Alberta Doctors' Digest March/April 2016

Alberta Doctors'

DIGEST March-April 2016 | Volume 41 | Number 2

Leading by stewardship We have an image(ing) problem

Leadership by design New CanMEDS 2015 Framework reflects the growing importance of physician leadership and advocacy

Seeking one’s glass slipper The Section of General Practice joins system partners to prove that fitting leadership opportunities is no Cinderella story

In Flanders Fields A leadership story of relentless artillery, lethal poisonous gas and a Canadian doctor/poet 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 Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP

6 18 20 26 27

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

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

Alberta Medical Association 12230 106 Ave NW Edmonton AB T5N 3Z1 T 780.482.2626 TF 1.800.272.9680 F 780.482.5445 amamail@albertadoctors.org www.albertadoctors.org

28 Dr. Gadget 33 PFSP Perspectives 36 Residents' Page 38 In a Different Vein 40 Classified Advertisements

FEATURES

Editor-in-Chief: Marvin Polis

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

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

8 Leading by stewardship: We have an image(ing) problem Physicians step up to tackle the inappropriate use of diagnostic imaging for low back pain

12 Leading change in tough times

This is an opportunity to make our work more efficient and effective

14 Seeking one’s glass slipper

The Section of General Practice joins system partners to prove that fitting leadership opportunities to the right physician volunteers is no Cinderella story

16 Leadership by design

May-June issue deadline: April 13

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.

22 Emerging Leaders in Health Promotion Grant program

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. © 2016 by the Alberta Medical Association Design by Backstreet Communications

AMA MISSION STATEMENT

New CanMEDS 2015 Framework reflects the growing importance of physician leadership and advocacy

Connecting with Nature

24 Emerging Leaders in Health Promotion Grant program

Lungs are for Life Smoking Prevention Program and Workshop Kit

30 In Flanders Fields

A leadership story of relentless artillery, lethal poisonous gas and a Canadian doctor/poet

32 The 2016 Tarrant Scholarship opportunity is here!

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

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. Derek J. Emery: "We need to ensure that time is available on MRI machines so that we can scan those patients who are most likely to benefit."

MARCH – APRIL 2016

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A SPECIAL ISSUE

5

We salute physician leadership in this special issue

W

ith many complexities facing the health care system, the call for physician "leaders" to step forward has never been more frequent or important. There are, of course, many kinds of leadership – and we examine a few of these aspects in this special issue of Alberta Doctors' Digest.

The Royal College of Physicians and Surgeons of Canada recently acknowledged the growing importance of leadership in its updated CanMEDS 2015. The concept of "leader" has replaced that of "manager." Read about what the change means and why it was made.

Meanwhile, Alberta's primary care leaders are turning their attention to the ongoing challenge of building the physician-leader workforce that will be needed in the short and the long term. We profile the Engaged Leadership Initiative of the Alberta College of Family Physicians (ACFP). Section of General Practice representative to the initiative, Dr. Kathryn L. Andrusky also writes about why and how the section is working with the ACFP on this endeavor.

Last but not least is our cover story. Dr. Derek J. Emery explains what led Alberta's diagnostic imaging physicians to promote appropriateness in lumbar spine testing – and how promoting appropriateness is an important part of leadership and stewardship of health care resources.

We hope you enjoy these perspectives. We also salute all of you who are leaders in your own right, working every day for a system that puts Patients First®.

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FROM THE EDITOR

On illness and other matters Dennis W. Jirsch, MD, PhD | EDITOR

On Being Ill

By Virginia Woolf with Notes from Sick Rooms

By Julia Stephen Paris Press, 2012

P

erhaps not surprisingly, I’m comforted reading accounts of illness. I’m neither referring to academic papers, with their rosters of test subjects, new treatments and searches for statistical significance.

Nor am I referring to the overstuffed aisles of self-help books that are generally based on hunches regarding our ailments and, buttressed by anecdotes rather than science, go on to urge ingestion of exotic roots or berries or avoidance of perceived toxins. Rather, I’m drawn to authors’ attempts to relay the experience of illness and the question we have as bystanders: What is it like?

What is it really like?

I first read Virginia Woolf’s essay, On Being Ill, years ago but couldn’t find it in the confusion of my library. When a new copy came in the mail – not yet delivered by drone!

– I found a handsome new edition of the work that was first published in 1926. Woolf’s essay is short – a mere 25 pages or so – but included with it now is another short piece, Notes from Sick Rooms that was written by Julia Stephen, Virginia Woolf’s mother. Stephen was a practicing nurse for many years and collected her thoughts on nursing in Notes from Sick Rooms.

Woolf, you may recall, is one of the literary lions – or would it be lionesses? – of the past century. She grew up in England, was married to editor/author Leonard Woolf and produced nine novels as well as abundant short fiction and non-fiction. Despite her fertile career, she was plagued by lifelong, recurring illness, prompting many to suggest she suffered from bipolar disorder or another malady. In 1941 at age 59, she committed suicide by drowning.

Woolf’s prose has been called transformative and On Being Ill would have us appreciate the sea change that illness can bring to our existence. Woolf’s arguments range widely and touch on language, religion, solitude, sympathy and reading. As if this weren’t enough, there are allusions to suicide, madness, the afterlife and,

AMA - ALBERTA DOCTORS’ DIGEST

thrown in for good measure, are references to dentists, electricity, an organ grinder, a giant tortoise, the coming ice age, worms, snakes, mice, Chinese readers of Shakespeare and housemaids on brooms swimming down the river Solent. This all – let me remind – in an essay of less than 4,000 words.

I’m drawn to authors’ attempts

to relay the experience of illness and the question we have as bystanders: What is it like? What is it really like?

Woolf’s writing is not quite earthbound and seems ready to slip the bonds of earth. But it doesn’t. The quirky web of connections she makes come marvellously close to portraying the change that is wrought by illness, its “otherness.” Her prose is unusual and even exotic, but it is clear and never murky or difficult; it “hangs together,” as critics would say.

Here is an example: the explosive, opening sentence of On Being Ill: “Considering how common illness is, how tremendous the spiritual change that it brings, how astonishing, when the lights of health go down, the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight whack of influenza brings to view, what precipices and lawns sprinkled with bright flowers a little rise of temperature reveals, what ancient and obdurate oaks are uprooted in us by the act of sickness, how we go down into the pit of death and feel the waters of annihilation close above our heads and wake thinking to find ourselves in the presence of the angels and the harpers when we have a tooth out and come to the surface in the dentist’s arm-chair and confuse his ‘Rinse the mouth – rinse the mouth’ with the greetings of the Deity stooping from the floor of Heaven to welcome us – >

> when we think of this, as we are so frequently forced to think of it, it becomes strange indeed that illness has not taken its place with love and battle, and jealousy among the prime themes of literature.”

Take a breath now and you will likely agree not much can compare with this 183-word opening gambit. The reference to dentistry is perhaps explicable, since teeth were pulled from time-to-time in this era for fevers and recalcitrant illnesses of unknown origin. Woolf’s web of strange associations succeeds, against all odds, to convince us that illness takes us beyond our ordinary lives. Other writers have noted this, but in prose that is typically more pedestrian and have come to call the place we occupy when we are ill “the other side.”

We do well to remember that the

word “patient” comes from the root meaning “one who suffers,” and that humanity must live at the heart of medicine.

The unbounded, seemingly whimsical and other-worldly aspects of On Being Ill show us this other place – the kingdom of illness – in spectacular fashion. Woolf’s masterpiece would not seem to fit with the companion piece written by her mother, straightforward advice from a practicing nurse, but strangely enough, it does. Notes from Sick Rooms sets off the unrestrained, rococo quality of Woolf’s prose with practical instructions from a nurse.

Notes from Sick Rooms focuses on the comfort that can be provided with proper nursing care. The mundane but very real problem of crumbs in a sickbed receives special mention, as does the vexing discomfort of wrinkled bed sheets. Pillows are uniquely important to an invalid and Stephen emphasizes the nurse’s special role in arranging them for comfort. She notes that visitors to the sick can be a problem too, since many callers are less than welcome. Visitors, she urges, should state their business in straightforward fashion and not stay long. They should, moreover – and I like this one, particularly – never sit on the bed.

There is too the issue of noise, “people who are … noisy have no business in a sick room.” And further, “As night

approaches the room should become gradually still.”

As one might expect, there are tips on feeding and the special nutrient quality of beef broth. Stephen has more to say regarding light in the room at night, enemas, the proper preparation of linseed poultices and truth-telling to the ill. Finally, there is even counsel in the event of death: “… in the presence of death all bustle is unseemly.”

To read Julia Stephen’s small manual is to remember just how much has changed over the past century and at the same time, how little. Routine enemas and linseed poultices are no more. The hospital ward has become a sort of production hive with little attention to noise, visitors and bed linens. Yet the care that may be offered by a nurse, physician or others, remains singularly important to patients.

Columbia University internist Dr. Rita Charon has written an afterword to Stephen’s essay and makes the point that the directions of Julia Stephen are truly “patient-centered.” As such, they’re worlds apart from modern organizational disruptions that are offered up as patient-focused but which are all (and only) about efficiency. Stephen offers up a word portrait of the ideal nurse, “who comprehends and does not fear mortality, derives dividends of joy from the craft of her practice, and develops toward the sick person a posture of engaged concern and educated humility.”

If there is a better description of an ideal nurse, I’d like to hear it.

Stephen’s no-nonsense account is in distinct contrast from her daughter’s. Virginia Woolf’s voice is that of a searcher, exploring the world for meanings which are deeply interior, and which can be difficult to define and grasp.

We do well to remember that the word “patient” comes from the root meaning “one who suffers,” and that humanity must live at the heart of medicine. With this in mind, Woolf’s essay and that of Stephen’s juxtapose perfectly, reminding us of the attention and regard appropriate for engagement with the sick and fusing the singularity of illness, its unknowability with the practical wisdom of caring.

I’d like to think that those ill enough to be in hospital, or indeed ill in any circumstance, would benefit if those charged with their care spent an enjoyable afternoon reading these pieces.

It is a fine little book.

MARCH – APRIL 2016

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COVER FEATURE Leading by stewardship: We have an image(ing) problem Physicians step up to tackle the inappropriate use of diagnostic imaging for low back pain

“R

adiologists have always recognized that some of the studies that we do are inappropriate,” says Dr. Derek J. Emery, Associate Chair, Research and Faculty Affairs in the Department of Radiology and Diagnostic Imaging at the University of Alberta (U of A) and a neuroradiologist with Medical Imaging Dr. Derek J. Emery Consultants. “The problem has been, though, that it’s difficult to document when and how these studies are being ordered and done – and we have lacked good information about whether or not they are appropriate.”

Lumbar spine X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) are some of the most frequently performed diagnostic imaging investigations in Canada. In the 2012 fiscal year, there were 30,271 lumbar spine MRI scans and 9,514 lumbar spine CT scans performed in Alberta. 13,249 patients underwent MRI scans, 3,980 patients had lumbar spine CT scans and 792 people had both a CT and MRI scan. These patients had an average of 2.2 scans during the 2012 year. Of the 18,021 patients who had lumbar spine scans during 2012, only 755 (4.2%) underwent spine surgery within the following two-year period.

Overuse of medical interventions such as MRI is a considerable problem, leading to excess costs and adverse outcomes. This overuse of imaging is driven by many factors, including patient expectations, physician concerns about litigation, and lack of physician awareness of and/or accountability for cost.

Discussion of this issue with Dr. Tom E. Feasby, now from the University of Calgary (U of C), quickly identified a common interest in getting to the root of the problem.

The Alberta physicians reached out to counterparts across the country. “We got together with doctors who are leaders in quality from Ontario and did a study on appropriateness in MRI for lumbar spine and for headaches,” reports Dr. Emery. “The results were AMA - ALBERTA DOCTORS’ DIGEST

the same in Edmonton and Ottawa. This is not a local phenomenon; in fact it probably occurs across Canada and even world-wide.”

In the late stages of concluding the study, an opportunity arose to become involved with the Choosing Wisely Alberta initiative, being implemented here under the 2011-18 Alberta Medical Association (AMA) Agreement by the AMA, Alberta Health (AH) and Alberta Health Services (AHS). The details appear below about what is being done to actively reduce unnecessary lumbar imaging in Alberta.

We had an identified problem

with national and provincial interest in doing something about it. In fact, reducing lumbar spine imaging was an area of interest for a number of the specialty areas involved in Choosing Wisely.

“It was perfect timing to become involved with Choosing Wisely Alberta,” Dr. Emery explains. “We had an identified problem with national and provincial interest in doing something about it. In fact, reducing lumbar spine imaging was an area of interest for a number of the specialty areas involved in Choosing Wisely.” The aim is to reduce diagnostic imaging for which there is little evidence of benefit and that may actually harm the patient.

The leadership linkage How does this all link to leadership of the profession?

“Because MRI is a limited resource, we need to use it intelligently,” says Dr. Emery. “We need to ensure that time is available on MRI machines so that we can scan those patients who are most likely to benefit.

We don’t want to book the machines full with scans that have no possibility of helping the patient’s care in a meaningful way.” >

> Dr. Emery and his colleagues realized that as physicians, they need to recognize that all health care resources are limited to some degree. They need to be used in a way that will benefit patients, not just individually but also as a population. This stewardship role is seen as important for all physicians, working as partners across the system.

“Primary care medicine is very difficult,” notes Dr. Emery.

“These physicians must deal with millions of different problems and possibilities for diagnostic testing.

We need to set up systems between primary and secondary/tertiary care that helps primary care manage the load. We need to make it as easy and straightforward as possible for physicians at all levels to practice appropriateness.”

How does this all link to

leadership of the profession? Because MRI is a limited resource, we need to use it intelligently.

What they did: The lumbar spine study, its conclusions and the Alberta-based intervention The study of MRI of the lumbar spine performed in Edmonton and Ottawa showed that less than half of all lumbar spine MRI requests are appropriate (Journal of the American Medical Association (JAMA) Intern Med. 2013 May 13;173(9):823-5). Within the Edmonton Zone, 70% of lumbar spine MRI requisitions had inadequate information to determine whether or not the request was appropriate.

As part of the Choosing Wisely Canada project, the Canadian Association of Radiologists and the College of Family Physicians of Canada have recommended: “Don’t do imaging for lower back pain unless red flags are present.” This is one of the items that the groups have identified under Choosing Wisely for physicians and patients to discuss and question. The objectives are to: 1. Ensure that diagnostic imaging physicians have adequate information on the requests for lumbar spine imaging studies to determine whether or not the study is appropriate.

2. Perform only appropriate lumbar spine examinations in order that limited imaging resources can be utilized for those patients who will most benefit.

In their Choosing Wisely recommendations, the groups noted that solutions will require strict adherence to

appropriate guidelines as well as better education of patients.

What then has been done in Alberta?

Dr. Emery notes that Choosing Wisely Alberta has taken essential steps by involving physicians from diagnostic imaging and primary care. Patients have been engaged.

Many individuals and programs with AHS, the AMA and AH have been contributed to the collective efforts.

The outcome has been the institution of a strict screening process for lumbar spine CT and MRI within the Edmonton Zone. This has resulted in a reduction in the number of inappropriate studies performed.

A lumbar spine screening form was designed to make it easy for referring physicians to provide adequate information for the imaging specialist to determine whether or not the request is appropriate. This form was launched in conjunction with publicity from Choosing Wisely Alberta on August 1, 2015 in the Edmonton Zone.

A similar form was pilot tested in a portion of the Calgary Zone.

The program has been well received. There have been very few complaints from referring physicians regarding the screening form.

The requisitions remain paper-based and are faxed to the hospital by referring physicians. This has made the system somewhat cumbersome as requisitions and screening forms must be hand-sorted and requests for further information faxed back to the referring physician.

In those cases where the request for imaging is declined, a letter explaining the reasoning for this is sent to the referring physician. This screening process has been in place for about six months. Measurement continues. In the first three months alone, though, in the Edmonton Zone there was a reduction of 452 examinations or 20% of requests. Further data collection and analysis will be required to see if these numbers are maintained.

A reduction of even 10% of the number of lumbar spine imaging studies would represent a significant contribution to a system where there are currently long wait lists.

Once this process has been implemented province-wide, there is the potential to save between 3,000 and 6,000 MRI slots and between 900 and 1,800 CT slots for those patients who will most benefit from imaging.

Dr. Emery’s group notes that currently the booking, protocolling and prioritization of requests for MRI and CT are done with paper requisitions. Instituting a computerized order entry system with decision support would streamline the process and provide instant feedback to referring physicians. Such a system could also be utilized to reduce inappropriate use of other imaging tests. >

MARCH – APRIL 2016

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Reduction in inappropriate lumbar spine imaging

>

D. J. Emery1, E. Sitler2, W. Anderson2, R. Walker2, R. Sevic2,3 University of Alberta1, Alberta Health Services2, University of Calgary3

Patient label here or information below is required

Lumbar Spine Imaging Screening Record

Last Name

Birthdate (yyy-Mon-dd) Personal health Number

First Name

Gender Male Female Daytime Phone

The following information is required in order for us to process your request for lumbar spine imaging.

Patient Age

Referring Physician (Print first and last name)

Was an MRI or CT recommended on a previous imaging report?

Yes

(If so, please include a copy of the report)

No

In suspected disc herniation or spinal stenosis, are symptoms severe enough that surgery would be considered?

Yes

No

Back Dominant Pain (Pain above gluteal fold and below the T12 rib)

Leg Dominant Pain, Sensory Radiculopathy (Below the gluteal fold, specific root distribution and Radiation below the knee) Objective Motor Weakness In Lower Extremity on Examination

Typical Neurogenic Claudication

Back Dominant Pain OR Leg Dominant Pain

(Bilateral buttock and posterior thigh pain aggravated by walking or standing, relieved by sitting)

Are any of the following “Red Flags” present?

Cauda Equina Syndrome

(Sudden or progressive onset of new urinary retention, fecal incontinence, saddle or perianal anesthesia, loss of voluntary rectal sphincter contraction)

Unexplained Weight Loss, Fever, Immunosuppression

History of Cancer

Use of IV Drugs or Steroids

Progressive Neurologic Deficit on Examination and Disabling Symptoms

Significant Acute Traumatic Event Immediately Preceding Onset of Symptoms

Severe Unremitting Worsening of Pain at Night and When Laying Down

Age Over 65 with First Episode of Severe Back Pain

AMA - ALBERTA DOCTORS’ DIGEST

Not Applicable <6 weeks 6 to 12 weeks >12 weeks

Duration of Symptoms:

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

>

Who requests lumbar spine imaging?

11

Chiropractor 1% Emergency physician 1% Family physician 77%

Physical medicine/rehab 2% Neurologist 2% Other 3% Neurosurgeon 4% Internist 5% Orthopedic surgeon 5%

Results

Conclusions

Family physicians order most of the lumbar spine CT and MRI within Alberta. Programs such as Choosing Wisely Alberta and Toward Optimized Practice are aimed at educating both patients and community physicians on the optimal care of low back pain and the role of imaging in that care.

Overuse of medical interventions, such as MRI, is a considerable problem, leading to excess costs and adverse outcomes. Overuse of imaging is driven by many factors, including patient expectations, physician concerns about litigation and lack of physician accountability for cost.

Solutions will require strict adherence to appropriate guidelines and better education of patients.

Requests

Number

Percentage

Total requested August

948

Total requested September

997

Total requested October (1–11)

324

Total imaging requests

2,269

Number of MRI requests

1,977

87

Number of CT requests

292

13

Declined – absent red flags

108

4.8

Declined – other procedure suggested

19

0.8

Declined – duplicate order or exam

145

6.4

Declined – incomplete request

180

7.9

Total declined

452

20

The institution of a strict screening process for lumbar spine CT and MRI within the Edmonton Zone has allowed the imaging specialists to reduce the number of inappropriate studies performed. Once this process has been implemented province-wide, there is the potential to save between 3,000 and 6,000 MRI slots and between 900 and 1,800 CT slots for those patients who will most benefit from imaging.

Currently the booking, protocolling and prioritization of requests for MRI and CT is done with paper requisitions. The institution of a system of computerized order entry with decision support would streamline the process and provide instant feedback to referring physicians. Such a system could also be utilized to reduce inappropriate use of other imaging tests.

References available upon request.

MARCH – APRIL 2016

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FEATURE

Leading change in tough times We have an opportunity to make our work more efficient and effective David A. Keegan, MD, CCFP(EM), FCFP | ASSOCIATE

PROFESSOR, FAMILY MEDICINE; ASSOCIATE DEAN, FACULTY DEVELOPMENT; CUMMING SCHOOL OF MEDICINE, UNIVERSITY OF CALGARY; MEMBER OF THE SECRETARIAT FOR ENGAGED LEADERSHIP IN FAMILY MEDICINE

C

an I state the obvious? We are practicing medicine in the toughest financial climate in Alberta since the 1980s. The challenges are many and include:

1. Massive declines in oil royalties.

2. A population that is growing older.

3. A wide geographical area of health care delivery.

As a family physician who worked in Newfoundland and Labrador during the difficult financial climate of the mid-to-late 1990s, I know first-hand how critical it is for family physicians and all physicians to step up and take principled leadership roles. In those days, the system didn’t even have the money to put a fresh coat of paint on a hospital wall that had become dingy and banged up.

Things were tough. Those were days when rural hospitals were denied access to blood-gas machines. Those were days when it was hard to get an MRI for even the most compelling, obvious reason.

4. A recognized need to strengthen primary health care.

5. Patient demands for the highest quality of health care at all levels.

6. Competing demands for governmental expenditures.

When you look at this list, it’s easy to think that the Honorable Sarah Hoffman, Minister of Health, needs all the help she can get. That’s exactly the point. She and the teams within Alberta Health (AH) and Alberta Health Services (AHS) need doctors to help figure out how to advance health care in our province despite a bleak economic outlook.

While we didn’t predict this exact convergence of challenges, a group of family physicians from the Alberta Medical Association’s (AMA’s) Section of General Practice, Alberta College of Family Physicians (ACFP), AHS, and the departments of family medicine at the University of Alberta and University of Calgary – have been thinking of how we can best help family physicians to step up and help with some of these difficult issues.

Our initiative is called Engaged Leadership in Family Medicine and has two main goals: 1. To connect family physicians with groups or services needing family physician perspectives and input.

2. To help family physicians develop their strategic and other leadership skills so they can be fully effective in these and other leadership roles.

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We are practicing medicine

in the toughest financial climate in Alberta since the 1980s.

Even so, those were days when the government reached out to the Newfoundland and Labrador Medical Association and the Discipline of Family Medicine at Memorial University and, together, we were able to put together targeted solutions that not only helped to stabilize the system, but invested in the social development of the province.

I’m not sure that the next five years we are facing in Alberta will be quite as grim as those days, but the feel of the situation seems to be in the same ballpark. This means it is our duty to step forward and help AH and AHS with consideration of all perspectives, making the hard decisions and tactically figuring out how to make things happen.

There is some good news in all of this. Physicians are often times called to take on local, regional or system level leadership roles. The Royal College of Physicians and Surgeons has been working extensively to renew its >

> CanMEDS Competency Framework. This CanMEDS 2015 Framework provides helpful guidance on where and how to focus our efforts and pursuit of education in its new leader role. Its four main areas of action are: 1. Contribute to the improvement of health care delivery in teams, organizations and systems, with a particular focus on patient safety.

2. Engage in the stewardship of health care resources, including allocating resources for optimal patient care and using evidence to guide health care expenditures.

3. Demonstrate leadership in professional practice.

4. Manage career planning, finances and health human resources in a practice.

In October, we will be hosting a facilitator certification training program at the University of Calgary under the LEADS Collaborative of the Canadian College of Health Leaders. This will enable us to grow our ranks so that we will have trainers throughout Alberta to respond to the leadership development needs of family physicians and others.

These times are tough for sure. But we all know that it’s in tough times when priorities become clearer and we are all pushed to make our work more efficient and effective.

The time is now for family physicians and all of Alberta’s doctors to support AH and AHS in improving the value for money that Albertans deserve in our system: high quality, safe and accessible health care to support them when they are ill, and to help them fully embrace and engage with life.

The time is now for family

physicians and all of Alberta’s doctors to support AH and AHS in improving the value for money that Albertans deserve in our system.

Together, these four pillars in the leader role are a call to action for medicine as a profession to stand for the careful use of public resources to lead to high quality and safe patient care for all Albertans.

Our Engaged Leadership initiative is working to connect the right family physicians (with the right experience, knowledge and skills) with the initiatives or groups that need them through a web-based tool at www. engageprimarycare.ca. AHS is working hard to prioritize which initiatives are in the greatest need of family physician input so that we can get to work on the most pressing issues.

In the background, our initiative is answering the call from family physicians who want to be part of the solution. They are asking for some training in strategic planning, interest-based negotiation and leading discussions through competing interests. As a partnership, we launched the first of our training workshops at the Annual Scientific Assembly of the ACFP in Banff, March 4-6; but this is just the start.

More opportunities – tightly focused on the needs of family physician leaders – developed in specific response to those self-identified needs, will be available in the coming months.

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MARCH – APRIL 2016

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FEATURE

Seeking one’s glass slipper The Section of General Practice joins system partners to prove that fitting leadership opportunities to the right physician volunteers is no Cinderella story Kathryn L. Andrusky, BSc, MD, CCFP | SECTION OF GENERAL PRACTICE EXECUTIVE; LEADERSHIP SECRETARIAT OVERSIGHT COMMITTEE MEMBER

I

t is an exciting time for the primary care world! Multiple primary care and system transformation projects are already underway or on the verge of being introduced. It’s encouraging to see the general acknowledgement of the baseline role that primary care plays within the overall health care system. This has been accompanied by increased emphasis on consulting with primary care physician leaders on various health (and other) committees.

The attention and increasing demand for physician input has been refreshing and most appreciated by primary care leadership. At the same time, it has led to some challenges in terms of supplying physician representatives for these projects or committees.

Additionally, it is a challenge to sustain communications with those representatives so that they are properly supported in their roles, knowledgeable about other changes within the system and confident that their experiences and insights are being fed back to other primary care leaders.

These requirements led to the Section of General Practice joining with Alberta Health Services and the Alberta College of Family Physicians to fund a “Leadership Secretariat.” Health system transformation needs an

AMA - ALBERTA DOCTORS’ DIGEST

The Leadership Secretariat was founded to essentially provide a “matching service” between primary care physicians who wish to take on a representative role and the various committees, agencies, etc., needing that grassroots family physician perspective.

active and engaged leadership team – at all levels of involvement. The Leadership Secretariat was founded to essentially provide a “matching service” between primary care physicians who wish to take on a representative role and the various committees, agencies, etc., needing that grassroots family physician perspective.

It is often apparent that there is a lot of passion out there; one just has to find the right issue or involvement opportunity. The Section of General Practice Executive Committee hopes that the Leadership Secretariat can provide a forum to find that “glass slipper” match between physician leader and leadership role.

It’s a shoe-in!

No doubt about it …

The kids win and as a CHAMPION you win, with the AMA Youth Run Club.

Since 2013, the Alberta Medical Association and its YRC partner, Ever Active Schools, have introduced organized running and activity to over 300 schools in 104 Alberta communities.

Chosen by the AMA Board of Directors as the Many Hands “star” project, the YRC enables physicians, residents and medical students to connect and build community relationships through volunteer work right here in Alberta.

Become a YRC Champion!

Join the pitter-patter of thousands of feet or support the educational side of YRC, with a good health presentation.

Find out more about the AMA Youth Run Club on the AMA website (www.albertadoctors.org/youth-run-club) or call Vanda Killeen, AMA Public Affairs, 780.482.0675 (vanda.killeen@albertadoctors.org)

Put your best foot forward with the AMA Youth Run Club.

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FEATURE

Leadership by design New CanMEDS 2015 Framework reflects the growing importance of physician leadership and advocacy

I

t might seem hard to believe, but the Royal College of Physicians and Surgeons of Canada published their first CanMEDS Framework in 1990. Much has changed in society and in our health care system in the intervening years, so much so that when the college began work on its CanMEDS 2015 update, they quickly recognized that the role of manager was no longer relevant and that physicians needed to concentrate on developing the leadership skills that can shape the future of health care.

“CanMEDS is now over 25 years old,” explains Dr. Jason Frank, an emergency physician and the director of specialty education, strategy and standards with the college. “In developing the original framework, physicians told us they wanted information on how to organize their practice to work effectively in the health care system.”

The original framework also included items relating to stewardship, as physicians were expected to help allocate precious health care resources and administrative skills that would support them in taking on committee or volunteer roles. “All of that became the manager role.”

The working group told us that

calling a physician a manager is outdated in the 21st century and we need physicians to behave like leaders.

When the college began work on the CanMEDS 2015 project, it became clear that the manager role had become anachronistic. “The working group told us that calling a physician a manager is outdated in the 21st century and we need physicians to behave like leaders.”

AMA - ALBERTA DOCTORS’ DIGEST

Dr. Frank notes that the change from manager to leader was one of the most controversial proposed changes in the entire CanMEDS 2015 project. “For some people, there was a worry that this change would somehow signal a hierarchy, where physicians saw themselves as being in charge of others, when that was the farthest thing from the truth.”

It’s not about being the boss –

it’s about being an influential care provider.

The thinking behind the change from manager to leader is detailed on the Royal College of Physicians and Surgeons of Canada’s website (http://www.royalcollege. ca/portal/page/portal/rc/common/documents/ canmeds/framework/canmeds2015_manager_to_ leader_e.pdf). The document explains the importance of collaborative leadership and that leadership is not tied to roles or titles.

“We really wanted it to help physicians display 21st century leadership behaviors, which includes understanding a problem in the health care environment and doing something about it,” notes Dr. Frank. “It’s about having the skills to develop a vision of better care for your patient and knowing how to influence key decision makers to make that better care happen. It’s not about being the boss – it’s about being an influential care provider.”

The framework’s emphasis on collaborative leadership recognizes the importance of collaboration in the 21st century health care system. “There are a lot of different leadership models out there, but collaborative leadership involves working with others rather than through others.

It asks you to gather like-minded individuals who are equally committed to improving patient care and collectively work toward a solution.” >

> In addition to changing the role of manager to leader, the CanMEDS 2015 Framework includes several other changes to the six other roles, including revising the role descriptions to be simpler and more direct and reducing overlap between roles. Competencies related to safeguarding and enhancing patient safety have now been integrated into each role. (http://www.royalcollege. ca/portal/page/portal/rc/common/documents/ canmeds/framework/framework_series_1_e.pdf) The role of health advocate has also been completely rewritten as part of the CanMEDS 2015 Framework.

“Now, the role of advocate is about physicians using their abilities to mobilize resources to affect change in health care, whether it’s an individual patient or an entire population,” says Dr. Frank. “We strongly feel that advocacy is a required ability for a Canadian physician.” He explains that this change came from the feedback they received through focus groups with the public, who spoke about what they need and want

from their physicians. “We had one participant who put it beautifully, saying, ‘Doctor’s have a privileged role in our society and we need you to use your power and knowledge to improve care for us.’ That’s what patients are telling us is important to them.”

The shift to leadership and the increased emphasis on advocacy are both reflective of the current health care system and the challenges it faces. “Right now, we’re in an environment where we know health care demand continues to rise. We have an aging population, fewer physicians per capita – especially compared to other Organisation for Economic Co-operation and Development countries – and we’re faced with increasingly limited health care budgets. So in this environment, how can we all contribute to making health care better? That’s the CanMEDS 2015 Framework goal – let’s help physicians be better at what we do, all in the name of improving care.”

MARCH – APRIL 2016

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18

HEALTH LAW UPDATE

You are a steward of health system resources – choose wisely Jonathan P. Rossall, QC, LLM | PARTNER,

A

t a recent symposium entitled “Physicians as Stewards of Resources: Roles, Responsibilities and Remuneration” (co-sponsored by the Alberta Medical Association [AMA] and Alberta Health), AMA President Dr. Carl W. Nohr spoke of the social contract between society and physicians. In this contract, physicians enjoy a privileged place in society, one that engenders respect, allows for self-governance, creates a monopoly on the provision of certain medical services and at the same time provides for a comfortable living. This social contract also carries responsibilities for the physician, including developing a trust between physician and patient, providing competent services, and acting as a capable steward of society’s health care resources. It is this last responsibility that I’d like to explore in this edition of Health Law Update.

The Merriam-Webster dictionary defines stewardship as “the careful responsible management of something entrusted to one’s care.” The 2015 version of the Royal College’s CanMEDS Physician Competency Framework refers to physicians as “leaders,” reflecting an emphasis on the skills needed by physicians to contribute to the shaping of health care.1 The key competencies required by these leaders engaging in resource allocation, as a function of good stewardship, are identified as follows: • Allocate health resources for optimal patient care.

• Apply evidence and management processes to achieve cost-appropriate care.

• Contribute to strategies that improve the value of health care delivery.2 It is no secret that the Alberta government is struggling to meet the needs of society in an economic downturn and is looking for cost-savings in virtually every area of service delivery, including health care. The AMA and physician members are being challenged to find efficiencies and strategies that will serve to manage scarce health care resources while continuing to deliver top-notch front line services to the patient population. As stated by the AMA

AMA - ALBERTA DOCTORS’ DIGEST

MCLENNAN ROSS LLP

at the symposium, “… using our limited resources wisely is no longer an option, but instead an imperative to sustain (our) health care system.”

How best to achieve this?

One way to address the responsibilities that flow from physicians’ roles as stewards is to focus on practice patterns. The AMA has outlined a list of recommendations to promote the well-being of patients while “serving as prudent stewards of the shared societal resources with which they are entrusted.”3 These include: • Basing recommendations and decisions on patients’ medical needs.

• Helping patients articulate their health care goals and form realistic expectations regarding the relationship between those goals and available interventions.

• Choosing a course of action requiring fewer resources where alternatives (offering a similar likelihood of benefit) require more.

Picking up on this, the AMA is spearheading the Choosing Wisely campaign in Alberta, which focuses on the reduction of tests, treatments and procedures identified as being of low or no value for patient care.4

It is no secret that the Alberta

government is struggling to meet the needs of society in an economic downturn and is looking for cost-savings in virtually every area of service delivery, including health care.

Another way is to align payment systems with behavior that supports efficient and responsible use of resources.

Currently, Alberta’s payment system (as reflected in the AMA Agreement with Alberta Health) employs the largest proportional reliance on fee-for-service billings of any >

> province or territory in Canada. Fee-for-service systems, by definition, reward physicians for maximizing procedures and tests, and provide little incentive for “choices of action requiring fewer resources.” On the other hand, plans that provide for incentive-based payments such as capitation models, blended capitation models or Alternative Relationship Plans, can free physicians to place more reliance on other health care providers in the context of a team approach to the provision of health services.

Statistics show that through the choices

they make, physicians are directly or indirectly responsible for as much as 70% of overall health expenditures in Alberta.

Finally, a more robust and usable province-wide electronic medical record would facilitate the integration of health care delivery and provide efficiencies such as real-time test results, immediate access to patient history and greater control over utilization of diagnostics and pharmaceuticals.

Statistics show that through the choices they make, physicians are directly or indirectly responsible for as much as 70% of overall health care expenditures in Alberta.

Proper control over those expenditures through responsible stewardship of health care resources will go a long way toward meeting the goals laid out in the Choosing Wisely campaign and meeting physicians’ responsibilities, under their social contract with society.

References available upon request.

MARCH – APRIL 2016

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20

MIND YOUR OWN BUSINESS

Agenda item: Do you prefer death by meeting or effective collaboration?

Practice Management Program Staff

M

eetings are a business process that, if done well, can result in good governance. Whether it is a clinic team, physician management or a primary care network board meeting, running effective meetings are a key element to the success of an organization. Well run organizations use their meeting time to keep alignment to the strategy and goals, as well as the status of various initiatives and projects.

1. Have a clear purpose that is aligned to your strategy • Draft an agenda and be clear on the objectives of the meeting.

• Identify items on the agenda – is it for information only, solicit input or require a decision?

2. Be prepared • Distribute the agenda and accompanying meeting materials in advance to allow attendees to arrive prepared for informed discussion.

Have you stopped attending because meetings:

• Ensure the right people will be at the meeting for content expertise and decision-making.

• Are a waste of time?

• Expect that attendees arrive having read the meeting materials so that individuals are wellversed on the topic being discussed.

• Don’t have a clear purpose?

• Are derailed by off-topic conversations?

• Leave attendees confused about what was decided and who is responsible?

• Re-visit previous decisions again and again?

• Run on … and on … and on?

Does the word “meeting” fill your heart with dread?

You are not alone.

However, it doesn’t have to be that way. The best meetings are short and highly productive. Everyone contributes, everyone comes away knowing something they didn’t know going in and everyone is clear on what needs to happen next. There some basic principles and steps that you can take to ensure your meetings are productive and positive. These principles are applicable ranging from a relatively informal clinic staff meeting to a meeting of a board of directors. The appropriate degree of formality and rigor will vary; however, the underlying basic themes apply.

Keep in mind these principles when running your next meeting:

AMA - ALBERTA DOCTORS’ DIGEST

3. Know your role • Each meeting should have a chairperson responsible to keep the meeting on time, attendees on topic and ensure everyone has the opportunity to provide input in respectful discussion.

• Understand the role and authority of your committee/board to ensure you are making decisions that are at an appropriate level and within your mandate.

4. Adopt some meeting protocols • Communicate the process by which items are added to the agenda.

• Agree on voting protocols for decision-making, such as: majority, consensus, unanimity, minimum number of attendees, etc. In a formal board or committee setting, these will be defined in your Articles of Association or Terms of Reference.

• Commit to some basic meeting behavioral expectations and hold each other accountable.

These might include arriving on time, notifying the chairperson in advance if unable to attend, allowing others to speak uninterrupted and silencing mobile devices. A formal board or committee should have a Code of Conduct around these expectations. >

> 5. Focus on the key stuff • Monitor time throughout the agenda and adjust, if required, to ensure sufficient time for priority items. If necessary, poll members to either extend the meeting time or defer other items to the next meeting.

• For board or committee meetings, use a consent agenda for items that are routine and don’t usually require discussion so they can be approved in a single motion, preserving time for discussion of the key agenda items. Items may be pulled from the consent agenda for further discussion and separate approval on an exception basis.

6. Stay on topic and on time • Review the agenda and, if walk-on items are permitted, ask for any additions at the beginning of the meeting to allow agenda to be time-adjusted.

• Don’t revisit past decisions unless there is new information or new circumstances that require the decision to be reconsidered.

• Defer agenda items that require additional information or input to make an informed decision.

• Keep discussions relevant to agenda items by acknowledging and capturing issues that don’t fit within the agenda or are relevant only to a subset of attendees before they hijack the agenda.

Once captured, these issues might be added to a future agenda or followed up outside the meeting structure.

7. Document your decisions • It’s common for people to come away from the same meeting with very different interpretations of what went on. To reduce the risk, email the minutes of what was accomplished to all who attended as soon as possible after a meeting.

• Even if you are not a formal board or committee, use motions to vote. A motion requires a restatement of the final wording to ensure each member is clear on the decision. It’s easy to lose the specifics of the final decision or an amended motion after a lengthy discussion.

8. Ensure stuff gets done • Document action items from the meeting with a timeframe and who will be responsible for follow-up and completion.

• Ensure you have an established process to communicate decisions to relevant people outside the meeting.

• Review the status of previous action items each meeting to ensure items are followed up and don’t get lost.

9. Effective participation • If you have meetings in which some attendees participate remotely, consider options to include them.

• Videoconferences can be more effective than conference calls, provided that all attendees have a fast Internet connection and good equipment. In a videoconference, you can see how other people react. That can give you helpful information you wouldn’t get in a conference call.

• Conduct one-on-one videoconferences with Skype, Gmail, FaceTime and other services. There is no shortage of options.

Meetings are an important method of communicating information, generating discussion, decision-making and good governance. Implementing these principles greatly increases the odds that your meetings will be a positive and productive way for groups of people to work together.

Maybe, just maybe, the reputation of meetings can be redeemed.

Agenda example: Meeting name: ABC Medical Clinic budget meeting Meeting place, date and time: ABC Medical Clinic, May 2, 2016 from 7 p.m. – 9 p.m.

Attendees: Guests: Regrets: Recorder: Attachments/reading list: 1. Call to order: chair, (time) 2. Welcome and introductions: chair 3. Approval of any additions to meeting agenda: chair 4. Possible amendments and approval of previous meeting minutes: secretary/recorder and chair 5. Updates/reports, etc.: 6. Unfinished business: 7. New business: 8. Other business: a. typically brought up during the meeting as a brief memo/FYI tidbit 9. Next meeting date: 10. Adjourn: closing time

MARCH – APRIL 2016

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FEATURE Emerging Leaders in Health Promotion Grant program Connecting with Nature project brings psychological and physical benefits to kids Vanda Killeen, BA | SENIOR

COMMUNICATIONS CONSULTANT, AMA PUBLIC AFFAIRS

In its fifth year, the Emerging Leaders in Health Promotion (ELiHP) Grant program provides funding to help medical students and resident physicians conceive and implement health promotion projects in support of the development of their CanMEDS/FM core competencies, particularly health advocacy. Jointly sponsored by the Alberta Medical Association (AMA) Health Issues Council and the Canadian Medical Association, ELiHP projects facilitate the growth of leadership and advocacy skills in a mentored environment while enhancing the wellbeing of the general Alberta population through education, advocacy or community service. devices deprives children of the proven psychological and physical benefits of spending time in the great outdoors.

Venessa targeted an under-served population segment and created a unique, mentally and physically beneficial health experience for approximately 120 Calgary students.

“The goal of our health promotion project was to provide an opportunity for students, from an area of the city where there are barriers to accessing the outdoors, to experience nature in the mountains around Calgary,” explains Venessa.

Venessa Shaneman, Connecting with Nature project lead, with her project mentor and team. Front row left to right: Jenny Strong, Joey Quevillon, Venessa Shaneman, Dr. Joe C.F. Vipond; Back row left to right: John Van Tuyl, Charlotte Breakey

“I

believe that there is a subtle magnetism in Nature, which, if we unconsciously yield to it, will direct us aright.” – Henry David Thoreau

You would be hard-pressed to find anyone who would argue with Henry David Thoreau’s assessment of the undeniable allure and intrinsic value of nature; especially not third-year University of Calgary (U of C) medical student and Emerging Leaders in Health Promotion grant (ELiHP) recipient and project lead, Venessa Shaneman.

With her Connecting with Nature ELiHP project, Venessa sought to address an important health concern: According to a recent Statistics Canada finding, children self-report spending an average of six hours per weekday in front of a screen. This considerable time spent on

AMA - ALBERTA DOCTORS’ DIGEST

Five classes from higher-needs schools in Calgary day-hiked a beautiful route on Mount Yamnuska last May and October.

“Many students surveyed during the hike had never been to the mountains before, so this was an opportunity not just to spend time in nature,” comments Venessa, “but to learn about the opportunities for recreation that exist so close to home.”

Venessa’s project team included U of C medical students Charlie Breakey, Joey Quevillon, Jenny Strong and John Van Tuyl, as well as staff from the Canadian Parks and Wilderness Society’s (CPAWS) Southern Alberta Chapter.

“My fellow med students played a key role in implementing this project, as each participated in a hike and talked with the kids about the benefits of healthy living,” Venessa explains. “The staff at CPAWS was also >

> integral to the project’s success, as they connected me with schools with students that fit the demographic I was targeting. They also provided licensed hiking guides who helped align the hikes with the school curriculums and they collaborated with us to integrate the health promotion aspects of the hike.”

In order to develop the health promotion component of her ELiHP project, Venessa reviewed the Alberta Board of Education’s Grade seven and eight curriculums to ensure that the health promotion aspects were at an appropriate level for the students. She sought to strike a balance between encouraging quiet appreciation of the mountain surroundings and the students’ co-existence with nature, and actively engaging them in discussion.

The students and facilitators discussed facts about the natural environment, suggestions for other fun, healthy activities they could do outdoors and the many physical and psychological benefits of those activities.

Established in 2011, the Emerging Leaders in Health Promotion Grant program sponsors successful medical student and resident physician applicants in the conception and application of a health promotion project targeting the general Alberta population. The Alberta Medical Association's Health Issues Council and the Canadian Medical Association have committed funds to support this grant program.

As she considers the health promotion advocacy skills she and her colleagues acquired, Venessa comments, “It was our hope that by advocating for the benefits that come from spending time in nature, combined with sharing our love of the outdoors and providing the students with a fun-filled day outside, the students will consider pursuing activities like this in the future.”

Careful coordination of the logistics of the project with both CPAWS and teachers at the two Calgary schools – Ian Bazalgette and Clarence Sansom – required extensive managerial, collaborative and organizational skills on the part of Venessa and her fellow med students.

“This project was run during my clerkship year, which was a challenge.” Venessa recalls. “But we managed to coordinate things very effectively through various means and by utilizing our communication and management skills. It was also a great experience for developing our presentation and communication skills with a younger audience,” she adds.

Students on Venessa’s Connecting with Nature hike pause on their Mount Yamnuska route to enjoy the view.

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FEATURE Emerging Leaders in Health Promotion Grant program Lungs are for Life Smoking Prevention Program and Workshop Kit Vanda Killeen, BA | SENIOR

COMMUNICATIONS CONSULTANT, AMA PUBLIC AFFAIRS

In its fifth year, the Emerging Leaders in Health Promotion (ELiHP) Grant program provides funding to help medical students and resident physicians conceive and implement health promotion projects in support of the development of their CanMEDS/FM core competencies, particularly health advocacy. Jointly sponsored by the Alberta Medical Association (AMA) Health Issues Council and the Canadian Medical Association, ELiHP projects facilitate the growth of leadership and advocacy skills in a mentored environment while enhancing the wellbeing of the general Alberta population through education, advocacy or community service.

“In a pig’s eye!” No, “In a pig’s lung!”

A

s a result of her 2014-15 Emerging Leaders in Health Promotion (ELiHP) Grant project, second-year University of Calgary medical student Alicja Krol-Kennedy knows all about the power of a pig’s lungs, particularly as they served to demonstrate the effects of smoking as part of her Lungs are for Life Smoking Prevention Program and Workshop Kit.

On the basis of her chosen health promotion issue of tobacco use as one of the leading causes of preventable death in Canada1 and the fact that most smokers will begin smoking by the age of 192, Alicja set to work developing a curriculum-based smoking prevention program and workshop that would “build knowledge, health literacy and resilience for elementary students in grade four.”

From the outset, Alicja realized that in order to get teachers involved in and supportive of her prevention program and workshop, it was essential that the program align with school curriculum. In the initial planning and writing stages of her program, Alicja partnered with Ryan Kennedy, a Grade 4 teacher at St. Cecilia Catholic Elementary School in Calgary.

“In addition to being a unique collaboration of an elementary teacher and a medical student,” Alicja explains, “I involved teachers, my physician mentor (Dr. Ginette Leroux) and students in brainstorming, developing and editing the activities in the workshop kit.

It’s important to involve your target audience in program development so your product is meaningful to them.”

AMA - ALBERTA DOCTORS’ DIGEST

The objectives of Alicja’s self-guided program kit for teachers – comprising week-long lesson plans culminating in a pig’s lung workshop – were to “discuss the role and function of the lungs and the effects of cigarette ingredients on health; raise awareness of the health and social consequences of smoking by providing an engaging and interactive representation of smokerversus-non-smoker lungs; and engage students in discussions about the importance of smoking prevention and the dangers of second-hand smoke.”

Through her program’s pilot and final workshops, Alicja and a team of teachers, parent volunteers and her project mentor delivered the program to 59 St. Cecilia students.

The teachers also conducted classroom lessons in preparation for the pig’s lung workshops, which included stations intended to “engage students in a discussion about the social consequences of smoking, including the cost of smoking and health care implications.”

For instance, one station asked students to imagine their responses when placed in precarious, smoking-related situations while other stations “actively built resiliency, as students practiced advocating for their own health and the health of others in their family and community,” Alicja explains.

The highlight of the workshops and the element that “left the most lasting impression,” according to Alicja, was the lung demonstration. >

>

25

St. Cecilia grade 4 students Ocean Burland (left) and Daniela Maria Angel (right) are hands-on with a healthy pig’s lung.

Beauty and the beast: Alicja Krol-Kennedy, Lungs are for Life project lead, with a smoking-diseased pig’s lung.

“It was the very obvious physical differences between the non-smoking pig’s lung and the smoking pig’s lung that really intrigued the students,” says Alicja. “Like the changes in elasticity, colour and the mass in the smoker’s lung that resembled a cancerous tumour, complete with a chemical dye to replicate the effects of tobacco on lung tissue. It presented a fairly stark, authentic contrast.”

Reflecting on her ELiHP project and her role as a health promotion leader and advocate, Alicja comments: “Our reach as medical professionals extends beyond the walls of hospitals or clinics and into schools, communities and homes. As trusted sources of health information, we have the potential to change the health trajectory of youth by teaching them health literacy, arming them with the resilience needed to navigate health challenges in the future and the skills needed to advocate for their health.”

Alicja’s project evaluation showed that while many students did have some prior knowledge about smoking, their knowledge did increase. Post-program delivery, Alicja provided the Catholic District School Board Resource Centre with her Workshop Kit and pig’s lung station, for potential future delivery to grade four students in 106 Calgary schools.

Reference available upon request.

MARCH – APRIL 2016

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INSURANCE INSIGHTS

TD Meloche Monnex: New improvements for you!

TD lnsurance is the first company in Canada to offer one-stop-shop auto collision repairs.

I

dropping off the vehicle, getting the vehicle appraised and renting a vehicle. The collision center is located at 4700 1 Street SE, Calgary.

New online estimate compare tool

The site offers greater flexibility to customers by offering extended hours, Monday to Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 4 p.m.

n their ongoing effort to provide excellent service to physicians, TD Insurance Meloche Monnex is excited to share some of the following initiatives with Alberta Medical Association (AMA) members.

This new addition to the “get a quote” box on the AMA TD Insurance home page (melochemonnex.com/ama) enables customers and prospects who are currently shopping for vehicles to get a quick estimate on what their auto insurance would cost depending on the vehicle they purchase. The tool is available for desktop, tablet and via mobile-friendly website at tdinsurance.com.

Calgary one-stop-shop auto collision repairs TD Insurance is the first company in Canada to offer this type of service. This one-stop-shop allows TD Insurance customers to complete all the steps in the auto collision repair process all at one location, including: filing a claim,

AMA - ALBERTA DOCTORS’ DIGEST

TD Insurance mobile app TD Insurance is there when you need them. That's why the new TD Insurance app lets you file an auto claim, get a quote and speak directly with a customer service representative 24-hours-a-day, seven-days-a-week.

All AMA members benefit from a dedicated phone line (1.844.859.6566) This phone line offers a preferred level of customer service when calling for information on your policy (or to get a new policy or make changes to your existing one).

LETTERS

27

Re: “An Open Letter to the Chief Justice of Canada”

January-February, 2016 Alberta Doctors’ Digest

I

read Dr. Kevin Hay’s open letter to the Chief Justice of Canada with some interest, having carefully followed the progress of events following the release of the Supreme Court decision in Carter vs. Canada (Attorney General) since last February. While I understand Dr. Hay’s concerns regarding the handicapped and vulnerable patients (both young and old), I feel obliged to address his comment that the College of Physicians & Surgeons of Alberta’s (CPSA’s) position regarding mature minors being treated as adults “… goes significantly beyond the ruling … which limited physicianassisted suicide/dying (PAS/PAD) to those over 18 years of age.”

In fact, the Supreme Court limited the availability of PAS/PAD to “competent adults”, and made no comment on exactly what was intended by that phrase. The use of the word “adult” leaves many options available to the legislatures and regulatory bodies, including potentially accepting provincial ages of majority, or (as the CPSA is advocating) accepting that mature minors fit into this category as well.

The difficulty with simply accepting ages of majority in defining “adults” is that those ages vary from province-to-province (and territory) thus creating further inequalities in the application of the decision.

The other point I feel compelled to make relates to Dr. Hay’s concern that physicians may be mandated to refer patients for the purpose of obtaining PAS/ PAD. My understanding is that the CPSA accepts the Supreme Court’s direction that nothing in its declaration will compel a physician to provide assistance in dying. However, clearly in defining the scope of “assistance,” it must balance the right of a physician to refuse to participate based on religious or ethical principles against the right of the patient to obtain legally available treatment. My guess is, in seeking to achieve that balance, the patients’ rights will trump those of physicians.

Yours truly, Jonathan P. Rossall, QC, LLM Partner, McLennan Ross

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MARCH – APRIL 2016

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DR. GADGET

Are you consultation impaired?

Wesley D. Jackson, MD, CCFP, FCFP

I

purchased my Apple Watch soon after it was available (not a surprise to those who know me) and have worn it every day since. Like many of my generation, wearing a watch is second nature and replacing old technology with this new device was very natural for me. I appreciate the comfort of the watch as well as the increased functionality, including ready access to weather, activity progress, calendars, texts, emails, phone calls, reminders to stand and even my pulse rate. I also see the tremendous potential for this and other wearables available today.

I am not alone in recognizing this potential. The Ochsner Health System in Louisiana has partnered with Apple and Epic to launch a pilot program involving hundreds of people with hypertension (http://www.healthcareitnews.com/news/innovationpulse-apple-watch-action). Patients are given a watch that provides reminders to take medications, weigh themselves and check their blood pressure, and that data, in turn, is fed into their medical record.

The software sends alerts when it spots issues with a particular patient so Ochsner physicians can conduct an intervention and, ideally at least, avoid hospitalization or readmission. Ochsner is "seriously considering giving physicians the Watch," and is working with Apple and Epic to feed statistics into the device.

EpiWatch, a ResearchKit app for the Apple Watch, allows users with Apple’s first smartwatch to record seizures and test the wearable’s sensors to better understand epilepsy. The app and research study, developed by researchers at Johns Hopkins University School of Medicine, uses the Apple Watch and the paired iPhone to allow epileptics to monitor and manage their condition. It collects data from both sensors and manual input, before, during and after epileptic seizures.

AMA - ALBERTA DOCTORS’ DIGEST

Novartis has released an Apple Watch and Android Wear app, ViaOpta, providing turn-by-turn navigation for visually impaired. With millions of watches being sold, many other health initiatives are underway, painting a bright future for Apple Watch and other wearables.

However, the tremendous functionality of the watch could also be its biggest downfall. Not long ago, I was consulting with a patient about a very significant emotional concern, when the familiar tap-tap of an incoming text came to my wrist. This was followed in rapid succession by several other similar sensations, lasting several minutes. I later learned that I was included in a particularly interesting and thought provoking group text, generating multiple replies from the other members of the group. While I did not look at my watch during this emotionally charged interview, I wonder if I was able to give my patient the full attention they rightly deserved. Was I contributing to an impaired doctor-patient relationship?

As professionals, physicians need to

balance the benefits of advancing technology with the duty to “be in the moment” with their patients.

Bernard Desarnauts, co-founder of Wristly Thoughts, a self-proclaimed “Independent Voice of Apple Watch” surveyed his readers to determine how the Apple Watch was used (https://medium.com/ wristly-thoughts/seconds-at-a-time-e8762b223476#. j2q0db8du). He found that, on average, owners use their watches four-to-five times per hour or 60-80 times per day. He went on to ask what specific functions were used more and whether or not users would check their watch in meetings or social >

> situations. Only 9% of users surveyed would not refer to their watch upon receiving a notification, highlighting the natural tendency to respond to notifications on a wearable device. It is important to note that even before the age of smartwatches, checking your watch was a cue that could easily be interpreted as a sign of losing interest, or not being engaged. Our “connected world” may run the risk of creating a disconnect of meaningful interpersonal relationships.

Now back to my scenario. I understood the importance of not allowing any distraction to interfere with the emotionally charged atmosphere in the examining room, so I did not even glance at my pulsating wrist. However, I must admit that my full

participation in that consultation was diminished by my vibrating extremity. As professionals, physicians need to balance the benefits of advancing technology with the duty to “be in the moment” with their patients. How that balance is achieved needs to be determined by the individual. I have decided that I will turn off notifications entirely during my time in clinic and check my watch only when it will not interfere with important face-to-face human interactions.

As medical professionals, we can look forward to advances in technology that have the potential for improving patient care in many ways. We need to always stay grounded in the doctor–patient relationship to avoid being carried away in the exciting, exhilarating and inevitable tide of discovery.

And ... I still love my watch!

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FEATURE

In Flanders Fields

A leadership story of relentless artillery, lethal poisonous gas and a Canadian doctor/poet Dr. J. Robert Lampard

O

n November 11, 2015, I was privileged to read In Flanders Fields at the Remembrance Day service in Red Deer. Dr. John McCrae wrote it 100 years ago, on May 3, 1915, during the second battle of Ypres. That was 11 days after the first German chlorine gas attack on the French/Canadian sector of the Ypres salient. Were the two events related? Yes. Born in Guelph, Ontario on November 30, 1872, he entered the University of Toronto on a scholarship in 1888 at age 16. Because of his life-long asthma attacks, he taught for two years before entering medicine in 1894.

Dr. McCrae graduated in 1898 as a gold medalist and then followed his older brother Dr. Tom McCrae to Johns Hopkins under Dr. William Osler.

Following in his father’s footsteps, he enlisted in the Boer War in 1899 as a lieutenant in the artillery, not the medical corps. After his return he became a major in the militia, before retiring to focus on earning a British Fellowship (1904) and membership in the American Association of Physicians (1910).

A published poet since his high school days, McCrae befriended Dr. Andrew MacPhail in Montreal. They had a common interest in poetry and the themes of bereavement and sorrow. In 1919, MacPhail published a character assessment of McCrae entitled In Flanders Fields.

McCrae co-authored a textbook of pathology for students with McGill’s chief of pathology, Dr. George Adami in 1912. After revising the 2nd edition on July 29, 1914, McCrae headed to England, arriving two days after World War I was declared on August 4, 1914.

Returning to Canada on the SS Calgarian, McCrae immediately joined the first contingent being assembled at Valcartier, Quebec. Since he was 42, he could only get an appointment as the medical officer for the 1st Brigade of the Canadian Artillery.

Major McCrae’s unit transferred to France on March 1, 1915 and participated in the Battle of Neuve Chapelle on

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March 10, 1915. Almost hit by a sniper’s bullet, he learned to only evacuate the wounded at night.

Despite signing the Hague conventions (1899, 1907), the Germans began using tear gas bombs in January 1915. By March 10, they had positioned 900 kilograms of chlorine gas opposite the French colonials. They were next to the 1st Canadian Division at the northwest end of the 12-kilometer long Ypres salient. The Canadians held 4.5 kilometers of the line. On April 21, a heavy German bombardment began. With a favorable west-wind, 1,600 German technicians opened 5,730 cylinders of chlorine gas at 5 p.m. on April 22 along a 6.5-kilometer front.

The French colonial troops bolted as they faced the asphyxiating green-yellow gas cloud, taking 6,000 casualties. Surprised by the decimation, the Germans had few reserves to mount a major offensive.

That afternoon, lieutenant colonel G. Nasmith and captain (Dr.) Allan C. Rankin (the future University of Alberta Dean of Medicine) from the 5th Mobile Unit, were in Ypres and heard of the gas cloud. They drove into the salient at 6 p.m. to see it. At the 2nd Canadian Field Ambulance, they met pathologist captain Dr. William Boyd who had just been injured. He was to be replaced by captain Francis Scrimger. Nasmith and Rankin then walked another half-mile into the salient until they felt the irritation of the now 33-meter high dispersing cloud, to be certain it was chlorine. The next day, Nasmith reported their observations to field marshall Henry Rawlinson.

That night, McCrae’s artillery unit was repositioned behind the French/Canadian lines, to replace the 54 guns that had been lost. The Canadian infantry was ordered to close the hole in the line in a night attack and were partially successful. Darkness had saved the day.

In the morning, McCrae’s unit discovered there was still a mile-long hole in the allied line directly in front of them. No infantry would cover it for 36 hours. That left the German trenches only 300-400 meters away. It was a very anxious time. They expected to die. For the first three days and nights, there was not a 60-second pause >

> in the shelling, but the larks still sang in the fields. The shelling continued and remained so constant that over eight days, sleep was occasional and boots and clothes were never changed.

Dr. Scrimger, he sent it off to a second magazine, Punch.

They published it anonymously on December 8, 1915.

Dr. MacPhail recognized it, even without McCrae’s signature, and wrote him a congratulatory letter.

On the morning of April 24, the Germans released chlorine gas against the Canadian line. The 8th and 15th battalions suffered severe losses.

On June 2, 1915, McCrae was notified that he was being transferred to the #3 General Hospital (McGill), as the chief of medicine. For him it was not a happy move. “All the goddam doctors in the world will not win this bloody war.”

He was also promoted to lieutenant colonel. With surgeon Dr. Edward Archibald, he visited several Paris hospitals en route. A nurse who had known him in Montreal didn’t recognize him, saying he had aged 15 years.

The only gas protection, thought to be the idea of Dr. Scrimger, was to cover one’s mouth and nose with a urine-soaked cloth, or insert it into one’s mouth and breathe. Otherwise, there was “no place to run.” At one station alone, there were 440 respiratory cases awaiting triage. Up to 33% would die, a figure later reduced to 4% by wearing masks. Fortunately, poisonous gases were inaccurate in their delivery and direction at a specified time, limiting their use.

As the Canadians consolidated their position, Dr. Scrimger’s advanced dressing station was pinned down with 20 wounded men. He stayed with them, covering the severely injured battalion commander with his own body, until there was a lull in the shelling and they were evacuated. Scrimger received a Victoria Cross for his action, only one of two to be awarded to Canadian physicians in World War I. On April 25, the 1st Canadian Division was replaced

by British troops. They had suffered 6,000 casualties amongst their 10,000 troops. British commanders noted how “the Canadians had saved the day,” and came of age, defeating a European army in battle – a first for a colonial army.

As the sun rose on May 2, the Germans initiated another chlorine gas attack, this time against the British lines.

Tragedy struck that morning when McCrae’s friend, lieutenant Alexis Helmer was killed on his way to his battery. With no padre at hand, McCrae conducted the burial service.

Helmer’s death deeply affected McCrae, but also inspired him. Back at his first aid station, he was noted, between barrages, to be sitting on the back of the ambulance penning his thoughts and writing letters. McCrae viewed the carnage, the unilateral use of poisonous gas, the high rate of death and debility that followed, the lack of mask protection and the unremitting artillery barrage as “the most significant event since the birth of Christ.” He turned to his most powerful tool – his pen – and captured the mood of the moment. In 20 minutes he wrote his 15-line sonnet, In Flanders Fields.

McCrae’s artillery brigade withdrew the night of May 3 or 4, without losing any guns to the enemy. It was fully pulled back on May 9, ending “The 17 days of Hades.”

His artillery unit had lost half of its men, the highest such figure for an artillery unit in World War I. McCrae sent the poem to the Spectator. A short while later he noted, “the babe hath returned to its mother.”

With encouragement from his commanding officer and

Opening on August 8, McCrae was in charge of as many as 100 patients a day, while managing the medical service. By 1916, he was answering 30-40 consults a day. He developed pneumonia from his frequent asthma attacks and was hospitalized with pleurisy for 10 days.

Still, he chose to live in the Indian Raj donated tents, with temperatures down to -20°C. In Flanders Fields struck a chord on the allied side. Lines were extracted from it to support the Canadian Union government’s election in 1917 and its victory bond fundraising. The poem was widely used in the United States of America (USA) to encourage the USA to join the war. It did more for civilian morale than any other prose or poetry.

The weight of the war and the many stalemates, particularly those involving the Canadian troops, were telling on McCrae. He became increasingly subdued, moody and asthmatic. Archibald thought he had been shell-shocked.

On December 28, 1917, McCrae was offered and accepted the command of the #1 General Hospital. On January 5, 1918, he was considered for a position as a consultant to the British Army and a promotion to a full colonel. When Dr. J.M. Elder, the #3 General Hospital commanding officer came to tell him on January 23, he found McCrae unwell but well enough to accept the appointment. The next day, McCrae diagnosed his own pneumonia. His condition deteriorated rapidly, leading to a septicemia and meningitis on January 26. He died on January 28.

McCrae’s funeral was attended by everyone of note from general (Sir) Arthur Currie and artillery general E.W.B Morrison, to Dr. Harvey Cushing and the Harvard Unit.

One hundred hospital nurses came. A memorial service was held in Montreal, Quebec on February 14, 1918.

McCrae was many things: an outstanding clinician, a natural teacher, an academic with an encyclopedic knowledge, a raconteur with a repertoire of thousands of stories, a sensitive poet and a duty-bound soldier. A man of high principles and strong spiritual values, he loved life, until the war broke his heart.

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FEATURE The 2016 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 2016 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 31 medical students and has provided over $325,000 in awards. This year, two $12,500 awards will be bestowed to one recipient from the University of Alberta and one from the University of Calgary.

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

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

• Demonstrate a dedication to rural medicine in their undergraduate studies and work.

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Physicians can donate to support the scholarship and rural medicine Last year, 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 to thank all who donated. Your contributions enabled the continuation of this important scholarship. The section encourages you once again to consider making 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.

Apply by May 20 Visit the AMA’s website at www.albertadoctors.org/ tarrant to download the 2016 Tarrant Scholarship application form.

PFSP PERSPECTIVES

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To err is human Jared E. Bly, MD | ASSESSMENT

PHYSICIAN, PFSP

condition deteriorated. It was recognized after some time that the endotracheal tube was esophageal. Rectifying that did not improve his condition and he died the next day of overwhelming sepsis.

This disaster involved errors at several points along the way. Improvement would have to come at different levels – individual practitioners and pre-hospital personnel or maybe at the level of the hospital, ER or inpatient unit.

A case like this should get some attention from those involved in quality assurance. There could conceivably be a complaint from the family. Maybe the College of Physicians & Surgeons of Alberta would become involved. It might even get medico-legal attention.

We do many more things right than wrong. To err is human, so is to succeed.

I

t is interesting to think about mistakes. Not one's own, of course, but other people’s. Mistakes are certainly part of life – and part of medicine. Unfortunately, mistakes are a part of medicine that can often be traumatic and painful, or even a trigger for destruction of careers, relationships and lives.

Many of us find it painful to consider the mistakes, accidents, errors or mishaps we’ve been involved in.

Some thrive on it. The systematic study of human error has blossomed in the last 20 years, including in the popular press. If you would like some perspectives on why we humans continue to err, consider titles such as Mistakes Were Made (but not by me); Why We Make Mistakes; The Folly of Fools: The Logic of Deceit and Self-deception in Human Life; Leadership and Self-deception: Getting out of the Box and Why Everyone (else) is a Hypocrite.

Or consider this example. A five-week-old baby was brought to the emergency room (ER) in respiratory failure.

The parents had taken him a week earlier to a clinic for assessment of his fever and poor feeding. He was diagnosed with a respiratory tract infection and prescribed antibiotics. He worsened over the course of the week until the evening they called 911. He was intubated prior to arrival in the ER. Despite aggressive resuscitation, his

Strangely, there is no place for mistakes in modern medicine. Society has entrusted physicians with the burden of understanding and dealing with illness. Although it is often said that “doctors are only human,” technological wonders, the apparent precision of laboratory tests and innovations that present tangible images of illness have in fact created an expectation of perfection. Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error. Hospitals react to every error as an anomaly, for which the solution is to ferret out and blame an individual, with a promise that “it will never happen again.”

Many of us find it painful to consider the

mistakes, accidents, errors or mishaps we’ve been involved in. Some thrive on it.

Paradoxically, this approach has diverted attention from the kind of systematic improvements that could decrease errors. Many errors are built into existing routines and devices, setting up the unwitting physician and patient for disaster. And, although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims.1 >

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> Although errors, mistakes and adverse events get the lion’s share of attention, success is the much more common outcome. “Human error is neither as abundant nor as varied as its vast potential might suggest. Not only are errors much rarer than correct actions, they also tend to take a surprisingly limited number of forms, surprising, that is, when set against their possible variety."2 There’s an important point in there. We do many more things right than wrong. To err is human, so is to succeed.

Taking our humanity into account, here are some tactics to minimize blunders.

Patients, who have an understandable

need to consider their doctors infallible, have colluded with doctors to deny the existence of error.

accuracy are not directly correlated. Psychologists are as accurate as their secretaries at diagnoses. Professional golfers consistently overestimate how successful they will be. Overconfidence is common among professionals as it is in the general population.4 From mountain climbing tragedies, to airline crashes, to incorrect diagnoses, many errors have occurred because people continue believing in their success, even when all the signs point to another looming possibility.

A warning about hindsight bias According to author James Reason in Human Error, many accidents are foreseeable, at least in hindsight. “Being blessed with both uninvolvement and hindsight, it is a great temptation for retrospective observers to slip into a censorious frame of mind and to wonder at how these people could have been so blind, stupid, arrogant, ignorant or reckless. I strongly caution against adopting such a judgmental stance. No less than the accident-producing errors themselves, the apparent clarity of retrospection springs in part from the shortcomings of human cognition.”2 To err is human.

After the storm…

1. Situational awareness The Canadian Medical Protective Association (CMPA) offers a lot of specific advice on how to avoid mistakes – look at the vital signs, read the nurses’ notes, get enough sleep before a night shift, adequately supervise learners, recognize that the classic symptoms of aortic dissection can be misleading, etc. Situational awareness is a general skill in risk mitigation.

Situational awareness should be consciously practiced by: • Being alert to the condition of the patient.

• Switching to more analytical and critical thinking, when warranted.

• Thinking ahead and anticipating problems.3 2. Take care of your brain If you want to be at your best, whether it be in sport, academics or human interactions, you have to take care of yourself. Adequate sleep, a proper diet, sufficient exercise and face-to-face social interactions are all fuel for the more advanced neocortex. Lack of these stimulates a stress response and the more primitive limbic system pushing for more primitive responses (displays of aggression, wanton reproduction, unbridled appetites, etc.). Simple. Often overlooked.

3. Strive for humility Overconfidence is a major source of human error. It’s actually very natural to think we’re better at things than we really are. And it’s interesting that confidence and

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Maybe the discussion around prevention is too late for some. You’re suffering through the effects of a medical error or adverse outcome. There might have been an error or oversight on your part. There might be systemic problems that made the error almost inevitable. There were likely many factors beyond your control. In a recent discussion with a group of physicians about just this topic, all these situations were described. But the reaction was surprisingly similar – emotional turmoil, introspection, self-doubt and hurt.

George Washington, and many others, have encouraged moving on from the error. “To rectify past blunders is impossible, but we might profit by the experience of them.”

Profit by the experience Here are some tips to weathering the storm of a mistake or adverse event.

1. Recognize your part of it. Some physicians might be predisposed to “an exaggerated sense of responsibility.”5 Maybe our institutions demand it of us. Maybe our own obsessive-compulsiveness, desire to achieve or thirst for excellence push us to personally take all the responsibility for an error. As discussed above, it is not usually the case that accountability rests with one individual. “It is a very hard and troublesome thing to dispose of whole, half and quarter-mistakes; to sift them and assign the portion of truth to its proper place,” said Johann Wolfgang von Goethe. A hard thing, but necessary for our well-being. >

> 2. Recognize which part of you is involved. Is it lack of sleep? Maybe some rescheduling is in order. Is stress at home distracting you? Maybe some attention to that vital aspect of life is imperative. Is it your anxiety about a person or situation that gets in the way?

There are resources to help there, too. Regardless, comprehensive self-condemnation is likely not the most helpful response.

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3. Do what you can. Often a personal apology or explanation to a patient or their family will be all that’s needed. If clinical skills or knowledge need honing or refreshing, there are conferences, textbooks, journals or online resources to guide you. You might not be able to clean the whole house of medicine, but you can tidy your corner of it.

The CMPA, hospital chief of staff or department head should be involved if the event is serious or involves multiple departments, individuals, disciplines or processes.

4. Talk to someone. Maybe it’s an understanding colleague. Maybe it’s a friend or family member outside of medicine. Maybe it’s a professional counsellor accessed through PFSP.

Although errors, mistakes and adverse

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events get the lion’s share of attention, success is the much more common outcome.

Errors will occur. If we recognize the predictability of human error, we can create safer environments on individual and systemic levels to examine errors and improve because of them.

According to Elbert Hubbard in The American Bible, “To make mistakes is human, but to profit from them is divine”.

Recommended reading: • PFSP publications, especially see Transcend Adversity by Nancy Love. https://www.albertadoctors.org/services/ physicians/pfsp/resources • The Resilient Physician. Effective emotional management for doctors and their medical organizations. AMA Press.

2002.

References available upon request.

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RESIDENTS’ PAGE

Alberta’s resident physicians: Future leaders in health care Submitted by the Professional Association of Resident Physicians of Alberta

W

hat does it mean to be a leader in health care? By including “leader” as one of the CanMEDS roles, what is being implied? How do resident physicians become leaders?

These questions form part of the framework that the Professional Association of Resident Physicians of Alberta (PARA) uses to assist in the development of future leaders in health care. While some might believe that leaders are born, PARA believes that leadership is developed and strengthened through experience. PARA strives to provide opportunities for leadership development.

Through their involvement with PARA, resident physicians gain valuable leadership experience and training.

Volunteering with PARA creates opportunities to network with colleagues and other health professionals, connect with the community they serve, advocate on behalf of all Albertans, and advocate on behalf of themselves and their colleagues.

Networking By volunteering to be PARA ambassadors, resident physicians are provided with opportunities to meet and develop relationships with other physicians and other health professionals. They are exposed to the trends and best practices in the profession and they are encouraged to provide input into the future of health care. Being a PARA ambassador allows resident physicians to experience the issues facing the broader health care system, moving them beyond the world of residency training.

Involved in our communities The PARAdime Campaign is PARA’s flagship annual community wellness initiative that provides support to some of Alberta’s most vulnerable. Collection bins are set up in several hospitals across Alberta where resident physicians and other allied health care workers are encouraged to drop off donations of new and gently

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used clothing, and other items most needed by partner agencies. During Resident Awareness Week, donations collected are delivered by resident physicians to local shelters and agencies.

PARAdime is an opportunity to increase resident physician awareness of the challenges faced by some of their neighbors. It is also an opportunity to engage other allied health care workers in providing basic necessities that will improve the health of some of those at risk.

While some might believe

that leaders are born, PARA believes that leadership is developed and strengthened through experience.

Advocating for Albertans Each year, resident physicians participate in Resident Physicians in the Legislature Day. During face-to-face meetings with elected representatives and senior government officials, resident physicians share their perspectives on issues relevant to health care delivery in Alberta. This continuing advocacy event provides resident physicians with an opportunity to foster strategic relationships and positively impact health care policy in Alberta and gain experience in CanMEDS roles of health advocate and communicator.

On November 16, 2015, a group of resident physicians met with 15 Members of the Legislative Assembly (MLAs), including a meeting with the minister of health. This year’s theme was seniors’ health care and our specific ask was that Alberta’s resident physicians be included in policy decisions related to developing a sustainable seniors’ care strategy in Alberta. As frontline health care workers, we experience first-hand the impact of the current seniors' care strategy on acute care delivery for all Albertans. >

> Our message and ask was well received by all MLAs and we look forward to carrying this advocacy effort forward.

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Supporting resident physician wellness Society – notably patients – are placing increasing emphasis on the importance of physician wellness being essential to effective health care. Resident physicians are no exception, but they are also in the challenging position of being both learners and front-line care providers.

Initiatives such as Resident Physician Wellness Week held the third week in May encourages resident physician wellness and recognizes resident physicians for the work they do.

The third week of February marked Resident Physician Awareness Week. It celebrated the critical role resident physicians play as frontline health care providers. They are passionate about patient care, healthy working and learning conditions and, assisting in shaping the future of health care delivery in Alberta.

Resident physicians will indeed be some of the future leaders of health care. Part of PARA’s mission is to empower resident physicians to be passionately engaged in being part of the solution – a continuously improving health care system. The health of all Albertans is at stake.

The PARAdime Campaign is PARA's flagship annual community wellness initiative that provides support to some of Alberta's most vulnerable.

The Professional Association of Resident Physicians of Alberta (PARA) is the voice of the more than 1,600 resident physicians providing round-the-clock medical care to Albertans in acute care hospitals and outpatient facilities. PARA advocates excellence in education and patient care while striving to achieve optimal working conditions and personal well-being for all its members. For more information: www.para-ab.ca.

PHYSICIAN(S) REQUIRED FT/PT Also locums required

ALL-WELL PRIMARY CARE CENTRES MILLWOODS EDMONTON Phone: Clinic Manager (780) 953-6733

Dr. Paul Arnold (780) 970-2070

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IN A DIFFERENT VEIN

Of managers and leaders: Too often missing the boat Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

Editor’s note: This story about leadership was written by Dr. Paterson 10 years ago and is still very relevant today. As a special treat, we pulled the story out of our Alberta Doctors’ Digest archives and did some light editing. Enjoy!

I

have just returned from a truncated sailing holiday on the Maine coast. First day on our boat, a 47-foot Jeanneau sloop, we were motoring out of Portland Harbor into the busy shipping lane when the engine gave a sickening, this-is-really-serious, clunk.

The skipper, plus one experienced crew and three inexperienced guests, were left bobbing on the ocean in a 12-knot breeze. A good manager with average sailing knowledge would have assessed the available skills, held a brief discussion and called for help and a tow. This skipper decided otherwise.

“The breeze is from the southwest. I’ve done this before.

We’ll sail her back into the slip.” And we did, beating up the main channel, shortening sail, turning to port into the marina on a beam reach, furling in all sails, stepping onto the wharf and cleating the bow line with the breeze snugging us in for a perfect port-side tie.

That was what a leader, our skipper, dear master mariner Ed did – a rapid assessment of our predicament and the crew’s capabilities, a brief explanation for his decision, followed by calm, confident orders.

Our elation at executing this maneuver was quickly squelched by discovering the cause of the engine failure.

No, it was not a line from the boat or a lobster pot around the propeller.

One of the crew had opened a slat in the aft cabin next to the engine and stowed a canvas bag there. This had caught in the gear cable, which had severed at the connection to the transmission.

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Cable, kit and caboodle, was tightly wrapped around the driveshaft. The entire shaft from transmission box to the now-leaking stuffing gland was wrapped in canvas, knickers, socks and running shoes. I spent the rest of the week with Allen wrenches, transmission and stuffing boxes.

Management is often confused

with leadership.

I got to thinking about leadership and the difference between leaders and managers.

Colin Powell, when working the “leadership seminar” circuit, said: “Leadership is the art of accomplishing more than the science of management says is possible ... tolerate rebels who tell the emperor he has no clothes.

Leadership is not a rank, privilege, title or money. It is responsibility for results.”

Powell’s idea of leadership demands enunciating a clear position. His view, I fear, is required for leadership in dangerous times.

Management is often confused with leadership. I have received invitations to attend “leadership sessions” in the organization where I practice. Few of the frontline clinical staff go to these meetings. They engender a cynical shake of the head and a rolling of the eyes.

When I’ve gone to these sessions in the past, there has been much grand talk about visions, missions, teamwork, excellence and other abstractions with a “facilitator” comfortably perched on the end of a table, rising from time-to-time to scratch on a flip chart that reads “patient care fragmented” or “we believe in cooperation and respect.” >

> By day’s end, the walls of the room are covered in paper with black and red scribbles. If I was asked what was said, I’d have some difficulty providing an answer – not because of poor memory but because there was little worthy of recall.

Sometimes there has been a hidden agenda in these sessions. In the ‘90s, there was the introduction of Total Quality Improvement, or TQI, as it chummily became known to the believers with its “quality circles” and anonymous “complaints and suggestions” boxes.

Many fine and efficient managers work in our clinics and

hospitals but they are not leaders. It seems evident to me that leaders are born and no leadership courses will change that.

These sessions often resulted in TIP, or Total Institutional Paranoia, and largely benefited the purveyors of this management gimcrackery but did little for quality patient care.

Next was Continuous Quality Improvement, or CQI, which was an attempt to keep the silly boondoggle going.

In the late ‘90s – most ghastly – was the “restructuring and accountability” movement: old mutton dressed as lamb, which appears in times of fiscal cutbacks, with reviews and reports often to people with little understanding of the background problems.

We tried to fight this bureaucratic assault by gambits such as resurrecting the (probably fake) quotation of the Roman Centurion, Caius Petronius Arbiter. “We trained hard, but it seemed that every time we began to form effective units we would be reorganized. I was to

learn later in life that we tend to meet any new situation by reorganization; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralization.”

None of the above exercises inspired. The companies organizing them worked to a formula and had their own agenda – profit.

Genuine inspiration regarding patient care must come from within – from the frontline clinicians. It is they who have the knowledge and confidence to inspire and form the “effective units” of Petronius Arbiter. This seems to be lost on those who seek to “increase efficiency.”

So what really is leadership? I was speaking to a hospital administrator in Edmonton some years ago. He was chuckling about how, in the old days, it was thought that leaders were born. “Of course,” he said, “that is not so. It is merely a matter of doing the right leadership courses.”

I disagreed at the time and still disagree. What he was failing to see was the difference between a leader and a manager.

Many fine and efficient managers work in our clinics and hospitals but they are not leaders. It seems evident to me that leaders are born and no leadership courses will change that. Certainly management can be taught.

Leadership has as many aspects as a Hindu goddess, and times and circumstances determine whether the leader is good or bad. A good leader is the right person at the right time who embodies action that educated, reasonable people recognize is required.

A leader’s tenure may be as short as it takes to sail a crippled boat back into a busy harbor, or as long as it takes to achieve a civil or human right. He or she has profound knowledge of his or her field and is able to inspire with ideas, expressing them clearly so that all may understand. Leaders should have the characteristics enumerated above by Colin Powell, but also be as inclusive as possible without becoming fence-sitters.

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CLASSIFIED ADVERTISEMENTS

LOCUM WANTED EDMONTON AB I am looking for a short-term obstetrics/gynecology locum for my obstetrics/gynecology practice from June 20 to June 30. We are associated with a tertiary care hospital in Edmonton and a free apartment is available during this time.

Contact: Dr. Chris Hoskins T 780.945.0518

PHYSICIAN WANTED CALGARY AB Pain specialist Dr. Neville Reddy is looking to recruit physicians (general practitioners and specialists) to join his team of dedicated health care professionals. Innovations Health Clinic has two locations (southeast and southwest), favorable 30% expenses offered.

Contact: Dr. Neville Reddy, MB ChB, FRCPC (Anesthesia) T 403.240.4259 C 403.689.4259 nreddy@innovationshealth.ca innovationshealth.ca EDMONTON AB Wanted – a general pediatrician to assume take over or join a large solo practice in southwest Edmonton; must speak Punjabi or Hindi.

Contact: T 587.521.9847 sunil.sunono@gmail.com EDMONTON AB To meet the growing need, we have a practice opportunity for gynecologists to join the Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC).

The PMC and MMMC are in south Edmonton and have high patient volume. You will enjoy working in a modern environment with complete AMA - ALBERTA DOCTORS’ DIGEST

electronic medical records, gynecology equipment, supplies and sterilizer.

There are a minimum of two examination rooms per physician, dedicated work/private office for physicians. Friendly and reliable staff for billing, referrals, etc., and onsite manager. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatrics).Both clinics have a pharmacy onsite, ECG machine and lung function testing.

Overhead is negotiable, flexible working hours and both clinics are open seven-days-a-week.

Terms of employment and wages: this position is permanent, part-time/ full-time fee-for-service with anticipated annual income of more than $300,000.

Anticipated start date is as soon as possible.

Contact: Harjit Toor Parsons Medical Centre 105-625 Parsons Rd Edmonton AB T6X 0N9 T 587.754.5600 manager@parsonsmedicalcentre.ca EDMONTON AB Villa Caritas, Edmonton’s acute psychogeriatric hospital, 16515 88 Avenue in Edmonton, is recruiting a general practitioner to share the general medical care of 150 patients.

This is a minimum 0.4 position to start on April 1. Remuneration is fee-for-service.

Contact: Medical Director Villa Caritas 16515 88 Avenue Edmonton AB T5R 0A4 sandra.demaries@covenanthealth.ca EDMONTON AB Family physician, pediatrician or internal medicine specialist needed part- or full-time for well-established south side practice. Stable patient population for more than 40 years, new and modern office with dedicated staff. Pharmacy and medicentre in

the same mall location. Excellent opportunity for all types of practice.

Contact: T 780.435.3648 (doctor line only) F 780.435.3691 EDMONTON AB Two positions are immediately available at the West End Medical Clinic/M. Gaas Professional Corporation at unit M7, 9509 156 Street, Edmonton AB T5P 4J5. We are also looking for specialists; internist, pediatrician, gynecologist and orthopedic surgeon to join our busy clinic. Full-time family physician/ general practitioner positions are available. The physician who will join us at this busy clinic will provide family practice care to a large population of patients in the west end and provide care to patients of different age groups including pediatric, geriatric, antenatal and prenatal care.

Physician income will be based on fee-for-service payment and the overhead fees are negotiable. The physician must be licensed and eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA), their qualifications and experience must comply with the CPSA licensure requirements and guidelines. We offer flexible work schedules, so the physician can adopt his/her work schedule. We also will pay up to $5,000 to the physician for moving and relocation costs.

Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 F 780.756.3301 westendmedicalclinic@gmail.com EDMONTON AB Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC) want you. To meet the growing needs, we have a practice opportunity for family physicians at PMC and MMMC. Both clinics are in south Edmonton. PMC and MMMC >

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are high-patient volume clinics with friendly reliable staff for billing, referrals, etc., as well as an on-site manager. Enjoy working in a modern environment with full electronic medical records. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatric).

Both clinics have on-site pharmacy, ECG machine, lung function testing and offer a large array of specialist services including: ENT, endocrinologist, general surgeon, internist, orthopedic surgeon, pediatrician and respirologist.

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

Contact: Harjit Toor T 587.754.5600 F 587.754.8822 manager@parsonsmedicalcentre.ca

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

Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton. Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray.

The physician must be licensed or eligible to apply for licensure 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 are a member of a primary care network.

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

Full-time chronic disease management nurse to care for chronic 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 RED DEER AB Family practice has an immediate opening for a physician or part-time physicians. Clinic has TELUS Med Access electronic medical records, primary care network support, varied patient population with everyday patients phoning looking for a family physician. Potential for increased income from hospital privileges, optional obstetrics, hospitalist work, operating room assisting, long-term care and hospice.

Red Deer provides fantastic specialist support. We are not a walk-in clinic and we strive to provide same day appointments. Red Deer is a thriving community with great recreational and educational opportunities.

Contact: Parkland Medical Clinic T 403.346.4206 Dr. L. Ligate lora.l@shaw.ca or Dr. B. Benson blben@shaw.ca SHERWOOD PARK AB Synergy Medical Clinic is seeking the services of a physician interested in accepting new patients and taking patients for a physician retiring early this year. The successful candidate must commit to building a patient panel and providing on-going comprehensive care to his/her cohort of patients.

The clinic is located in Sherwood Park at the Synergy Wellness Centre and is part of the Sherwood Park-Strathcona County Primary Care Network. We offer physicians a collegial and collaborative environment where one can provide care to a wide range of patients. Physicians are supported by a tremendous team and the clinic uses the Wolf electronic medical records for enhanced patient care.

Physician compensation is based on fee-for-service payment. The interested physician must be licensed and eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA), their qualifications and experience must comply with the CPSA licensure requirements and guidelines.

Relocation reimbursement is available for interested out-of-province physicians.

Contact: Mel Snihurowych Chief Administrative Officer T 780.400.3303 msnihurowych@synergymedicalclinic.ca www.synergymedical.ca

PHYSICIAN AND/OR LOCUM WANTED SHERWOOD PARK AB The Sherwood Park Primary Care Network is looking for several physicians to cover a variety of locum periods in a variety of Sherwood Park offices. Practice hours vary widely.

Majority of practices run electronic medical records. Fee splits are negotiated with practice owners. Some practices are looking for permanent associates.

Contact: Dave Ludwick T 780.410.8001 davel@sherwoodparkpcn.com >

MARCH – APRIL 2016

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> SHERWOOD PARK AB Dr. Patti Farrell & Associates is a new, busy, modern family practice clinic with electronic medical records and require locum coverage periods throughout 2016. Fee split is negotiable. Current clinic hours are Monday to Friday 8 a.m. to 4 p.m. are negotiable. Dr. Farrell is a lone practitioner (efficient clinic design built for two doctors) looking for a permanent clinic associate.

Contact: C 780.499.8388 terrypurich@me.com

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 turnkey construction management available.

Contact: NorthWest Healthcare Properties Lindsay Hills, Leasing Manager, Calgary T 403.282.9838, ext. 3301 lindsay.hills@nwhreit.com Shelly Fedorak, Leasing Manager, Edmonton T 780.293.9348 shelly.fedorak@nwhreit.com OKOTOKS AB Exceptional opportunity for individual medical doctors or a medical group.

New medical building planned in the fast-growing community of Okotoks.

16,000 sq. ft. multi-disciplinary medical building site near Costco with quick access off Highway 7 to Calgary, High River and Turner Valley.

Contact: Dr. Paul Hicke T 403.472.1351 www.southbankmedical.com

complete with a boat launch and a private buoy where you can see your boat at all times.

This beautiful new home offers three bedrooms, two bathrooms and a large deck overlooking miles of lake, as well as a lovely pond area to enjoy some shade or your morning coffee.

The home has floor to ceiling windows capturing every view of the sparkling lake.

The master suite offers privacy and is beautifully appointed with two large closets, luxurious stone bathtub with a separate large shower. There are many places to relax both outside and inside of this light-filled home. Kitchen is fully stocked and has high-end appliances. No detail has been left out from the mid-century mix of furniture to the expensive linens on every super-comfortable bed.

A short walking distance will take you to the Okanagan Museum and a cafe. A short hike will take you to three wineries. Hiking and biking are popular activities and we have nearly 10 kilometers of lake side trails.

The Kelowna International Airport is 12-15 minutes from this lovely modern home.

A short drive will take you to galleries, culinary experiences and night life.

Come and join us and experience the beauty of the area. I promise you will want to come again as many of our guests return every year.

You will be greeted upon arrival with your choice of red or white wine produced by one of our local wineries.

No detail has been overlooked making it a great get-away for families or couples. This spectacular home offers jaw dropping views year round.

If you are planning a winter ski retreat, let us know and we will see if we can accommodate you.

Contact: june.gagnon1@gmail.com For additional information, booking and pictures of the home and area

VACATION RENTAL

COURSES

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From sun rise to the glorious setting of the sun over Okanagan Lake, you will view the breathtaking beauty this area offers.

Imagine being steps from the beach,

AMA - ALBERTA DOCTORS’ DIGEST

WEST COAST WAYFARER June 13-19 Focus: Internal medicine and infectious diseases Ship: Crystal Serenity BALTIC AND NORTHERN CAPITALS June 19-July 1 Focus: Cardiology, neurology and gastroenterology Ship: Celebrity Silhouette GREECE AND TURKEY July 9-16 Focus: ER medicine: Novice to expert Ship: Celebrity Equinox ICELAND AND NORWAY July 16-28 Focus: Neurology, cardiology and psychiatry Ship: Holland America Zuiderdam MEDITERRANEAN August 7-21 Focus: Psychiatry and endocrinology Ship: Navigator of the Seas September 24-October 8 Focus: Guide to healthy heart living Ship: Celebrity Silhouette ALASKA GLACIERS August 14-21 Focus: Renaissance in primary care Ship: Celebrity Infinity JAPAN AND KOREA September 18-29 Focus: Endocrinology and dermatology Ship: Celebrity Millennium HAWAII October 15-22 Focus: Family medicine (University at Sea) Ship: NCL Pride of America DUBAI AND UNITED ARAB EMIRATES October 24-November 3 Focus: Exploring the world of medicine Ship: Azamara Journey TRANS-ATLANTIC BARCELONA TO BARBADOS November 5-21 Focus: Mental health in the workplace Ship: Silver Spirit BAHAMAS SANDALS RESORT November 6-13 Focus: Bringing best evidence to MDs Resort: Emerald Bay, Exuma Island >

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TAHITI AND MARQUESAS November 19-December 3 Focus: Endocrinology and dermatology Ship: Paul Gauguin

SERVICES

SOUTHERN CARIBBEAN December 21-January 2, 2017 Focus: Clinical pearls in primary care Ship: Celebrity Eclipse

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.

SOUTH AMERICA January 22-February 5, 2017 Focus: 4th Annual McGill CME Conference Ship: Celebrity Infinity AUSTRALIA AND NEW ZEALAND February 5-17, 2017 Focus: Optimizing patient care Ship: Celebrity Solstice BAHA AND SEA OF CORTEZ February 9-21, 2017 Focus: CME with BC Medical Journal Ship: Azamara Quest BALI TO SINGAPORE: MALAY ARCHIPELAGO February 23-March 7, 2017 Focus: Hot topics in medicine Ship: Crystal Symphony EASTERN CARIBBEAN March 12-19, 2017 Focus: Gastroenterology update 2017 Ship: Holland America: New Amsterdam RHINE AND DANUBE RIVER September 1-16, 2017 Focus: Clinical update in medicine Ship: Avalon Illuminations JAPANESE EXPLORER September 24-October 5, 2017 Focus: Save the date – topic coming soon!

Ship: Celebrity Millennium TUAMOTUS AND SOCIETY ISLANDS TAHITI October 18-28, 2017 Focus: Save the date – topic coming soon!

Ship: Paul Gauguin

ACCOUNTING AND CONSULTING SERVICES

Contact: N. Ali Amiri, MBA Consultant Seek Value Inc. T 780.909.0900 aamiri.mba1999@ivey.ca aliamiri@telus.net DOCUDAVIT MEDICAL SOLUTIONS Retiring, moving or closing your practice? Physician’s estate?

DOCUdavit Medical Solutions provides free paper or electronic patient record storage with no hidden costs. We also provide great rates for closing specialists.

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

Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com E TRANSCRIPTION SERVICES E Transcription Services allow hospitals, clinics and specialist to outsource a critical business process, reduce costs and improve the quality of medical documentation. By outsourcing transcription work, you will be able to increase the focus on core business activities and patient care.

Our goal is to exceed your expectation.

Call for a free trial.

GLOBAL MEDICS CANADA Global Medics Canada have been successfully placing family physicians in roles across Canada for the last six years and are currently working with many Canadian and CFPC eligible physicians from the United Kingdom, Ireland and Australia looking for short, medium, long term and permanent roles in Alberta. Company and service overview plus many fantastic references available on request. We can help you recruit the perfect family physician for your clinic in the most efficient and hassle free way possible.

No money is due upfront and no exclusivity is required. Our placement fee is only payable once the (recruited) physician has arrived and started work for you. If you’re interested or just keen for further information, please contact us.

Contact: Phil Martin Business Manager T 250.307.4352 phil@globalmedics.com

DISPLAY OR CLASSIFIED ADS 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

Contact: TF 1.877.887.3186 www.etranscription.ca

PATAGONIA November 25-December 2, 2017 Focus: Adventures in medicine 2017 Ship: Stella Australis For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com MARCH – APRIL 2016

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For more information on AMA dr2dr Secure Messaging, visit https://www.albertadoctors.org/leaders-partners/ama-dr2dr-secure-messaging Email info@dr2dr.ca