.” But I’m still with Judge Oliver Wendell Holmes: “Oh, to be 10 years younger!” References

1. Dancer SJ, Duerden BI. “Changes to clinician attire have done more harm than good” (2015). JRCPE Vol 44 Issue 4. 2. Humble RM. “While You Sleep; A personal journey in anaesthesia.” Melrose Books, Cambridgeshire, UK, 2011. Also available from www.royhumble.com.

LETTERS I wish to congratulate Dr. Kimberly G. Williams on her article in the May-June 2015 issue of Alberta Doctors’ Digest (“Do leaders need to change the world? Nice idea. Not necessary.” Page 26). Dr. Williams seems to have a vision of leadership that encompasses the values, beliefs, traits and skills that underlie an effective definition. As a member of the International Expert

AMA - ALBERTA DOCTORS’ DIGEST

Working Group for the 2015 Can MEDs revision, I suggested that the core role “manager” be changed to “leadership” because I believed that would be in closer alignment with a vision that embraced those qualities in every physician and, indeed, every health care team member.

perspective to see people gravitate to “leader” roles with little evidence of leadership abilities. Leadership skills are required by everyone on the health care team and focusing on skill, rather than role, will have a positive effect on our culture and on the health care team.

Regardless of the role a physician has, leadership qualities will enhance it. It is not uncommon from my

Dr. Scott Allan Lang Calgary AB

CLASSIFIED ADVERTISEMENTS

PHYSICIAN WANTED CALGARY AB Med+Stop Medical Clinics Ltd. has immediate openings for permanent full-time physicians to provide primary health care to patients at our four Calgary locations. Requirements are MD degree and must be eligible to be licensed by the College of Physicians & Surgeons of Alberta. Experience is an asset but not required. Our family practice medical centers offer pleasant working conditions in well-equipped modern facilities, high income based on fee-for-service, TELUS Health Solutions electronic medical records, low overhead, no investment, no administrative burdens and a quality of lifestyle not available in most medical practices. We also have some part-time positions available at two of our clinics.

Collaborate with our large network of family physicians and their referrals to maximize outcomes for your patients. Opportunities for group therapy and corporate health are available. There are also opportunities to help develop leading programs for mental health at all levels of primary care within our multiple sites located throughout Calgary and Edmonton. An attractive compensation package will be offered to the successful candidate. All candidates must be immediately eligible for licensure or already licensed with the CPSA and provide proof of malpractice insurance from the Canadian Medical Protective Association. Compensation is fee-for-service.

Contact: Marion Barrett Med+Stop Medical Clinics Ltd. 290-5255 Richmond Rd SW Calgary AB T3E 7C4 T 403.240.1752 F 403.249.3120 msmc@telusplanet.net CALGARY AND EDMONTON AB Imagine Health Centres in Calgary and Edmonton have an immediate opening for a psychiatrist certified with the College of Physicians & Surgeons of Alberta (CPSA). Imagine Health Centres are dynamic multidisciplinary clinics with a large array of services including family physicians, specialists and many other allied health professionals such as pharmacists, physiotherapists, psychologists and more. Imagine Health Centres are dedicated to promoting the health of patients utilizing the most up-to-date preventative and screening strategies. The successful candidate will work closely with our multidisciplinary team to optimize management of our patients with mental health issues.

All inquiries will be kept strictly confidential and only qualified candidates will be contacted. Submit your CV to: Dr. Jon Chan physicians@imaginehealthcentres.ca EDMONTON AB The College of Physicians & Surgeons of Alberta is looking for physicians of all specialities to serve on its Complaint Review Committee or hearing tribunals. Candidates must have a minimum of five years of practice experience and be in good standing with the college. Deadline to apply is September 15. Contact: adele.gendron@cpsa.ab.ca >

AMA Physician Locum Services

Locums needed. Short-term & weekends. Family physicians & specialists. Experience: •

Flexibility – Practice to fit your lifestyle.

•

Variety – Experience different Alberta practice styles.

•

Provide relief – Support rural colleagues and rural Albertans.

•

Travel costs, honoraria, accommodation and income guarantee provided.

ContaCt: Barry Brayshaw, Director, AMA Physician Locum Services ®

barry.brayshaw@albertadoctors.org T 780.732.3366

TF 1.800.272.9680, ext. 366

www.albertadoctors.org/services/physicians/practice-help/pls

JULY - AUGUST 2015

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 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 Family physicians needed in Edmonton. Beverly Medical Clinic Inc. is a new state-of-the-art medical clinic that is expanding rapidly. The clinic is growing and needs more dedicated family physicians as one of the physicians is planning to slow down. We are currently seeking two family physicians.

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Terms of employment and wages: The family physician positions are permanent, full-time, fee-for-service with anticipated annual income of $300,000. The physician and the clinic will share fee-for-service billings, 70% (physician) and 30% (clinic) for overhead expenses. Flexible work hours: Clinic is open 9 a.m. to 9 p.m. weekdays and weekends allowing physicians to have flexible work hours and flexible work arrangements. Job duties: The physician will be providing primary care to patients of the Beverly Medical Clinic, including diagnosing and treating medical disorders, interpreting medical tests, prescribing medications and making referrals to specialist physicians as appropriate. Education and experience: Medical degree with specialist training in family medicine. Preference will be given to candidates with family practice experience and candidates must be eligible for registration with the College of Physicians & Surgeons of Alberta. Preference will be given to candidates that are College of Family Physicians of Canada certified and preference will be given to Canadian citizens and permanent residents. Skills required: Specialist training in family medicine, ability to work effectively, independently and in a multidisciplinary team, effective written and verbal communication skills. Contact: Dr. A. Elfourtia or Dr. Z. Ramadan Beverly Medical Clinic 4243 118 Ave Edmonton AB T5W 1A5 T 780.756.7700 or C 780.224.7972 EDMONTON AB Dx Medical Centres is a new, spacious and modern clinic in Mill Woods with high-visibility exposure in a busy residential area. We are looking for general practitioners for the growing practice to join our team working collaboratively with multiple disciplines of the health care field. Our clinic offers a pleasant working environment in a contemporary facility. The clinic is paperless with excellent support staff. We would like to offer you the opportunity to work in an enhanced practice environment

that fits your lifestyle, needs and availability without investment or administrative time commitments. We provide competitive split to our valued physicians on a fee-for-service schedule. Candidates must be licensed or eligible to apply for licensure with the College of Physicians & Surgeons of Alberta. Contact: Christina T 780.705.8400 info@dxmedical.ca EDMONTON AB Family physicians needed in Edmonton. The Beverly Towne Medical Clinic is a new medical clinic in Edmonton at 11730 34 Street. (The clinic is operated by the Beverly Medical Clinic Inc.) We are currently seeking three family physicians to join this new practice. Terms of employment and wages: These family physician positions are permanent, full-time, fee-for-service with anticipated annual income of $300,000. The physician and the clinic will share fee-for-service billings, 70% (physician) and 30% (clinic) for overhead expenses. Flexible work hours: The clinic is open 9 a.m. to 9 p.m. during the week, and also on weekends, allowing physicians to have flexible work hours and flexible work arrangements. Job duties: The physician will be providing primary care to patients of the Beverly Towne Medical Clinic, including diagnosing and treating medical disorders, interpreting medical tests, prescribing medications, and making referrals to specialist physicians as appropriate. Education and experience: Medical degree with specialist training in family medicine. Preference will be given to candidates with family practice experience and candidates must be eligible for registration with the College of Physicians & Surgeons of Alberta. Preference will be given to candidates that are College of Family Physicians of Canada certified and preference will be given to Canadian citizens and permanent residents. Skills required: Specialist training in family medicine; ability to work effectively, independently and in a multidisciplinary team; effective written and verbal communication skills. >

Contact: Dr. A. Elfourtia or Dr. Z. Ramadan T 780.756.7700 or C 780.224.7972 Beverly Towne Medical Clinic 11730 34 St Edmonton AB EDMONTON AND FORT MCMURRAY AB MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic each have 10 examination rooms and Alafia Clinic with four examination rooms are looking for six full-time family physicians. A neurologist, psychiatrist, internist and pediatrician are required at all four clinics. Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton. Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray.

The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines. The physician income will be based on fee-for-service with an average annual income of $300,000 to $450,000 with competitive overhead for long term commitments; 70/30% split. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records (paper free) and member of a primary care network. Full-time chronic disease management nurse to care for chronic disease patients at Lessard, billing support and attached pharmacy are available at the Lessard and West Oliver locations.

PHYSICIAN(S) REQUIRED FT/PT Also locums required

Work with a nice and dedicated staff, nurse available for doctorâ&#x20AC;&#x2122;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 WESTLOCK AB The Associate Medical Clinic is seeking permanent full-time general family practitioners for our active multidisciplinary clinic. We are in a rural setting but easily accessible to Edmonton (90 kilometers north) so you can enjoy the best of both worlds. The Aspen Primary Care Network works very closely with our clinic to enhance patient care delivery and to optimize your practice. The clinic currently has six general practitioners and two orthopedic specialists. We also enjoy the services of visiting internal medicine and general surgeon. The Westlock Healthcare Centre in our community is a very busy, well-equipped modern 45-bed facility with 24-hour emergency department, rehabilitation services, stroke program, maternity services, operating theaters, full diagnostic imagining services and on-site laboratory. Our support staff are easy to work with and look forward to making your work life as pleasant as possible. Physicians in our community enjoy rural recruitment incentives as well as the standard fee-for-service.

ALL-WELL PRIMARY CARE CENTRES MILLWOODS EDMONTON

Contact: Karen Bouman Clinic Manager Associate Medical Clinic 203-10030 106 St Westlock AB T7P 2K4 T 780.349.3341 F 780.349.6686 amc_mgr@telus.net >

Phone: Clinic Manager (780) 953-6733 Dr. Paul Arnold (780) 970-2070

JULY - AUGUST 2015

PHYSICIAN AND/OR LOCUM WANTED CALGARY AND EDMONTON AB You require balance â&#x20AC;Ś you demand the best. Join the fastest growing medical group in Alberta to practice medicine the way it was meant to be. Imagine Health Centres (IHC) is currently looking for family physicians and specialists to join our dynamic team in either Calgary or Edmonton. Physicians will enjoy extremely efficient workflows allowing for very attractive remuneration, no hospital on-call, paperless electronic medical records, friendly staff and industry-leading fee splits. Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. Come and be a part of our team which includes physicians, physiotherapists, massage therapists, psychologists, nutritionists and pharmacists. Imagine Health Centres prides itself in providing the very best support for family physicians and their families in and out of the clinic. Health benefit

plans and full financial/tax/accounting advisory services are available to all IHC physicians. There is also an optional and limited time opportunity to participate in ownership of our innovative clinics. Compensation is fee-for-service. Current positions available are locum, part- or full-time. We currently have three Edmonton clinics with a fourth opening this fall in Windermere (southwest Edmonton). The current clinics are near South Edmonton Common, Old Strathcona and west Edmonton. We currently have one clinic in southeast Calgary with a second clinic that opened downtown in April. All inquiries will be kept strictly confidential and only qualified candidates will be contacted. Submit your CV to: Dr. Jon Chan physicians@imaginehealthcentres.ca DEVON AB Devon Medical Clinic requires physicians or locums to help meet the needs of our growing community. We currently have one physician on maternity leave and a few others are looking to reduce their work load. The clinic uses TELUS Wolf electronic medical records, a diagnostic imaging clinic and pharmacy are the same building, and the hospital is across the street. Emergency room shifts are optional, we are part of the Leduc Beaumont Devon Primary Care Network and we are closed on weekends. We enjoy a pleasant working environment with excellent support staff. Contact: Kim T 780.987.3315, ext. 227 kbabiy@devonmedical.ca EDMONTON AB Summerside Medical Clinic and Edge Centre Walk-in Clinic require part- and full-time family physicians, specialists and locums are welcome. The clinics are in the vibrant, rapidly growing communities of Summerside and Mill Woods. Examination rooms are fully equipped with electronic medical

AMA - ALBERTA DOCTORSâ&#x20AC;&#x2122; DIGEST

records, printers in all examination rooms and affiliated with the Edmonton Southside Primary Care Network. The Edge Centre has 5,000 sq. ft. and can accommodate other medical professionals such as dentist, massage therapist, physiotherapist, chiropractor, etc. Contact: Dr. Nirmala Brar T 780.249.2727 nimmi@theplaza.ca 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 2015. 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 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

PRACTICE WANTED CALGARY AB I am a family doctor looking to take over any medical clinic from which the owner is relocating or retiring. I would also consider buying a medical building. If you are a family physician or specialist looking for part- or full-time work please contact me. Contact: Dr. D. Das T 403.585.6840 drddebasish@gmail.com >

SPACE AVAILABLE EDMONTON AB Office space available would be most suitable for an orthopedic surgeon, rheumatologist or general practitioner interested in patients with musculoskeletal issues. Other specialties are also welcome. Our office currently has six orthopedic surgeons and an endocrinologist. We have been paperless for 15 years and currently use Accuro electronic medical records. We do not have radiology facilities on sight, but are electronically linked to several radiology facilities. Excellent long term support staff is also available. Contact: Marilyn Nelson Clinic Manager T 780.433.7033 manelson@telus.net

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SOUTH AMERICA February 28-March 9, 2016 Focus: Hot topics in medicine Ship: Celebrity Infinity CARIBBEAN March 13-20, 2016 Focus: Primary care review Ship: Liberty of the Seas TASTE OF THE EAST April 12-May 2, 2016 Singapore, Asia, India and United Arab Emirates Focus: Adventures in Medicine Ship: Regent Seven Seas Voyager WEST COAST WAYFARER June 13-19, 2016 Focus: Internal medicine and infectious diseases Ship: Crystal Serenity BALTIC AND NORTHERN CAPITALS June 19-July 1, 2016 Focus: Cardiology, neurology and gastroenterology Ship: Celebrity Silhouette GREECE AND TURKEY July 9-16, 2016 Focus: ER medicine: Novice to expert Ship: Celebrity Equinox ICELAND AND NORWAY July 16-28, 2016 Focus: Primary care Ship: Holland America Zuiderdam JAPAN AND KOREA September 18-29, 2016 Focus: Endocrinology and dermatology Ship: Celebrity Millennium MEDITERRANEAN September 24-October 8, 2016 Focus: Cardiology and endocrinology Ship: Celebrity Silhouette For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

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Contact: N. Ali Amiri MBA Consultant Seek Value Inc. T 780.909.0900 aamiri.mba1999@ivey.ca aliamiri@telus.net DOCUDAVIT MEDICAL SOLUTIONS 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. DOCUdavit Solutions has achieved ISO 9001:2008 and ISO 27001:2013 certification validating our commitment to quality management, customer service and information security management. Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com

DISPLAY OR CLASSIFIED ADS TO PLACE OR RENEW, CONTACT:

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

JULY - AUGUST 2015

“I DIDN’T KNOW WHAT TO EXPECT AS I TRANSITIONED FROM MEDICAL STUDENT TO RESIDENT. MD HELPED MAKE IT EASIER.” “When you’re entering residency, your goals seem a long way away. MD listened to my goals—like buying a house and car, and planning for my wedding—then prepared me well to achieve them. That’s when I fell in love with MD. They’ve done amazing work for me. I feel very safe and secure knowing they’re always there.” – Dr. Noor Amily, Obstetrics and Gynecology Resident

EVERY PHYSICIAN HAS A STORY. HEAR MORE FROM YOUR PEERS: MD.CMA.CA/MYSTORY

FOUR TIMES MORE PHYSICIANS TRUST MD.1

Fifty-three per cent of Canadian Medical Association members trusted MD Financial Management as their primary financial services firm, four times more than the next closest individual competitor at twelve per cent. Survey respondents (MD clients and non-MD clients) were also asked to identify their primary financial institution (MD or Other), and rate their level of trust associated with that institution. MD received the highest trust rating compared with all other firms rated. Source: MD Financial Management Loyalty Survey, June 2014.

MD Financial Management provides financial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca. Incorporation guidance limited to asset allocation and integrating corporate entities into financial plans and wealth strategies. Professional legal, tax and accounting advice regarding incorporation should be obtained in respect to an individual’s specific circumstances. Banking products and services are offered by National Bank of Canada through a relationship with MD Management Limited.

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