Alberta Doctors' Digest March/April 2017

Alberta Doctors'

DIGEST March-April 2017 | Volume 42 | Number 2

Special issue: Daring ideas for health care in Alberta Standardization of refugee care across the province

Recognizing that community and the health care system are both important at end-of-life

Pregnancy Pathways helps homeless pregnant women build a better future Patients FirstÂŽ

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CONTENTS DEPARTMENTS

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

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

Editor: Dennis W. Jirsch, MD, PhD

6 From the Editor 12 Health Law Update 14 Insurance Insights 20 Dr. Gadget

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Editor-in-Chief: Marvin Polis President: Padraic E. Carr, BMedSc, MD, FRCPC, DABPN President-Elect: Neil D.J. Cooper, MD, FRCPC, Dip. Sport Med. Immediate Past President: Carl W. Nohr, MDCM, PhD, FRCSC, FACS 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 May-June issue deadline: April 12

FEATURES

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. © 2017 by the Alberta Medical Association Design by Backstreet Communications

8 My daring idea for health care in Alberta

Standardization of refugee care across the province

10 A tribute to Dr. Gerald L. Higgins

(September 16, 1929 – January 6, 2017)

17 The 2017 Tarrant Scholarship opportunity is here!

Medical students can apply; practicing physicians can give back through donations

18 My daring idea for health care in Alberta

Recognizing that community and the health care system are both important at end-of-life

22 My daring idea for health care in Alberta

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.

30 PFSP Perspectives 36 In a Different Vein 39 Classified Advertisements

Multidisciplinary chronic disease management

24 My daring idea for health care in Alberta

Physician health ambassadors in schools across Alberta

26 Our daring idea for health care in Alberta

Let’s change the lens on seniors’ care

28 My daring idea for health care in Alberta

Investment in multidisciplinary care for rheumatoid arthritis patients

34 A daring idea in action

Pregnancy Pathways helps homeless pregnant women build a better future

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.

To request article references, contact:

daphne.andrychuk@albertadoctors.org COVER PHOTO:

Dr. Annalee Coakley's daring idea: Standardization of refugee care across the province MARCH – APRIL 2017

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A SPECIAL ISSUE

Daring ideas for health care in Alberta Check out some thoughts from your visionary colleagues Marvin Polis | EDITOR-IN-CHIEF

W

e’ve had such great response to our specially themed issues over the past year that we’re going to keep the tradition rolling along! So welcome to the first of several themed issues for 2017. And it’s a great one indeed.

In this issue of Alberta Doctors’ Digest, your colleagues share their visionary thoughts and “daring ideas” for health care in Alberta. The ideas are clever and practical. Except, of course, for Dr. Paterson’s idea in his In a Different Vein column. Daring? Yes. Practical?

Well, you can decide for yourself.

We’d like to thank the many Alberta doctors who generously volunteered their time and effort to helping us put together this special issue. Their ideas are truly inspiring.

Marvin Polis Editor-in-Chief Alberta Doctors’ Digest

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MARCH – APRIL 2017

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FROM THE EDITOR

Old dogs and new tricks Dennis W. Jirsch, MD, PhD | EDITOR

M

y last editorial was an investigation – of sorts – regarding my memory. You may recall that losing my car keys has been a longstanding bugbear in my life, a bête noire. Though my memory is undoubtedly worse with age, I was able to commit 40 lines of T.S. Eliot’s Love Song of J. Alfred Prufrock to memory without incident and that component of my being has held up. If I can’t blame my problem with my car keys on my memory, I wonder whether it is my attention that’s at fault.

We tend to regard attention as

something generally unchanging, but our techno world has altered both our environment and ourselves dramatically.

Dr. William James, psychologist, philosopher and trained physician, worked at Harvard over 100 years ago, pioneering much of psychology, including the study of attention. He offered this definition: “Attention … is the taking possession by the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought.

Focalization, concentration of consciousness are of its essence. It implies withdrawal from some things in order to deal effectively with others, and is a condition which has a real opposite in the confused, dazed, scatterbrained state which is called distraction in French and Zerstrutheit in German.”1 I’d like to take umbrage at James’ “confused, dazed, scatterbrained,” but maybe it’s true and I’m just

AMA - ALBERTA DOCTORS’ DIGEST

inattentive. James also went on to say, agreeing with Aristotle, that one’s life is what attends to, a truism promising that if I just attended to my car keys properly, I wouldn’t have a problem.

I learn there are at least two kinds of attention. There is bottom-up processing, also known as stimulus-driven attention, referring to voluntary allocation of attention to a stimulus – say a fire engine screaming by, or a tree in the road. I recall Boswell Johnson writing: “When a man knows he is to be hanged … it concentrates his mind wonderfully.”2 Top down or endogenous control of attention is what I’m in search of, I realize, driven from within and goal-directed: I need to consistently and reliably find my car keys.

We tend to regard attention as something generally unchanging, but our techno world has altered both our environment and ourselves dramatically. Polymath Herbert Simon was the first to see how the world had changed: “… in an information rich world, the wealth of information means a dearth of something else: a scarcity of whatever it is that it consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attendance efficiently among the overabundance of information sources.”3 Many authors associate the poverty of our attention with our modernity. Neil Postman, for instance, in his book, Amusing Ourselves to Death,4 felt that the attention span of humans was increasingly troubled as our use of technology proliferates. Internet browsing and social media came along after Postman, but contemporary writers such as Nicholas Carr would concur. A recent headline caught my eye, announcing that our attention span is now shorter than that of a goldfish. Results have shown that the average human attention span has fallen from 12 seconds in 2000, at the beginning of the mobile revolution, to a current eight seconds. Goldfish, on the other hand, are considered to have an attention span of nine seconds.5 >

> I recently read Jon Kabat-Zinn’s Full Catastrophe Living6 and was impressed with the use of meditation to help practitioners focus on moment-to-moment awareness.

It has helped people with chronic pain, anxiety and mood disorders achieve lives that are zestfully aware and under control.

I give meditation a try. Straightforward really. No pretzel poses, just persistent focus on one’s breath. Mind doesn’t want to focus on breath. I try harder, over a period of weeks, till I am able to sit comfortably focused on the rise and fall of my breathing. It reminds me of Warren Buffett’s advice to would-be investors: it’s simple, but it’s not easy.

I think it has worked. Or at least it has worked in part.

I’ve become an oasis of calm, and I think I sleep better, have ruddier cheeks. I’m encouraged. Last week, though, on my way out the door with yoga mat in hand, I couldn’t find my keys. Not in my coat, my briefcase or even in the little brass saucer I’ve positioned near the door. They seem to have a life of their own. I found them, in a drawer I don’t often use, but later the same day, found them again, this time in my slippers.

A recent headline caught my eye,

announcing that our attention span is now shorter than that of a goldfish.

I remained calm throughout, though, and when I looked in the mirror I thought I had developed a resemblance to Mahatma Gandhi, or more particularly, to Ben Kingsley playing Mahatma Gandhi. If anything, my resolve has increased. There are more arrows in my quiver and I’ll explain.

We have brains, I’m told, because we have arms and legs, the power of movement. Though we need to focus and attend to things as we move through the world, that’s not all. As Dr. James noted a century ago, and as Charles Duhigg relates in his recent work, The Power of Habit,7 much if not most of what we do is ingrained, automatic behavior, such as driving across town or walking to the store. That’s what I need, I reckon – better habits.

I’ve worked on a promising habit loop. I’ll drop my car keys into a bowl at the front door whenever I come in.

I’ll reward myself with candies that I’ll leave in a bowl at the door. Once I’ve dropped my keys into the bowl, I’ll give myself a candy and voila, my car keys will be there when I need them. Do this twice or thrice a day for a couple of months and, presto, a new habit will be inculcated, available and helpful.

I try this new tack, but there are problems. On day three of my nascent routine, I find the candies gone, pilfered and the brass dish has new occupants: three paper clips and a ratty-looking rubber ball. My habit loop suffered even more the next day when the dish had disappeared.

Under some duress, my housekeeper told me that Cub Scouts had been by on a bottle drive, and lacking pop bottles, she’d given the Cub Scouts my candies and the dish to boot. My quest for habit has become a quicksilver thing, tricky and difficult.

I’m not a quitter, though. Remember the arrows in my quiver. Let me tell you …

I’ve had three sets of keys made. Two sets, I’ll leave pretty well anywhere, though I’d like to think one set will find a home in my jacket pocket, another set I’ll leave on the night table beside my bed. I’m nonchalant here, since my ace-in-the-hole will be my third car key, which I have secreted on the outside of my vehicle, held securely in place under a fender by a space-age magnet that promises to never give up.

I’m en route now to visit my favorite bookstore in a mall.

One car key is comfortably palpable in my pocket and there is still the other one, secured on my car. But I’m aware of an old sense of dread, prodromal anxiety from the time before I explored memory, focus, meditation and habit.

What it is is plain enough: I can’t remember where I parked my car. Each of the mall exits I pass looks strangely familiar, yet not familiar enough. As well, I can’t remember which of the mall’s three levels I’ve parked on.

There it is: I’ve lost my car.

Let me confess. It’s happened before. I know what to do.

I’ll return by cab at midnight. With all the cars gone, we’ll circle a while, but my car should be easy to find.

I’m back to Prufrock. I identify:

I should have been a pair of ragged claws, Scuttling across the floors of silent seas.

But I think my “lost car keys, lost car” vignettes amount to more than a cautionary tale. They speak, rather, to the difficult nature of real change, especially as it pertains to absent-mindedness, to distractibility. I think it best to regard my foibles more gently and with more charity.

These are minor sins, after all, and we are defined by our peccadilloes as much as we are defined by our efforts to overcome them.

In a world where we all have devils, what is the old saw?

“Better the devil you know than the devil you don’t.”

I’d like to think so, anyway.

References available upon request.

MARCH – APRIL 2017

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COVER FEATURE

My daring idea for health care in Alberta Standardization of refugee care across the province Annalee Coakley, MD, CCFP, DTM&H

F

or refugees fleeing war and violence, Canada offers safety and the promise of a better future. But arriving in a new country can be overwhelming, especially for people with health issues. As the medical director of the Mosaic Refugee Health Clinic in Calgary, I see first-hand the struggles refugees face.

I continue to look for ways to ensure my refugee patients get the care they need.

We have people arriving with a range of complex health issues. Sometimes they’re dealing with conditions that have been neglected for years. The clinic, located in northeast Calgary, provides comprehensive primary care for refugees during their first two years in Canada. The clinic also links them to other health and community resources.

My experience working with refugees, including the recent influx of Syrian refugees to Calgary, has given me a unique understanding of how we can better support them. I would really love to see a standardization of refugee care across the province. The Edmonton refugee clinic is in threat of closure. It shouldn’t matter if you arrive in Calgary, Edmonton or Lethbridge, you should receive the same level of care. I would also love to see an organization like Edmonton’s Multicultural Health Brokers better funded and expanded into Calgary. They are such a wonderful, under-resourced organization that I would like to see imported into Calgary.

Refugees don’t take opportunities

for granted and are incredibly loyal to their new country.

Arriving as a refugee is challenging, especially if you don’t speak the language, or struggle with literacy and numeracy. To help alleviate that struggle, the clinic uses reliable drivers to chauffeur patients to appointments.

I accompany the refugees’ medical tests when possible, and ensure my sickest patients have my cell phone number so they can reach me.

My concern for my patients has also led to advocacy work, including a national effort to get the federal government under Stephen Harper to reverse cuts to refugee health funding. I’m not at all political, but I had to do something. Because if not me, who? Although the Trudeau government has since reversed the cuts,

AMA - ALBERTA DOCTORS’ DIGEST

Prescription medication is a particular challenge because of gaps in coverage or urgent need upon arrival.

Refugees arrive here with nothing but the clothes on their backs, so can’t afford medications. In response to this need, I join my colleagues at Mosaic Refugee Clinic to put our teaching money into a donation account with the Calgary Health Trust. This helps pay for much needed medications.

Above all, I wish for more compassion and kindness in the world. The unwillingness to help our fellow global citizens that is occurring in parts of the world right now worries me. Refugees are in desperate circumstances and to reject people who are in such need creates an environment that allows extremist views to take hold.

I feel Canada’s refugee policy needs to be exported around the world, because we are an example for how refugees should be welcomed.

I also wish more countries recognized the strength that refugees bring with them. We often describe refugees as vulnerable, but they are also resilient and resourceful.

They arrive here willing to learn, so they are grateful for the opportunities that Canada offers. They don’t take opportunities for granted and are incredibly loyal to their new country.

If you want to create a patriot, give a refugee the chance to build a new life.

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FEATURE

A tribute to Dr. Gerald L. Higgins (September 16, 1929 – January 6, 2017)

I

n this issue of Alberta Doctors’ Digest, we pay tribute to a past editor of our publication, Dr. Gerald Higgins, who passed away on January 6. Dr. Higgins was a physician and academic who enjoyed immensely his collections: art, porcelain, books and music.

He also found pleasure in making things such as pottery and, once, a kayak. But he especially liked to read widely, for pleasure and to understand himself, his profession and above all, his Christian faith, the foundation of his life.

Gerald L. Higgins, MB, ChB, FCFP

Born in Wales in 1929, Dr. Higgins attended medical school in Bristol, England where he met and married his wife, Jean. He is survived by Jean and also his children (Robert, David and Rachel), their spouses (Beverly and Mark), eight grandchildren and 12 great-grandchildren. His son, Paul, predeceased him.

Recognized as one of Alberta's Top 100 Physicians of the Century, he was known for his pioneering role in family medicine at the University of Alberta and for his editorials written during his 25 years as editor of Alberta Doctors' Digest.

He loved his family and had a true interest in everyone he met. His droll humor and gentle ways remained to the end.

Dr. Higgins’ family wishes to thank the staff at Grandview Care Centre.

AMA - ALBERTA DOCTORS’ DIGEST

MARCH – APRIL 2017

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HEALTH LAW UPDATE

Dear Minister: Please clean up your acts Jonathan P. Rossall, QC, LLM | PARTNER,

I

MCLENNAN ROSS LLP

n this special edition of Alberta Doctors’ Digest, columnists have been invited to share their daring ideas for health care. Mine is a straightforward wish for Alberta: clean up your health care legislation.

since then. One of the more out-of-touch aspects of this legislation is the investigative process for questionable claims and reassessment. The process essentially dates back to the inception of the legislation. It is highlighted by draconian powers embedded in the administration of the act and, ultimately, the minister. These powers don’t come close to demonstrating the principles of fairness which the legal community has come to expect.

Alberta has 30 pieces of health legislation and over 100 regulations on its books, many of which are archaic, out of touch and in some cases, just plain irrelevant. It would be nice if a new provincial government bent on reforming the health care system, bending the cost curve and bringing innovation to the delivery of health care services would take an introspective and critical glance at the rules that bind them.

The act also falls woefully short in attempting to define one of the most critical features of the plan: exactly what an “insured service” is. I won’t keep you in suspense: it’s a service that is “medically required.”

There’s clarity for you.

Hospitals Act Even though Alberta has enjoyed (and I use this word loosely) the evolution of health care management into the hands of initially a big bunch of regional health authorities (17), and then a smaller bunch (nine) and then ultimately a much smaller bunch (one), we still operate under the overarching umbrella of Alberta’s Hospitals Act. This act still speaks of hospitals as run by hospital boards and being responsible creating medical records when that responsibility was assumed by regional health authorities (now authority) in 1994. The Hospitals Act dates back to the days when hospitals were run as independent, separately funded fiefdoms. It desperately needs revision, if not outright repeal.

Alberta Health Care Insurance Act Another example of outdated legislation is the Alberta Health Care Insurance Act. This legislation owes its origins to the initial Alberta Health Insurance Act passed by the United Farmers of Alberta in 1935. Fast forward to 1969, when Medical Services (Alberta) was superseded by Canada’s national Medicare program which, in turn, led to the passage of the Alberta Health Care Insurance Act. It has remained on the books relatively untouched

AMA - ALBERTA DOCTORS’ DIGEST

Alberta has 30 pieces of health

legislation and over 100 regulations on its books, many of which are archaic, out of touch and in some cases, just plain irrelevant.

Health Information Act And then, of course, there is the relatively new Health Information Act. Passed in 1999, the act created a regime for the gathering, use and disclosure of patient health information focused on the identity of the user of the patient’s health information, not the owner. Words like “custodian” and “affiliate” have tormented and confused Alberta physicians since the passage of the act.

Notwithstanding a section requiring a “comprehensive review of the act” within three years after its coming into force, and subsequent non-mandated reviews, nothing has been done to address this gap. In fact, in 2009, the act was amended to specifically reference the creation of the electronic health record, the successor to Alberta’s >

> Wellnet. However, even that relatively recent amendment still speaks of “authorized custodians” contributing information.

Others in need of clean up Don’t even get me started on the Mental Health Act (the current incarnation passed in 1988) or the Health Disciplines Act (what is its continued reason for existence in the face of the Health Professions Act?). Then there’s the Health Facilities Accountabilities Statutes Amendment Act (a grandiose name reflecting the promise of great change) which was passed in 2007, but never proclaimed. In fact, the link on the Alberta Health website takes you to the following ominous message: “We're sorry, we're not able to find the page you requested.

It has either been moved or no it longer exists.”

So my daring idea for Alberta’s health care system? Clean up your acts.

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MARCH – APRIL 2017

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INSURANCE INSIGHTS

The art and science of underwriting: Analysis of the whole picture Dennis Farronato | MANAGER,

UNDERWRITING, ASSOCIATION & AFFINITY BUSINESS, SUN LIFE ASSURANCE COMPANY OF CANADA

U

nderwriting is the analysis of medical, non-medical and financial information about a member to determine the effect these factors statistically have on mortality or morbidity.

This is also called risk classification.

Comorbidities are present when “one plus one” no longer equals two. The analysis of comorbidities which complicate the primary condition can be complex and challenging. For risk selection purposes, a nuanced analysis of the full range of severity of comorbidities is considered to determine insurability.

No one can accurately predict how long any particular individual will live or when (and if) they will develop health conditions. However, morbidity and mortality risks can be assessed by analysis of comparative outcomes of groups with similar risk factors. Underwriters maintain a global perspective, continuously monitoring global medical trends to help them accurately address diverse medical issues in populations of applicants.

Underwriting risk classification

Underwriters assess an insurance applicant’s medical history and health conditions to determine morbidity and mortality risks. They rely upon the applicant’s self-report and the doctor’s report (if required) to help them accurately assess the risk. In contrast to clinical medicine where a physician has several opportunities to revise their clinical analyses, underwriters have only one opportunity to assess medical risk, often projecting risk 30 years or more into the future.

Analysis of comorbidities is a very important aspect of underwriting the whole picture and it is of vital interest to insurers. Insurance applicants (who are also patients) can have multiple medical conditions including obesity, diabetes, cardiac disease and cancer. These concurrent conditions can interact synergistically and become important factors in predicting insurance risk.

Underwriters analyze the risk as a whole, rather than addressing each factor individually. The underwriter exercises sound judgement by looking at the big picture to effectively stratify risk. Underwriters work in teams, collaborating with other professionals including insurance physicians (from a diverse range of specialists), actuaries and business experts.

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represents a unique application of business practice and science. It is intended to ensure fair business pricing in determining whether a risk can be accepted within the association’s pricing parameters.

These are some examples illustrating the underwriters’ analysis of Type 2 diabetes and comorbidities.

• A person with Type 2 diabetes, chronic obstructive pulmonary disease and asthma may have more difficulty with diabetic control than diabetes without these comorbidities. Treatment with Prednisone adds potential medical risk, including making diabetic control more difficult.

• A person with inflammatory bowel disease who has insufficient dietary intake due to symptoms or has to undergo surgery, will have subopitmal diabetic control under these circumstances.

• Rheumatologic conditions treated with Prednisone will worsen diabetic control. Increased cardiovascular risks are associated with some rheumatological conditions, which add to the cardiovascular risk associated with diabetes. >

> • Chronic kidney disease (CKD) in a person who also has diabetes adds to the overall morbidity and mortality risks. The underwriter must consider kidney function, severity of CKD and additional relevant comorbidities such as hypertension control.

Additionally, a person might have various multiple symptoms from two or more conditions that may not appear to be related at first glance. Multiple physicians involved in medical care add to complexity as each physician may analyze only part of the overall medical picture. The family physician has a key role in bringing the pieces together but may not have all the medical records and test results from specialists.

Diagnosis or treatment may be delayed, which may affect the prognosis. This delay may increase the risk for disability or mortality as the symptoms may have unduly progressed.

Patient compliance is relevant as some patients have suboptimal compliance with medical advice. Psychiatric comorbidities such as depression, which is highly prevalent, impact compliance, response to and recovery from disease.

Underwriters must assess the whole picture, keeping in mind that a person with certain conditions such as diabetes may not recover as quickly or respond to treatment as well as a person without those conditions.

Also, underwriters recognize that within the group of applicants who have a medical condition such as Type 2 diabetes, some applicants have much better outcomes than others. Underwriters utilize a balanced approach, weighing favorable and unfavorable features for each medical situation.

Underwriting risk classification represents a unique application of business practice and science. It is intended to ensure fair business pricing in determining whether a risk can be accepted within the association’s pricing parameters. It uses sound actuarial principles and is based on reasonably anticipated experience.

Underwriters rely on sound underwriting judgement to arrive at the fairest and most reliable price when assessing risk. For example, it is known that obesity, high blood pressure, diabetes or renal disease are risk factors that have a greater impact on adverse mortality together than individually.

The underwriter has a very important role in ensuring the whole picture is assessed and to accurately determine a member’s insurability. The underwriter must review each case based on its own merit, always keeping in mind the combination of all factors and their impact on each other. There are endless examples of the various types of comorbidities that have an impact on mortality or morbidity; each must be assessed carefully.

The client’s physician has an important role in partnership with the underwriter. The information the physician provides has tremendous value to inform the underwriter’s nuanced, accurate risk assessment.

Our common goal is to help the patient. Underwriters’ daily work helps people acquire the financial protection they need for themselves and their families when unanticipated illness or death occurs. Insurance coverage provides a promise that is potentially life-altering: to deliver support at the time of greatest need in our lives.

Underwriters rely on sound

underwriting judgement to arrive at the fairest and most reliable price when assessing risk.

Comorbidities are complex issues and their true relationship to a disorder may be difficult to disentangle, since comorbidities could represent a precursor risk factor, consequence and/or coincidence, in varying combinations. The underwriter must follow established risk classification principles that differentiate fairly on the basis of sound actuarial principles and/or reasonable anticipated mortality or morbidity experience, while providing a nuanced analysis of each unique case.

Northern Alberta (Red Deer north) Ms Kelly Guest, EPC, CHS Insurance Advisor T 780.482.0306 kelly.guest@albertadoctors.org Southern Alberta Ms Mona Yam, CFP, CLU, CHS, BComm, BA Insurance Advisor T 403.205.2088 mona.yam@albertadoctors.org

MARCH – APRIL 2017

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AMA - ALBERTA DOCTORS’ DIGEST

FEATURE

17

The 2017 Tarrant Scholarship opportunity is here!

Medical students can apply; practicing physicians can give back through donations

T

he Section of Rural Medicine (SRM) is accepting applications for the 2017 Tarrant Scholarship, named in honor of the late Dr. Michael Tarrant, a dedicated family physician and champion of rural medical undergraduate education.

The Tarrant Scholarship serves as a well-received and highly valued incentive for qualified third-year medical students to focus their undergraduate studies (and ultimately their careers) on rural medicine.

As one of Alberta’s largest unrestricted medical school undergraduate awards, the Tarrant Scholarship is presented every fall to third-year medical students from the University of Alberta (U of A) and the University of Calgary (U of C) who demonstrate a strong interest in and dedication to rural medicine during their undergraduate years.

Since its inception in 2004, the Tarrant Scholarship has been awarded to 33 medical students and has provided over $350,000 in awards. This year, two $12,500 awards will be given, one to a recipient from the U of A and one to a recipient from the U of C.

Medical students can apply Medical students are eligible to apply for the scholarship if they meet the following criteria: • U of A or U of C medical student who will enter third-year medical school this fall

Physicians can donate to support the scholarship and rural medicine

• keenly interested in building a career in rural medicine in Alberta

to thank all who donated. Your contributions enabled the continuation of this important scholarship.

• dedicated to rural medicine in undergraduate studies and work

The section encourages you once again to consider a tax-deductible donation to help ensure the continued future of the Tarrant Scholarship as it works to sustain the educational development of future rural physicians.

Physicians can donate to support the scholarship and rural medicine For the past few years, SRM partnered with the Canadian Medical Foundation and the Alberta Medical Association (AMA) to enable members to contribute on a charitable basis to the Tarrant Scholarship program.

A great response was received. The section would like

Application form Visit the AMA’s website at albertadoctors.org/tarrant to download the 2017 Tarrant Scholarship application form.

The application deadline is May 26.

MARCH – APRIL 2017

18

FEATURE

My daring idea for health care in Alberta Let's recognize that community and the health care system are both important at end-of-life Eric A. Wasylenko, MD, CCFP (PC), BSc, MHSc (Bioethics)

P

alliative end-of-life care programs are maturing in Canada, still with somewhat spotty application of resources and expertise. Programs in Alberta continue to be among the leaders, some with a 20-year history of cross-sectoral integration, hospice development, home care capacity, acute and long-term care expertise.

Recent efforts in Alberta to incorporate "assessment and treatment in place" with unique paramedic partnerships do a better job of keeping people in their homes, if that is their desire. Province-wide 24/7 telephone connection with specialists better supports community physicians in caring for their palliative patients. Terrific partnerships with disease specialty groups and our education institutions have embedded strong palliative care capacity within many chronic disease environments such as renal, heart failure and neurodegenerative disease programs. Our advance care planning initiatives, bereavement programs and community organizations that support children and families through loss help buttress palliative end-of-life care. Specialized pediatric palliative care facilities and programs are now well established.

It’s not only about the health care system.

It’s also about the community.

Many smaller communities have programs that strive to meet local needs. The Foothills Country Hospice (countryhospice.org) in Okotoks has had unique success in the rural environment, as has the work of the Olds and District Hospice Society (oldshospice. com). Many other community groups and numerous church or philanthropically sponsored groups, supported by physicians and colleagues, are working in similar ways. Dr. Douglas Armstrong’s work with the Pilgrims Hospice team in Edmonton and Dr. Simon Colgan’s ground-breaking efforts for street-involved persons needing palliative end-of-life care (CAMPP – Calgary’s Allied Mobile Palliative Program) are two good examples.

AMA - ALBERTA DOCTORS’ DIGEST

It is long past the time that we should consider the formal health system as being able to meet all end-of-life needs. The capacity and funds just aren’t enough, despite valiant efforts and commitments. Rather, our society ought to embrace the notion of citizens and communities caring for each other, supported by what formal agencies can provide. We are only two-and-one-half generations removed from a time when people were born and died at home surrounded by the skills and connection of family.

I’m not suggesting we should return to that. But neither should we depend on “the system” to do it all. When we over-medicalize this important time of life, it becomes easy to forget several critically important things about the journey toward death.

It is long past the time that we should

consider the formal health system as being able to meet all end-of-life needs. The capacity and funds just aren’t enough, despite valiant efforts and commitments.

First, rather than a time of waiting to die, it is an important time of living, growth and transitioning – both for the person dying and for those in their circle who will remain living. This time of the approach of death is full of potential for dignity-enhancing life.

Second, remembering that human existence is fundamentally a relational thing, the opportunities for growth, understanding and service that exist as we care for each other should not be discounted. I always marvel at the transformation in family members from fear of death to healthy acceptance of one’s own potential mortality, after they have been deeply immersed in cooperative caring for family members at home or in a hospice, together with expert teams. Third, the rituals of dying, of completing the arc of life, of making way for the >

>

next generation, of valuing a degree of loving dependence on others, all need to be better incorporated into the education system and into our community life.

Perhaps moving in these directions will help us get away from the death-fearing focus of our society, which is also understandably and perhaps unintentionally well-entrenched in our health care system.

I really value the work of my colleagues and our organizations in doing what they can to improve the skills, resources and capacity for our formal end-of-life care programs. In conjunction, some areas might deserve some special focus, spurred either from the formal system, or even better, from communities themselves.

Family and cultural end-of-life practices One example is support for social circle groups who spring into action to assist people remaining at home or who support family members who require assistance for facility visits. Such groups – and I have seen this in wonderful action – help people meet activity of daily living needs as part of a community effort of caring for neighbors. Instead of re-creating this organic infrastructure each time, perhaps philanthropic or system grants could produce simple how-to guides, informed by community groups who have become experienced in this voluntary work.

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Additional focus increasingly should be on gaining broader understanding of the norms of end-of-life practices in our culturally diverse populations. We must be more sensitive to those norms and needs, and we can learn so much about living and dying by experiencing how people throughout the world, including our Indigenous peoples, view dying, rituals, legacy and inter-generational existence.

Exciting programs are underway that, if successful, can be scaled up to support community and family connection. Specific examples include the technologically advanced Aging-in-Place Laneway Housing project underway in Calgary that is designed to keep frail elders safe and in close living proximity to their family, while maintaining some degree of independence. Another is the Butterfly model of living for those with dementia (dementiacarematters.com) that could be adapted for rural environments.

While many people work, thankfully, very hard, to advocate for more funding for palliative end-of-life care programs and continue to develop that capacity, hopefully we will remember that dying is a fundamental aspect of community human existence. As such, let’s remember to include community members and organizations as necessary participants in caring service.

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20

DR. GADGET

My daring idea for health care in Alberta Let’s consider how technology affects our relationships Wesley D. Jackson, MD, CCFP, FCFP

N

ot long ago, I was listening to a TED Talk by Dr. Robert Waldinger,1 given in November 2015, about the Harvard Study of Adult Development.

This study, which began in 1938, prospectively tracked the lives of 724 men for more than 75 years, year-after-year, asking about their work, home lives and health to determine what keeps us healthy and happy as we go through life. The answer to this question was not fortune or fame, as many of the participants predicted as youth. Instead, the clear message that came from the study was encapsulated in the following simple statement: “Good relationships keep us happier and healthier.”

Dr. Waldinger notes that the study highlights three main lessons about relationships.

1. People who are more socially connected to family, friends and community are happier, physically healthier and live longer than their peers who are less well connected.

2. It’s not the number of friends you have, or whether you are in a committed relationship, but it’s the quality of your relationships that matters.

3. Good relationships don't just protect our bodies, they protect our brains.

Today’s technology offers incredible opportunities to be close to those we care about. A couple of weeks ago, my almost two-year-old grandson called his grandma just to “talk.” He was playing with his mother’s phone, saw grandma’s picture, tapped it, and in just a few seconds he was able to see, hear and interact with his grandma. He didn’t care about the years of development, the incredible design of the technologically advanced tool, or the time and effort

AMA - ALBERTA DOCTORS’ DIGEST

his mother had spent to insert the picture and connect it to the correct number. He only cared about the relationship (and so did grandma).

Conversely, technology, used improperly, can interfere with and often harm relationships. A recent survey of Canadians conducted by McAfee2 revealed the following about those surveyed.

• 38% spend equal time online at home as they spend face-to-face with others.

• 40% feel that their partner gives more attention to their device when together.

• Another 45% report arguments over being on a device when together.

Good relationships keep us happier

and healthier.

Anyone who has had an argument using text messages can attest to the deleterious effect this form of communication can have on otherwise reasonable human beings. This same tool, texting, used properly, can bring people more in touch and help build relationships. Social media, which has incredible potential to bring people closer together, can quickly become un-social media as etiquette and tact tend to be lost with hurtful, unfiltered comments.

Depression can deepen with the impression that “everyone else’s life is better than mine.” It seems that self-esteem is established by the number, rather than the quality, of relationships where “friends” are replaced by “followers.” >

> The McAfee survey suggested in conclusion: Keep your devices close but your relationships closer.

Not surprisingly, there is an app for that. A group of developers (REDspace) in Nova Scotia have released Put Your Phone Down3 available on Android and Apple, which encourages users to do just that for as long as possible. Interestingly, initial use suggests that the average time away from the phone is around 10 minutes, but individuals have been showing improvement the more they use the app.

21

It seems that self-esteem is established by the number, rather than the quality, of relationships where “friends” are replaced by “followers.”

Of course, technology is also an important factor in the medical field. Electronic medical records (EMR) are incredible tools allowing the opportunity for unprecedented knowledge about our patients and can be amazing teaching tools when used correctly.

Unfortunately, the EMR can also dominate the patientphysician interaction if we allow this to happen.

As physicians we also have remarkable online tools available to us, such as Smart Decisions4 on the MyHealth.Alberta.ca website. These tools, while educating patients and guiding them to focus on a particular decision point, can be isolating. They will be much more effective when discussed face-to-face, after the homework has been done.

My almost two-year-old grandson was playing with his mother's phone, saw grandma's picture, tapped it, and in just a few seconds he was able to see, hear and interact. He only cared about the relationship (and so did grandma).

So my wish would be for everyone involved with technology in any way (and that would include just about everyone) to consider how the technology is used and how it affects relationships. After all, our physical and mental health and, in fact, our very lives may depend on this. As Dr. Waldinger asks: “If you were going to invest now in your future best self, where would you put your time and your energy?”

Links: 1. ted.com/talks/robert_waldinger_what_makes_a_good_life_ lessons_from_the_longest_study_on_happiness 2. securingtomorrow.mcafee.com/consumer/consumer-threatnotices/connected-relationships-valentines-2017/ 3. putyourphonedownapp.com 4. myhealth.alberta.ca/health/pages/conditions. aspx?Hwid=share#hw160633

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22

FEATURE

My daring idea for health care in Alberta Multidisciplinary chronic disease management Jacqueline Bakker, MD, FRCPC (Neurology), BscPT

T

reating those who suffer from chronic disease has unique challenges. I practice as a neurologist specializing in multiple sclerosis (MS), a chronic neurologic disease that cannot be fixed or cured at this time. It can only be managed. Unfortunately, despite various therapies, the disease will progress. Each patient’s disease course is unpredictable as are the person’s medical needs.

It is difficult to manage these patients effectively in a private office with only a physician and an administrative assistant. In an ideal medical world, we would have the resources we need at our fingertips and unlimited funds to support those resources. In our real medical world, however, these are not available. There are positives to this, however: the situation allows patients to be self-motivated and self-directed in their own care.

It is important for patients to be involved with and take charge of their medical concerns, with some guidance. This control may mean booking or waiting for appointments, arranging transportation and having the motivation to participate. But it ultimately gives the patients responsibility.

In the MS Clinic in Red Deer, we are fortunate to practice in a medical specialty clinic that shares multidisciplinary resources such as nurses, occupational therapists, dieticians and social workers. We have access through referral to physiotherapy, speech pathology and pharmacists, and we refer patients to the MS Society for social support. The goal of the MS Clinic is to promote the well-being of the patients and encourage them to direct their overall care.

At one appointment, an MS patient’s medical, psychosocial, functional, nutritional and educational needs can be managed. The patient sees the physician for medical assessment. An MS-specialized nurse provides education, deals with managing any medication side effects, deals with any bladder and bowel control

AMA - ALBERTA DOCTORS’ DIGEST

issues through conservative strategies and allows for subsequent follow up over the phone to see if the patient is managing with the medical plan.

If the patient has issues with daily living such as fatigue, managing job or school work, dressing, eating, driving, or cognitive problems, these issues can be assessed and assisted by our occupational therapist. If a patient has questions and concerns regarding disability, housing or counselling, our social worker can help with appropriate paper work and/or suggest appropriate resources. Our dietician sees any patient who has dietary concerns.

By working with a team that can

offer multidisciplinary resources, patients feel they have accessible resources if and when they have questions or new medical issues.

A major hole in our immediate team approach is mental health. Many of our patients have anxiety, depression and stress that are accentuated by the diagnosis of a chronic unpredictable disease. And they need help working through these emotions. Whether dealing with a new diagnosis or navigating through family stressors influenced by their disease, patients sometimes have nowhere to turn. Although we can refer these patients to outside resources, these are limited and the wait time is often long.

By working with a team that can offer multidisciplinary resources, patients feel they have accessible resources if and when they have questions or new medical issues.

Through this approach, I believe we reduce hospital visits and allow for better quality of life for the patients and their families or caregivers.

Makes me feel

(Comments from YRC members, Mee-Yah-Noh School, Edmonton)

… “healthier and happier.” (grade 4) … “more less stressed.” (grade 6) … “welcome and needed.” (grade 6)

Favorite thing

(Comments from YRC members, Mee-Yah-Noh School, Edmonton)

“I feel that running club is my family.” (grade 6) My favorite part of run club is “running with my friends.” (grade 6) My least favorite part is “that it’s only once a week.” (grade 6)

Survey says … healthy students are better learners AMA Youth Run Club supports physician health advocacy in schools Evidence shows that active children are physically, mentally and socially healthier and happier, and they’re also better learners.

ImPRovINg CommuNITY hEAlTh ThRough PhYSICIAN lEAdERShIP ANd AdvoCACY (394 schools and 23,000 students)

The AMA is proud to partner with Ever Active Schools on the AMA Youth Run Club, a school-based program that through organized activities (running, walking, hiking, snowshoeing and more) and School Health Advocacy Talks helps children and youth develop lifelong, healthy habits.

How can you get involved with the AMA Youth Run Club?

Be an AMA YRC CHAMPion! Run with or help coach a club, help school staff set up and manage a YRC, or give a School Health Advocacy Talk (talking points for seven suggested topics are available on albertadoctors.org/YRC).

For more information, contact: Vanda Killeen, AMA Public Affairs vanda.killeen@albertadoctors.org / 780.482.0675

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MARCH – APRIL 2017

24

FEATURE

My daring idea for health care in Alberta Physician health ambassadors in schools across Alberta Kimberley P. Kelly, MD, CCFP, FCFP

I

was fortunate to recently share my daring idea with a roomful of trailblazers from the education sector at Shaping the Future, the only conference in Canada promoting Comprehensive School Health, a preventative approach recognized by the World Health Organization that aims to improve the health outcomes for children and youth. My daring idea is to have a physician ambassador associated with every school in Alberta!

We all know that if we invest more in prevention, we can save money in the long run and improve health outcomes for our children and youth. Schools are a perfect environment to access children for 13 years.

The potential to influence the development of long-term healthy behaviors is huge.

By leaving my office one half-day a

week and engaging with my school community, I was rejuvenated and healed from cynicism.

Now let’s reverse roles and pretend that you are a teacher or a principal. Imagine your school community having access to a physician or a medical student, someone who is typically found in a sterile hospital setting or in a busy clinic. To have the opportunity to build a relationship with a health professional would be invaluable for the school. Students would have an additional trusted, knowledgeable adult to share concerns with, to laugh with and to have fun with on a more informal level.

We have complex problems to solve: childhood poverty, lack of equity, stigma, discrimination, addiction and mental illness, to name a few. We know these complex problems can’t be solved by a pill. We also know that our society prioritizes illness over wellness. I feel we can improve the pivotal relationship between doctors, children and youth. We can easily do this by promoting and supporting connections between physicians and students in school communities. Creating these relationships has the potential to change culture and drive society to prioritize wellness over illness.

I know my daring idea is possible because it happened to me. I jumped in with both feet and became a health champion at my sons’ school. I started by volunteering with our Alberta Medical Association (AMA) Youth Run Club and in our school’s outdoor garden. I then progressed to leading a walking school bus initiative which next led to creating a wellness team and becoming an Ever Active School.

For a moment, let’s imagine a school assembly with you addressing the student body and staff on how exercise is connected to improved mood or why sleep is so important to students’ wellbeing and ability to learn.

Perhaps you are also able to tie in the need to decrease screen time and promote playing outside to reduce stress, improve physical health and boost creativity.

It took time and patience, but the school culture changed to a healthier one. This transformation occurred by simply showing up and becoming part of my school community. By listening, being open, collaborating and sharing my knowledge, I was able to work with others to identify and address priority health needs for our community.

Let’s further imagine a second event where you are attending a school community BBQ and are casually conversing with students and parents about the benefits of outdoor activities at their school, like a Terry Fox Run or snowshoeing. In these scenarios, the chance of you having a positive impact on your community is great.

My experience illustrates that a doctor can help create a healthy school community, but surprisingly, I learned that the community can help the doctor. By leaving my office one half-day a week and engaging with my school community, I was rejuvenated and healed from cynicism. >

AMA - ALBERTA DOCTORS’ DIGEST

> I reignited the spark inside that called me to serve many years ago.

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I feel it’s time to scale and spread my experience provincially! It may seem like a daunting task, but the AMA Youth Run Club already has 40 physician and medical student ambassadors. A next step would be to recruit parent physicians who have a vested interest in their children’s school communities and other interested physicians.

We all know that if we invest more in

prevention, we can save money in the long run and improve health outcomes for our children and youth.

My experience ¡llustrates that a doctor can help create a healthy school community, but surprisingly, I learned that the community can help the doctor.

Over 250 years ago, poet William Blake said, “What is now proved was once only imagined.” The education sector has been an excellent health advocate over the past decade and Comprehensive School Health continues to gain momentum. It is time for physicians to join forces with our education partners and become health ambassadors in our schools across the province. Truly, it is a natural fit!

I reignited the spark inside that called me to serve many years ago.

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MARCH – APRIL 2017

26

FEATURE

Our daring idea for health care in Alberta Let’s change the lens on seniors’ care Sheny Khera, MD, CCFP (COE), FCFP, MPH (left) Marjan Abbasi, MD, CCFP, CAC (COE) (right)

T

he proportion of Canadians 65 years and over is growing more rapidly than any other age group.

According to Statistics Canada data from 2005, seniors will account for 22.8% of the Canadian population by 2031. Frailty and chronic complex conditions, both more common in seniors, have emerged as drivers of high health care utilization, such as emergency visits and hospital admissions. Social costs, such as dependency and caregiver burden are also increasing. As a result, seniors’ care is a priority for our current health care system, and this necessitates health reorganization and innovative models of care delivery to meet growing needs.1

shows that integrated care systems that coordinate care and promote continuity are associated with better patient experiences, improved quality of care and improved efficiency of health and social services.2

Successful transformation of care requires a change in the current lens on seniors’ health. First we need to be mindful that the majority of Canadian seniors are in good health, financially secure, well housed and safe. They are active and key contributors to society by paid or volunteer activities. Secondly, given that individuals are living longer, they are more likely to be living with complex comorbidities and the current health system has not kept up with this demographic shift. While care has long been in the hospital (which worked when health issues were predominantly acute in nature such as infections and injuries), current needs and trends necessitate a more community-centric, proactive care model that embraces prevention, upstream health promotion and chronic disease management in an aging population.

Engage in conversations on shared overarching vision of seniors’ care, develop key standards of care across the continuum and share funds to achieve common outcomes. These key outcome measures should include outcomes that matter to patients and should define the performance indicators of services provided.

Achieving an integrated model of seniors’ care requires collaborative efforts supported by policy and funding to ensure that the right blend of supports and services are provided in the right place at the right time. Evidence

• living with frailty (primary health care teams working with seniors and caregivers in care and support planning/navigational support)

AMA - ALBERTA DOCTORS’ DIGEST

Here are some steps toward an integrated model of seniors’ care that can be achieved right now.3

Walk the journey of care as experienced by seniors and caregivers Explore the gaps and opportunities in care from prevention through to end-of-life. Involve seniors and caregivers in service redesign, especially at transitions/ interfaces across the continuum of care. Solicit important values and priorities from people.

Network with other organizations to collectively commit to health system change

Design components of care for seniors along the spectrum of care needs Think in terms of care needs for seniors who are: • fit and aging well (health promotion) • vulnerable (self-management, physical/mental/ social supports)

• needing end-of-life care (coordinated palliative care services, early discussions of care goals) >

>

Frailty and chronic complex

conditions, both more common in seniors, have emerged as drivers of high health care utilization, such as emergency visits and hospital admissions.

Share experiences and lessons learned from local innovative leaders/services/strategies for collective benefit Several Alberta initiatives in primary care are underway creating fertile ground for innovations in care delivery, such as primary care network evolution and strategic clinical networks. These can aid the collaboration between primary care physicians, specialists, interprofessional teams, patients and family/caregivers.

We can learn from the transformations in the acute care and community care circles, such as elder-friendly units, enhanced geriatric skills of health care workers and outreach community care services for seniors and caregivers.

Seniors’ care is a priority for our current

health care system, and this necessitates health reorganization and innovative models of care delivery to meet growing needs.

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Changing the seniors’ care system may seem overwhelming, but it can be done. And it can be started right now. No single best-integrated system exists. The system needs to arise out of the local context and be a collaborative effort between local catalysts of change, patients and families, care providers and stakeholders both from bottom-up and top-down approaches. These efforts in designing a value-based, person-centered, integrated model of care that aims to understand and meet the needs of seniors and care providers will improve the health care system for all of us.

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MARCH – APRIL 2017

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28

FEATURE

My daring idea for health care in Alberta Investment in multidisciplinary care for rheumatoid arthritis patients Steven J. Katz, MD, FRCPC

R

heumatology is an exciting field of medicine to be a part of right now. This is particularly true when talking about rheumatoid arthritis management.

Twenty years ago, the goals of care for the nearly 30,000 Albertans with rheumatoid arthritis were limited. Mangled and deformed joints were typical outcomes for those with this disease. Half of our patients were disabled within 10 years of disease onset, unable to work and contribute to society. Extra-articular manifestations were common and studies show many patients were dying 10 years earlier than age-matched populations, often due to higher rates of cardiovascular disease.

Seemingly small changes can have

a profound impact on the arthritis sufferers in our province, across the country and around the world.

Much has changed. Biologic medications have made a significant impact on rheumatoid arthritis treatment. Goals of care now include no pain, no swelling, normal function and joint damage prevention. While biologics have played a key role, they are expensive. In fact, biologics are consistently the most expensive drug cost in Alberta each year. Fortunately, the way we use other traditional

AMA - ALBERTA DOCTORS’ DIGEST

disease modifying medications such as methotrexate has also changed. Twenty years ago, a typical starting dose of methotrexate would be 7.5 mg weekly, slowly titrated up over time and slowly combined with other medication options. Today we treat aggressively – but safely – intervening early with higher doses of methotrexate, almost always in combination with other diseasemodifying antirheumatic drugs (DMARDs) using dual or triple therapy. Data show this strategy is as effective as expensive biologics for many patients.

The thing is, we can still do so much better for our patients, while reducing costs for our health care system, the province and all Albertans. What would I like to see?

Treat-to-target goals We need to work on achieving remission by employing treat-to-target goals for every patient with rheumatoid arthritis. One solution might be more rheumatologists to see patients regularly and adjust drug therapy for those with active disease. But this fix is too simple for a problem that is much more complex. What we need is dollars invested in multidisciplinary care for rheumatoid arthritis patients, where a holistic and comprehensive approach becomes the norm with advanced care nurses, physical and occupational therapists and/or pharmacists providing evidence-based care strategies (treat-totarget) for every patient.

Early investment in these human resources today will save dollars by delaying or preventing the need for biologics tomorrow. Adding a dozen allied health professionals to the arthritis team in a collaborative care model will improve access to and quality of care as well – if not better – than hiring a dozen more rheumatologists. >

> Therapy adherence Adherence is an important issue in all of medicine and we should help ensure DMARD therapy is readily obtainable and as easy to administer as possible for our patients. Subcutaneous methotrexate injections are more effective and better tolerated than oral methotrexate, yet we provide these injections like we live in the dark ages, asking patients to use a needle and syringe to draw up their own drug. We stopped asking diabetics to do this years ago. The technology exists, but because methotrexate has been around for decades, the pharmaceutical industry appears to incorrectly perceive little economic value to take the lead on this common-sense innovation. Why can’t rheumatoid arthritis patients buy their methotrexate in cartridges just like insulin and dial up their dose in a methotrexate pen?

The data show this method improves adherence in patients with diabetes. Can you imagine the impact a methotrexate pen would have for patients with rheumatoid arthritis who may have painful joints and impaired fine motor skills? Improved adherence will likely lead to better results, again delaying or perhaps preventing expensive biologic use and ensuring patients remain tax-paying, contributing members of society.

29 The municipal-operated Keyano Medical Centre in the community of Wabasca is located 1.5 hours NE of Slave Lake and 3.5 hours north of Edmonton. Living in the heart of the Canadian boreal forest means enjoying year-round recreation such as hunting, fishing, snowmobiling, quadding, boating, and wildlife viewing. Nestled between two large lakes, Wabasca has a population of approx 5,000 and is growing, with new amenities added each year such as the Lakeview Sports Centre, the Eagle Point Golf & Country Club, an ATB branch and Registry.

This opportunity is a contract position, not a fee for service, with a guaranteed annual income of $360,000. The on call ratio is currently 1:4 with hospital billings going to the physicians, RRNP eligible to max of $60,000. Accommodation in a newer three-bedroom, two bath home is included in the contract!

Your opportunity awaits….

Contact us by email or telephone for more details Helen Alook, Chief Administrative Officer 780-891-3778 | CAO@mdopportunity.ab.ca Michelle Grach, Clinic Manager 780-891-2847 | mgrach@mdopportunity.ab.ca

Better data Rheumatology and inflammatory arthritis care need to be demystified. Rheumatoid arthritis is a serious medical condition. It kills, full stop. Despite this, we still don’t fully understand the burden of disease in the population.

Data from Alberta suggest a population prevalence of 1%, although the number treated with disease-modifying agents or biologics is less clear. It is imperative to resolve this public health issue; we need to determine if this treatment gap is real, and if so, how we can work with the public, patients and physicians to close this gap.

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While these are lofty goals, I have to believe they are not just pie in the sky. These are real targets we can achieve. As we celebrate 50 years of rheumatology in Edmonton this year, I invite you to contact me through the Alberta Medical Association if you can help to make these things happen.

How can we convince government and big pharma that we can do better for our patients in a financially prudent way? Seemingly small changes can have a profound impact on the arthritis sufferers in our province, across the country and around the world.

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MARCH – APRIL 2017

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PFSP PERSPECTIVES

Managing fatigue, relationships and digital technology Vincent M. Hanlon, MD | ASSESSMENT

L

PHYSICIAN, PFSP

ate in 2016, the last physician with burnout was identified and treated – about 30 years after the term “physician health” was coined. It looked at first like a career change might be necessary, but the doctor responded well to a novel combination of drugs, talk therapy and Alberta Health Services workplace modifications. That doctor is, for the most part, happily back at work. The medical profession breathed a sigh of relief, and now the spotlight has shifted away from physician health back to sick patients.

My anecdotal experience

On a more serious note, sincere thanks to all the family doctors and psychiatrists who continue to collaborate with the Physicians for Physicians (P4P) initiative of the Physician and Family Support Program (PFSP). These are our colleagues who take on physicians as patients or make themselves available for timely consultations. PFSP is grateful to all physicians who care for our colleagues, residents and medical students.

My past experience talking to physicians about their health bears witness to these changes. In 2008, I presented “Spirituality for surgeons” in seven minutes.

Six years later I spoke about “Mindfulness for emergency physicians.” That was for 10 minutes, including Q & A. In 2017, I will address “Physician mental health for family doctors” in 30 minutes. I may not have enough slides to fill the time.

PFSP 2016 stats

Research into physician health, including meticulous literature reviews such as “Physician Wellness: A Missing Quality Indicator” (Lancet, 2009) by the University of Calgary’s Drs. William Ghali, Jane Lemaire and Jean Wallace, have helped to stimulate interest, action, teaching and learning about physician health. Thanks to increasingly robust physician health literature, doctors in 2017 have a more clear understanding of the complex interconnectedness of their physical, mental and occupational health issues.

Another year goes by. In 2016, 1,574 individuals received services through the PFSP, up 8% from the 1,445 served in 2015. During 2016, 735 physicians, 199 residents and 110 medical students phoned the PFSP helpline. The most common reasons for calling are relationship/family issues and mental health problems – primarily stress, anxiety and depression.

Provincial physician health programs like PFSP began to appear a generation ago. When I began working with PFSP in 2005, about 500 individuals per year accessed program services. We are witnessing among physicians a gradual increase in awareness and acceptance of our own health issues; in particular, more physicians are looking for help with their relationship difficulties and mental health issues.

AMA - ALBERTA DOCTORS’ DIGEST

Thanks to increasingly robust

physician health literature, doctors in 2017 have a more clear understanding of the complex interconnectedness of their physical, mental and occupational health issues.

A number of problems remain part of the physician health landscape. I’ll mention just three that won’t disappear anytime soon: • fatigue and insufficient sleep • fraught and fractured relationships • ambivalent relationship with digital technology >

> All three issues are implicated in good patient care, physician well-being, quality training and work environments. And all three, to some degree, are inter-related.

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Fatigue Getting sufficient quality sleep is a problem for many physicians over the course of their training and the span of their careers. Wakefulness during night work, recovery from off-hours work and the sleep disruptions of night call are challenges for residents, as well as mid-career and older physicians.

As a profession and as individuals, we continue the uneasy business of reconciling physician well-being and preparedness with long hours of work, ubiquitous fatigue, sleep disruption and good patient outcomes across diverse work scenarios and training programs. There is no holy grail of sleep and fatigue management. That is one of the conclusions in the report Fatigue, Risk and Excellence: Towards a Pan-Canadian Consensus on Resident Duty Hours (Ahmed, N et al. 2013).

Naps, micro-breaks within the working day, getting additional rest before anticipated night work, and a cool, dark and quiet (both aural and digital silence) sleep environment are all pillars of fatigue management.

As a profession and as individuals, we continue the uneasy business of reconciling physician well-being and preparedness with long hours of work, ubiquitous fatigue, sleep disruption and good patient outcomes …

Fraught relationships

A cool and quiet sleep environment is a pillar of fatigue management.

OK, maybe not this cool!

In my work as an assessment physician on the helpline, I frequently hear from physicians about their difficulties communicating with a spouse/partner. Another recurrent theme is difficulty parenting children – either their own or the children of their blended families. Providing care for and communicating with elderly parents also strains some relationships.

Former PFSP assessment physician and education consultant Dr. Sara Taylor recently published an e-book on the albertadoctors.org website: The Well-Being of Medical Relationships: Striking a Balance with Your Spouse, Colleagues & Self. In this brief and practical book, Dr. Taylor references the work of psychologist Dr. John Gottman and offers some practical tips to strengthen your marriage.

• Develop rituals of connection (for example, making and eating food together).

Canadian psychiatrist Dr. Michael Myers, in the Handbook of Physician Health (American Medical Association, 2000) describes common (and still current) issues in the dysfunctional marital relationships of physicians:

• Pay attention to daily partings and reunions with your spouse.

• overwork as the cause and the result of relationship strains

• If you have children, discuss shared parenting goals.

• trouble communicating

Most of us are familiar with these strategies. Consistently attending to them in our intimate relationships is the hard part. >

• extra-relationship affairs

• Schedule together time for you and your spouse.

• Express gratitude to your spouse.

• alcohol • mood and anxiety disorders

MARCH – APRIL 2017

> Digital disconnections

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As skilled as we might like to think we are at multitasking and making timely virtual connections, Sherry Turkle, author of Reclaiming Conversation – The Power of Talk in a Digital Age, reminds us that our digital devices sometimes promise more than they deliver. Digital communication can compromise the quality of personal interactions and steal time from our flesh-and-blood encounters.

Some days, I feel overwhelmed. All those unread emails.

A hundred new tweets to chase down. My scintillating social media presence to maintain. At the end of the day, I’m often left with little time and less desire for face-to-face conversations.

Here are some suggestions for you and your spouse/ partner to consider: Digital commun¡cation can compromise the quality of personal interactions and steal time from our flesh-and-blood encounters.

• Anticipate an upcoming conversation with your spouse or partner. Can you each identify a couple of ways in which digital technology has improved your relationship, or reduced your fatigue?

• Are either of you aware of any detrimental effects this technology has on your sleep or your relationship? Any tips you would offer to other couples?

The moving challenges of digital technology at home and in the workplace will continue for the foreseeable future – even after Moses eventually comes down the mountain with the perfect electronic medical record.

The moving challenges of digital technology at home and in the workplace will continue for the foreseeable future - even after Moses eventually comes down the mountain with the perfect electronic medical record.

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

Explore our professional development programs and courses PROGRAMS 2017

COURSES 2017

Rural Videoconference Program

Cannabis – Implications for Health: Understanding Its Uses, Risks and Benefits

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MARCH – APRIL 2017

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FEATURE

A daring idea in action

Pregnancy Pathways helps homeless pregnant women build a better future John T. Lilley, MD, FRCPC, DABA & Ameeta E. Singh, BMBS(UK), MSc, FRCPC

O

n average, each year in Edmonton approximately 100 pregnant and parenting homeless women live on the streets and struggle to survive.

That’s a sad, sobering statistic and situation.

Without homes and roofs over their heads, these women face myriad challenges, including limited access to prenatal care, addiction, poor nutrition and violence.

Once their delivery dates arrive, the infants often wind up in the social services system, and the new mothers return to the streets and lives of struggle.

That reality prompted Dr. John Lilley, a retired anesthesiologist, to join forces with others who were equally concerned about expectant mothers with few resources and even less hope. The result is Pregnancy Pathways, a many-partner coalition whose goal is to secure a 10 to 12 unit apartment building as a residence for pregnant and infant-parenting homeless women.

“I was seeing all these homeless, pregnant women in labor in the case room,” says Dr. Lilley, “and I knew something had to be done.”

Dr. Lilley, chair of the Edmonton YMCA’s Welcome Village campaign in 2012, began approaching his contacts at the time and found them receptive to the idea of creating more resources for expectant, homeless women.

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No small feat: 25 partners Since then, more than 25 community organizations and agencies – including Alberta Health Services, the Royal Alexandra Hospital (RAH), RAH Foundation, Boyle McCauley Health Centre, Bent Arrow, Edmonton Community Foundation, Homeward Trust, Capital Region Housing, the City of Edmonton, Catholic Social Services, the YMCA and many others – have partnered to procure a multi-suite apartment complex that will provide a safe place for these women to call home.

Dr. Ameeta Singh has worked closely with Dr. Lilley from the start. A clinical professor with the University of Alberta Division of Infectious Diseases, Dr. Singh first became aware of the struggles of pregnant, homeless women while working as the medical director of the Edmonton Sexually Transmitted Infections Clinic. During a large syphilis out-break in the mid-2000s, they began seeing a lot of babies born with congenital syphilis.

“It raised the question of ‘why is this happening?’ because we have been screening for syphilis for years.

What we realized is that many of these babies were being born to homeless women who hadn’t received prenatal care.”

Down in the valley An outreach team was formed. “I would go out with the team,” says Dr. Singh, “And although I don’t live in a bubble, I was utterly horrified to see how these women are living. We’d go into the river valley, under the High Level Bridge and find pregnant women living in tents … just a few meters from these beautiful homes on Saskatchewan Drive. It was just completely unacceptable to me and I knew something had to change.”

Pregnancy Pathways’ housing-first approach is based on a similar program in Vancouver that has been highly successful. In addition to offering safe housing for stays of 12 to 18 months, Pregnancy Pathways will also link women to other services and provide 24-hour on-site support, with the goal of graduating women to their own stable housing. “We’re hoping to have the three-year pilot in place by next spring,” explains Dr. Singh. >

> An annual operating budget of approximately $500,000 is anticipated for the project. To date, the project partners have already received funding commitments from Merck for Mothers and individual physicians. They remain hopeful that other funders will come on board.

Coming together to make a difference “We’ve really been pleasantly overwhelmed by the response this project received from the various community partners, who all recognize the importance of this work,” says Dr. Lilley.

“It’s a combination of acute health care providers and community agencies,” he continues, “which is a unique partnership, as these groups often work in silos. It seems that everyone who hears about it is interested in becoming involved.”

As he looks forward to continuing to work with all the partners to develop the project to fruition, Dr. Lilley adds, “Although there’s still a lot of work to be done, the response from our partners gives us hope for what we can accomplish and the difference we can make to pregnant women who feel they are alone.”

For more information on Pregnancy Pathways or to make a donation: RAH Foundation (royalalex.org/100tonone/) or email Dr. Singh at ameeta@ualberta.ca

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

4th Annual

Women’s Health in Primary Care CALGARY, AB

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FEATURED SPEAKER Celebrities and Popular Culture in Medicine Tim Caulfield LLM FRSC FCAHS Canada Research Chair in Health Law and Policy; Trudeau Fellow; Professor, Faculty of Law and School of Public Health; Research Director, Health Law Institute

FOR FURTHER INFO CONTACT Lauren MacLellan, Program Assistant lauren.maclellan2@ucalgary.ca

cumming.ucalgary.ca/cme

MARCH – APRIL 2017

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IN A DIFFERENT VEIN

Genies in bottles and my daring idea for Alberta Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

T

he problem with genies lurking in bottles and granting wishes is the unintended consequences along the lines of: “The best laid schemes of mice and men gang aft agley.” For example, the 60-year-old man who wishes his wife/girlfriend was 30 years younger and (poof!) he’s transmogrified into a 90-year-old.

The problem with genies lurking

in bottles and granting wishes is the unintended consequences.

With this caveat in mind, here are a few of my wishes before I reveal my daring idea for Alberta: • To see a lot less of Justin Trudeau’s mug in my morning newspaper. Every day there’s a photo or two with him, top shirt button open, microphone in hand smiling winningly, pointing at someone in the audience with a fake “hey, don’t we know each other” smile. We’re weary of personality cults.

• Less anti-Americanism from the sanctimonious pointy heads in the CBC (and from my daughter Hilary, a lawyer who lives in the USA and who is a wobbly-kneed idolizer of Obama. “He can tell an appropriate joke on the spot, Dad.” “Well, I know how to do that…”

“No, you don’t.”) The strangely targeted, seemingly off-the-cuff travel ban (why not Saudi Arabia and Libya?) is their business.

• To live without fear as climate agnostics, able to discuss climate science without being accused of supporting the Holocaust. In science nothing is ever “decided.”

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Climate is a complex interaction: the effect of sunspot cycles, the earth’s tilt and rotation, moon and tides, atmospheric greenhouse gases, heat transfer from volcanic eruptions and earthquakes, and the effect of man’s activities – especially the doubling of the world’s (sorry, the planet’s) population in the last 50 years.

So, with our climate in mind and if the genie in the bottle is up to snuff, my daring idea for Alberta would be: • To have the province tectonically slide further south for a few months each year. If a southward tectonic shift were impossible, then I would wish for a tax-deductible Vacation Savings Account (“VSA”) for travel to California, Nevada or Arizona for two weeks in mid-winter. Think of the happiness. All Albertans need to go south in winter during the “Why-Am-I-Living-inNorthern-Finland?” months. Alberta is a great place for eight months of the year, but the cold and dark make the other four months trying.

Here are two winter retreats to spend your VSA on: one familiar to the geriatric and stiff joints club, the other perhaps familiar to some backpackers and the more adventurous.

The Coachella Valley You know you’ve arrived in Palm Springs Airport with the Tannoy announcements: “If you have lost your knee brace, please return to security” or “Announcing the arrival of WestJet Flight 202 from Edmonton. Five runners with wheelchairs to Gate 4.” This contrasts with the three months physical training required to get to your departure gate at the absurd new Calgary Airport international wing. First aid and resuscitation stations are needed every 800 yards.

In Palm Springs, Palm Desert, Rancho Mirage or La Quinta, there’s anxiety when a cloud is spotted in the clear blue sky, and disbelief and panic when it rains.

“It’s never rained here for 40 years,” said one stunned Coachellita. “What do we do?” They run like rioters from a water cannon. >

> The golf is great, reasonably priced and afterwards you can go to The Nest in Indian Wells, a well-known jazz joint, to eat and dance with other funky 80-year-olds and count the number of double and treble facelifts.

The Coachella Valley, that desert kingdom sucking up huge volumes of water, is where Californians fool themselves that they are conservationists by forbidding paper towels (sign in bathroom: “paper towels not used in our public toilets to preserve nature’s forests”). Instead they use ear-splitting electric hand dryers. A forest of bird-massacring windmills on the north edge of Palm Springs contributes to the illusion of sustainability by supplying 30% of the energy requirements.

Joshua Tree National Park is a must visit. Go on a national holiday when the entrance is free. The Joshua trees remind me more of pom-pom waving cheerleaders than of Joshua raising his hands in prayer.

There are no backpackers here.

My daring idea for Alberta would

be to have the province tectonically slide further south for a few months each year.

Nicaragua Nicaragua is a budget backpacker’s bliss. Land of the Contras and Sandinistas, Ronald Reagan’s Iran/ Contra Scandal.

Calgary's early December 2016 freeze forced us down to the capital, Managua, to review the cancer programs and see if there was anything useful we could do. It’s valuable for students and physicians to visit foreign places and see different systems – more valuable than to memorize another bloody molecular pathway. It balances your thinking; stops you from whining about life in Canada.

The cancer programs are struggling. The doctors are knowledgeable and smart, but lack access to drugs (especially expensive biologicals) and have minimal access to MRIs. But there’s an infectious enthusiasm often lacking in other developing countries. We can help with educational programs and exchanges, but these are harder to organize with recent massively increased bureaucratic surveillance here. I regret to report that Alberta Health Services has taken over the “approvals” for foreign “observers” and will contribute its usual frustrating, bumbling delay to an already burdensome task for hosts.

There’s fun to be had in Nicaragua. The country is a mix of market-friendly communism (with bossy, mind-numbing bureaucracy) and Roman Catholicism mixed with tireless cheerfulness and optimism.

Managua was destroyed by an earthquake in 1972, so there’s not much of a downtown. The communist government of Daniel Ortega keeps the population happy with an old trick, the selective handout, the delusion that you’re getting a free gift, forgetting it’s your own money.

The Purisimas (Festival of the Immaculate Conception) was about to start and that meant one month’s bonus wages for all; every government department had a stall with religious tableaux on the Avenida Bolivar, handing out goodies (bags of rice, fruit, vegetables) much to the populace’s approval.

The image building business is thriving in Nicaragua.

Hugo Chavez, the savior of Venezuela, enjoys a special place in the pecuniary hearts of Nicaraguans for his sending gasoline and oil money to his pals in Managua.

I was amazed to see Chavez’s youthful physiognomy in lights at a major roundabout, re-named Hugo Chavez Eternal Commander Rotunda, in the centre of Managua.

This stirring image of the Bolivian revolutionary is surrounded by curly golden steel trees erected by Rosario Murillo, the president’s wife, a skilled artist (especially when spending the public’s money). These trees (like metallic Joshua trees) are sprouting all over Managua.

At $30,000 a pop, 45 feet high and lit by thousands of light bulbs, they are copies of Gustav Klimt’s “Tree of Life.” Rosario has recently focussed her artistic skills on adorning herself with funky jewelry and clothing. But, hey, it’s all fun and the people like it. The more intelligent Managuans roll their eyes.

Weathering Hurricane Otto and an earthquake off the Pacific coast, we had a brief look around the country.

I wanted to visit Sevia Negra, a coffee plantation for organically cultivated coffee run by German expats, Eddy Kuel and Mause Hahn.

Highway CA1 from Managua to Matagalpa is the major road north. Lester, our driver, was happy to leave Managua and was looking forward to visiting a girlfriend. Medical Spanish is manageable, with so many words being Latin-derived cognates, but Lester spoke Nicaraguan Spanish and no English, so communication was hit and miss, mostly miss. Horses were tied by the roadside grazing the grass short; scabby dogs ran across the road; washing hung outside shacks; a worker dozed in the back of a pick-up truck. And a tank skulked at the entrance to Selva Negra Coffee Plantation – a reminder of the brutal Sandinista-Contra war 30 years ago.

We got the honeymoon suite ($90 per night) with a lovely view over the northern hills and plantations. The power to the unit for light and hot water (no fridge or TV) was supplied by three solar panels attached to a large battery. Giggling visitors came to see what we >

MARCH – APRIL 2017

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> were up to. It was friendly curiosity (“nosiness” in our privacy obsessed Western world). We also had a night visitor, a scratching burrower into the sod roof who did not understand that corrugated iron was a harder job than sod.

In drenching rain, I went on a night walk with a guide, named, of course, José, and four others, including a backpacker from Montreal. “Wow, that’s weird, man,” he said, on seeing a stick insect in José’s flashlight.

Everything we saw – a couple of little birds like feather-balls (visiting travellers like us to warmer climes) asleep on the end of a tree branch to avoid predators, was “Hey, aah-some, taw-dally aah-some” as were the thumbnail-sized frog, a Monarch butterfly, a bullfrog and two small deer.

In the resort farm, 250 workers are employed, increasing to 800 when the coffee is picked. The workers’ cottages, food and energy costs are “free” – though they receive small wages. They all seemed happy enough, with mothers and children tumbling around. The owners’ lovely house on the hillside would bring a smile to George Orwell as it towered over the happy peasants below.

If a southward tectonic shift were

impossible, then I would wish for a tax-deductible Vacation Savings Account (“VSA”) for travel to California, Nevada or Arizona for two weeks in mid-winter.

“The estate workers are wonderfully hard workers,” said Mausi Hahn, who runs things now that her husband, Eddy, has retired to writing books.

No artificial fertilizer is used – human and cattle manure is mixed with millions of worms by hand (no gloves) and packed around the coffee shrubs. The farm has cattle, pigs, vegetables (though no potatoes, which are difficult to grow in the acidic soil) and fruits (oranges, lemons, bananas, papayas and guavas). Vultures hovered.

The coffee at Sevia Negra is superb and a demonstration of the superiority of expert coffee production compared to the bitter nasty commercially produced Arabica served up in North America. The plants are allowed to grow for seven years before picking (compared to two years in the commercial outfits). Banana and lemon trees are interspersed to provide shade and impart through their roots a hint of lemon flavor. Only the ripe berries are picked, washed, dried and bagged for export. You can buy this coffee in Wholesome Foods. I had no difficulty picking out the Sevia coffee in a blind test of four different brands.

Isla Ometepe, Lake Nicaragua The ferry from Puerto San José to Mayagalpa, Isla Ometepe, costs 50 escudos ($2) and was loaded with backpackers, large and fleshy, dwarfing the Nicaraguan crew. We were the only two with roller bags; everyone else carried sporty backpacks with national flags. The old ferry chugged over the lake before we piled down the gangplank.

Being the ferry’s gringo plutocrats, the usual bunch of t-shirted con artists descended on us. But I’m pretty experienced dealing with these guys. If there’s a chapter in “The Art of the Deal” I should be an invited contributor. I’ve handled these guys the world over from Calcutta’s dawn to Egypt’s dusk. I’ve been hustled and ripped off so many times that I know all the moves.

Lesson 1: surprise them by putting an arm round them, hugging them and saying, “Two dollars with a big tip at the end of the ride. Take a risk with me.” The comedian Tommy Cooper, a notorious cheapskate, used to carry tea bags in his pocket. At the end of the ride, he’d press one into the hand of the taxi driver. “Have a drink on me,” he’d say.

At the Hotel Villa Paraiso, we snagged a nice room overlooking the lake, moseyed down to the beach and waded into a swarm of tiny gnats that clung to your hair and clothes, flew into your mouth and up your nose all the way into your lungs. The fishermen love them. This bug ecstasy party lasted till midnight, at which point the insects died having given birth to tomorrow’s generation.

Spiders’ webs like black-spotted veils covered the shrubs with lurking overfed spiders. The maids swept up the dead insects in the morning.

“Like Mr. Trump?” I asked. He winced.

We climbed Volcan Maderas, an inactive volcano, in the rain, wandering past cedar, mango and guava trees.

We ate well, slept well and loved the winter warmth.

Nicaragua will soon be spoiled by too many tourists, so if you have an adventurous spirit, go for a couple of weeks.

Visit Leon and Granada as well. You won’t regret it.

Eddy has written 17 books on the history of the region, the people and coffee. But not politics.

And look after that little flickering candle, your genie in his bottle. Sometimes it’s all you’ve got left.

Eddy’s office was like mine – computerized but lots of paper. He still walks around the resort and farm in a red baseball cap.

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CLASSIFIED ADVERTISEMENTS

PHYSICIAN WANTED CALGARY AB Exciting opportunity to join a busy psychiatric clinic that carries a patient load of over 2,000 to whom we offer collaborative care, with a focus on promoting optimal health wellness and prevention of illness. We are looking for part- and/or full-time family physicians to join our team to work in partnership with other health care professionals to provide enhanced patient care. Our team will streamline the care of patients with ease. Compensation to be discussed. Only qualified candidates will be contacted.

Contact: Dr. Salim Hamid to submit your CV psychiatry.consult@telus.net CALGARY AB Pain specialist Dr. Neville Reddy is looking to recruit physicians (general practitioners and specialists) to join his team of dedicated health care professionals. Innovations Health Clinic has two locations (southeast and southwest), favorable 25% expenses offered.

Contact: Neville Reddy, MB ChB, FRCPC (Anesthesia) T 403.240.4259 C 403.689.4259 nreddy@innovationshealth.ca www.innovationshealth.ca CALGARY AB An exciting opportunity is available for family physicians and specialists to join Revolution Medical Clinic. We are located in the bustling Signal Hill Shopping Centre. Come and join the most modern and innovative clinic in southern Alberta. We offer a very competitive fee split in exchange for a superior patient-focused approach.

Part- or full-time, flexible hours to accommodate work/life balance,

very competitive fee split. Possible partnership opportunity available to committed members of our team.

Contact: Dr. Riyaan Hassen C 403.688.7867 rhpc@shaw.ca CALGARY AND EDMONTON AB Retiring? Semi-retiring? Want someone to take over your panel?

Imagine Health Centres (IHC) is growing and welcomes semi-retired and/or retired physicians who want to ensure continuity of care for their patients.

Come work part- or full-time and allow us to introduce ourselves to your patients. Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. IHC prides itself in providing the best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians.

Do you want your patients to be cared by a team that collaborates with other health care professionals for enhanced patient care? If so, contact us.

Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB Capstone Medical Clinic is a brand-new family medicine clinic in west Edmonton. It is in close proximity to an assisted-living facility, diagnostic imaging and multiple pharmacies. This is an ideal location for family doctors looking to build a new practice, as well as physicians with an existing panel.

Both part- and full-time positions are available.

Clinic hours are flexible and payment is fee-for-service. We use TELUS Health Solutions (Wolf) electronic

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medical records. We are part of the Edmonton West Primary Care Network (PCN) and have access to a PCN nurse on site. Interested physicians must be licensed with the College of Physicians & Surgeons of Alberta.

Contact: Dr. Christopher Gee T 780.708.3012 info@capstonemedicalclinic.com 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); 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 >

MARCH – APRIL 2017

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> EDMONTON AB To meet our growing needs, we have a practice opportunity for a pediatrician at the Parsons Medical Centre. The clinic is in south Edmonton and is a high patient volume clinic.

You can enjoy working in a modern environment with full electronic medical records, friendly reliable staff for billing, referrals, etc., as well as an onsite manager. Parsons serves a large community and wide spectrum age group (birth to geriatric). The Parsons Medical Centre has a pharmacy onsite, ECG machine and offers a large array of specialist services.

Parsons Medical is a member of the Edmonton Southside Primary Care Network which allows patients to have access to an on-site dietitian and mental health/psychiatry health services. Overhead is negotiable, flexible working hours and open seven days a week.

Contact: Harjit Toor T 587.754.5600 manager@parsonsmedicalcentre.ca

EDMONTON AB Windermere’s newest clinic is looking for physicians to start as soon as possible.

Imagine Health Centres (IHC) newest clinic, Currents of Windermere is a top-notch, high-profile retail development within the proximity of Riverbend and McGrath.

A multidisciplinary family medicine clinic with a focus on health prevention and wellness, IHC prides itself in providing the best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians.

We are looking for part- and full-time family physicians. Imagine Health Centres has an excellent opportunity to take over existing patient panels at our Edmonton locations.

Do you want to be part of a team that collaborates with other health care professionals for enhanced patient care? Do you want to make a difference in your patients’ care and take a proactive instead of a reactive approach to health care?

Compensation is fee-for-service and inquiries are kept strictly confidential.

Only qualified candidates will be contacted.

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Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AND FORT MCMURRAY AB MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic, each with 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 with 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 we are a member of a primary care network (PCN).

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

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

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

Contact: Management Office T 780.757.7999 or T 780.756.3090 F 780.757.7991 mdgroupclinic@gmail.com lessardclinic@gmail.com GRANDE PRAIRIE AB IMJ Medical Clinic is looking for a full-time family physician to join an established physician group.

Requirements are current registration with the College of Physicians & Surgeons of Alberta, qualifications and experience CCFP or equivalent.

Compensation is fee-for-service with a 40/60 split with an estimated annual income of $200,000 to 300,000.

Contact: Stanley Muwonge muwonge@telus.net MILL BAY BC Excellent opportunity for a family physician to join a well-established family practice in Mill Bay on beautiful Vancouver Island. Six full-time family practices share office. Full functioning electronic medical records for the past 12 years, X-ray, ultrasound and laboratory on site. Hospital work and obstetrics are optional. Eligible for rural subsidy agreement ($10,000 recruitment incentive, 4.2% fee premium and annual rural CME subsidy).

Mill Bay is 30 kilometers north of Victoria and 19 kilometers south of Duncan. Home to two of Canada’s leading private high schools (Brentwood College and Shawningan Lake School). Mill Bay’s population is 3,200 and is one of the many villages located in the Cowichan Valley (population 80,000). Endless outdoor recreational opportunities await.

Contact: Dr. Kim Grymaloski Mill Bay Medical Centre T 250.743.5579 kwgrymaloski@mac.com >

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PHYSICIAN AND/OR LOCUM WANTED CALGARY AB State-of-the-art brand-new clinic, Zamin Medical Centre has opportunities for locums and part- or full-time physicians. If you are an experienced family physician or a new medical graduate, we can help you build your practice in a supportive team environment. Excellent location, flexible hours and free underground parking.

Contact: sjmzhome@gmail.com or fauziakareemi@gmail.com CALGARY, EDMONTON AND RED DEER AB Imagine Health Centres (IHC) is currently looking for family physicians and specialists to come and join our dynamic team in part-time, full-time and locum positions in Calgary, Edmonton and Red Deer. 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 health clinics with a focus on preventative health and wellness. Come and be part of our team which includes family physicians, physiotherapists, psychologists, nutritionists, pharmacists and more.

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 equity opportunities in IHC and related medical real estate.

Enjoy attractive compensation with our unique model while being able to maintain an excellent work-life balance.

We currently have three Edmonton clinics. The clinics are near South Common, west Edmonton and Currents of Windermere.

We currently have two clinics in Calgary. The clinics are located downtown and south Calgary. We also have compelling opportunities available in Red Deer. All inquiries will be kept strictly confidential.

Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB To meet the growing needs, we have a practice opportunity for family physicians to start as a locum (with an option to join part- or full-time) at Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC). Both clinics are in south Edmonton. PMC and MMMC are high patient volume clinics with friendly reliable staff for billing, referrals, etc., as well as an on-site manager. Enjoy working in a modern environment with full electronic medical records.

PMC and MMMC serve a large community and wide spectrum age group (birth to geriatric). Both clinics have on-site pharmacy, ECG machine, lung function testing and offer a large array of specialist services including: ENT, endocrinologist, general surgeon, internist, orthopedic surgeon, pediatrician and respirologist.

PMC and MMMC are members of the Edmonton Southside Primary Care Network which allows patients to have access to an on-site dietitian and mental health/psychology/psychiatry health services. Overhead is negotiable, flexible working hours and both clinics are open seven days a week.

Contact: Harjit Toor T 587.754.5600 manager@parsonsmedicalcentre.ca SHERWOOD PARK AB Dr. Patti Farrell & Associates is a new, busy, modern family practice clinic with electronic medical records. We require locum coverage periods throughout 2017. Fee split is negotiable. Current clinic hours 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 SHERWOOD PARK AB Well-established busy clinic with five family physicians seeks a locum or associate part- or full-time to replace a departing physician who has relocated to another city. We are located in a professional building with lab and X-ray on site, primary care network nurse support and excellent office staff.

Clinic has been using Med Access electronic medical records for 10 years.

Contact: Dr. Lorraine Hosford T 780.464.9661 hosford6@telus.net SHERWOOD PARK AB Nottingham Medical Clinic is looking for part- or full-time family physicians.

Locums welcome. Clinic has a modern appearance. Pharmacy and dietitian services in the clinic, on-site laboratory and diagnostic services are also available. We currently have five family physicians and are looking for at least another three. Appointment-based practice, flexible schedule and clinic uses Med Access electronic medical records. Moving bonus, 70/30 split.

Contact: Dr. Steve Denson T 780.298.6109 sdenson@shaw.ca

SPACE AVAILABLE CALGARY AND EDMONTON AB Medical offices available for lease in Calgary and Edmonton. We own full-service, professionally managed medical office buildings. Competitive lease rates, attractive building amenities and turn-key construction management available.

Contact: NorthWest Healthcare Properties Lindsay Hills Regional Leasing Manager T 403.282.9838, ext. 3301 lindsay.hills@nwhreit.com Michael Lobsinger Leasing Manager, Edmonton T 1.877.844.9760, ext. 3402 michael.lobsinger@nwhreit.com >

MARCH – APRIL 2017

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CLINIC AND PRACTICE FOR SALE EDMONTON AB Established southside Edmonton family medical clinic and practice for sale. Clinic is in mint condition and beautifully designed. Built at the end of 2012 and became operational in January 2013. Ready to operate, full turn-key clinic and is suitable for one or two physicians.

Clinic is in a strip mall, pharmacy next door and another family medical clinic next door (well-established with three friendly family physicians operating for over 20 years). Ample free parking, three transit stops footsteps from the clinic and two transit stops next to the mall. Laboratory and diagnostic imaging facilities within blocks. Quick access to Gateway Boulevard/Calgary Trail and Anthony Henday Drive.

The modern, spacious, well-built, 1,100 sq. ft. clinic with nine-foot ceilings has a bright interior. The clinic is comfortable and has a modern design with a mix of glass, steel and wood laminate materials using high-quality construction and fixtures. Furniture is modern and in new condition, as well as ample storage cabinetry.

Two large examination rooms are each 10 feet by 8 feet. Multi-purpose workstation room (e.g., primary care nurse [PCN], associate, etc.), physician’s personal office, kitchen, public wheelchair-accessible washroom and staff bathroom. Clinic entrance has glass vestibule with outer and inner power doors.

Touchless washing stations with automatic faucets and hand soap dispensers throughout clinic. New condition, powered Ritter 223 examination tables are four years old and BpTRU six-cycle blood pressure units in every examination room are four years old. Four Dell Optiplex desktop PCs (Windows) and printer in every examination room are in new condition. Built-in Gigabit networking hardware and Cat5e Ethernet cables.

TELUS PS Suite electronic medical records (formerly Wolf EMR; ASP-based for security).

Support staff is very experienced with medical office assistant managing day-to-day matters and PCN registered nurse is available.

AMA - ALBERTA DOCTORS’ DIGEST

Price is negotiable and flexible with easy terms.

Contact: pandas.paw100@gmail.com

ALASKA CME AWAY™ CRUISE August 20-27 Focus: Infectious diseases and dermatology Ship: Celebrity Infinity

COURSES

RHINE AND DANUBE RIVER CME AWAY™ CRUISE September 1-16 (Sold out, wait list only) Focus: Cardiology, sport medicine and dermatology Ship: Avalon Illuminations

CME CRUISES WITH SEA COURSES CRUISES • Accredited for family physicians and specialists • Unbiased and pharma-free • Canada’s first choice in CMEatSEA® since 1995 • Companion cruises FREE BERMUDA CME AWAY™ CRUISE April 30-May 7 Focus: Primary care and neurosurgery for the non-neurosurgeons Ship: Celebrity Summit SPAIN CME AWAY™ LAND TOUR May 12-22 Focus: Internal medicine and medical/legal updates Spanish land tour exploring Madrid, Vigo and Rioja WESTERN MEDITERRANEAN CME AWAY™ CRUISE May 29-June 9 Focus: Rheumatology and pediatrics Ship: Celebrity Reflection ICELAND CME AWAY™ LAND TOUR June 3-9 Focus: Optimizing patient care, chronic pain and urology Iceland land tour SCANDINAVIA AND RUSSIA CME AWAY™ CRUISE July 6-18 (Limited space) Focus: Emergency medicine and diabetes management Ship: Celebrity Silhouette WESTERN MEDITERRANEAN CME AWAY™ CRUISE July 22-August 3 Focus: Sexual health, men’s health Ship: Holland America Ms Westerdam WESTERN CARIBBEAN CME AWAY™ CRUISE August 13-20 (Featuring: Kids summer camp at sea) Focus: Family medicine, vaccines and geriatrics Ship: Celebrity Summit

ADRIATIC AND AMALFI COAST CME AWAY™ CRUISE September 6-16 Focus: Family practice and chronic pain: Update on 2017 pain guidelines Ship: Azamara Quest JAPANESE EXPLORER CME AWAY™ CRUISE September 24-October 5 (Limited space) Focus: Cardiology, internal medicine and endocrinology Ship: Celebrity Millennium LAS VEGAS CME AWAY™ RESORT October 1-6 Focus: Save the date – CME AWAY™ Resort Resort: Encore Resort Las Vegas TUAMOTUS AND SOCIETY ISLANDS TAHITI CME AWAY™ CRUISE October 18-28 (Bucket list destination) Focus: Cardiology and emergency medicine Ship: Paul Gauguin EXUMA, BAHAMAS CME AWAY™ RESORT November 5-12 (Book early – sold out quickly last year!)

Focus: Family medicine Resort: Sandals Emerald Bay Resort (adults only) CHILE, PATAGONIA, CAPE HORN AND ARGENTINA CME AWAY™ CRUISE November 25-December 2 Focus: Neurology and infectious diseases Ship: Stella Australis SINGAPORE TO HONG KONG CME AWAY™ CRUISE December 5-17 Focus: Rheumatology and pain management Ship: Regent SS Voyager >

> EASTERN CARIBBEAN CME AWAY™ CRUISE December 30-January 6, 2018 Focus: Male/female sexual health and endocrinology Ship: Royal Caribbean: Harmony of the Seas AUSTRALIA AND NEW ZEALAND CME AWAY™ CRUISE February 3-17, 2018 Focus: Pain management, chemical dependency, rheumatology and endocrinology Ship: Celebrity Solstice RIVIERA MAYA MEXICO CME AWAY™ RESORT February 4-11, 2018 (Voted best Sea Courses resort in 2016) Focus: Save the date – CME AWAY™ Resort Resort: Grand Velas Resort (all-inclusive) INDIA AND SRI LANKA CME AWAY™ CRUISE March 23-April 7, 2018 Focus: Save the date – CME AWAY™ Cruise Ship: Celebrity Constellation BALI TO HONG KONG CME AWAY™ CRUISE March 24-April 8, 2018 Focus: Anesthesia and emergency medicine Ship: Regent Seven Seas Voyager AUSTRALIA GREAT BARRIER REEF CME AWAY™ CRUISE March 30-April 11, 2018 Focus: Cardiology, obstetrics, pediatrics and cultural anthropology Ship: Celebrity Solstice MARQUESAS – TAHITI CME AWAY™ CRUISE April 14-28, 2018 Focus: Save the date – CME AWAY™ Cruise Ship: Paul Gauguin HAWAII CME AWAY™ CRUISE May 3-13, 2018 Focus: Endocrinology and cardiology Ship: Royal Caribbean Radiance of the Seas ITALY AND CROATIA CME AWAY™ CRUISE May 28-June 10, 2018 Focus: Save the date – CME AWAY™ Cruise Ship: Celebrity Constellation

MEKONG RIVER CME AWAY™ CRUISE October 16-31, 2018 Focus: Neurology and endocrinology Ship: AmaWaterways – AmaDara For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

SERVICES ACCOUNTING AND CONSULTING SERVICES Independent consultant, specializing in accounting and tax preparation services, including payroll and source deductions, using own computer and software. Pick up and drop off for Edmonton and areas, mail or courier options available for rest of Alberta.

Contact: N. Ali Amiri, MBA Consultant Seek Value Inc. T 780.909.0900 aamiri.mba1999@ivey.ca aliamiri@telus.net

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

algo+med algo+med are a medical billing service submitting to both Alberta Health and Workers’ Compensation Board Alberta. We provide timely submissions, detailed reports and advanced analytics of billing data.

Our processes are secure, ensuring privacy and confidentiality of both physician and patient information. Our rates are competitive and new clients receive their first month free.

Contact: T 1.866.218.8041 www.algo-med.com DOCUDAVIT SOLUTIONS Retiring, moving or closing your practice? Physician’s estate?

DOCUdavit 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,

MARCH – APRIL 2017

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MY MD ADVISOR NOT ONLY KNOWS THE FINANCIAL BUSINESS OF MEDICINE, BUT ALSO UNDERSTANDS

MY JOURNEY. Dr. Anthea Lafreniere, Anatomical Pathology Resident

Trust your MD As a CMA company, we understand physicians’ finances better than anyone.

For personalized advice, call 1 800 267-4022 or visit md.cma.ca.

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.