Alberta Doctors' Digest May/June 2014 by Alberta Medical Association

Alberta Doctors'

DIGEST May-June 2014 | Volume 39 | Number 3

What do yoga and financial management have to do with being a good doctor? Medical students find out

Physician disruptive behavior What it is and how you can address it constructively

Build a panel, build a medical home Guide to Panel Identification shows you how

We said what?

AMA tracker survey measures your opinions

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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

4 From the Editor 8 Health Law Update 12 Mind Your Own Business 18 Residents' Page

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Editor-in-Chief: Marvin Polis President: Allan S. Garbutt, PhD, MD, CCFP President-Elect: Richard G.R. Johnston, MD, MBA, FRCPC Immediate Past President: R. Michael Giuffre, MD, MBA, FRCP, FRCPC, FACC, FAAC 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 July-August issue deadline: June 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. 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. © 2014 by the Alberta Medical Association Design by Backstreet Communications

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

22 Dr. Gadget 24 PFSP Perspectives 32 In a Different Vein 35 Classified Advertisements

FEATURES 6 What do yoga and financial management have to do with being a good doctor? Medical students find out. 10 Physician disruptive behavior What it is and how you can address it constructively. 14 Build a panel, build a medical home Guide to Panel Identification shows you how. 16 A brief history of our profession and the Alberta government

It is unusual for a historian to venture into the present, let alone contemplate the future.

20 Know some outstanding rural colleagues? Here’s how to recognize them.

Students, patients, staff and colleagues now have a new way to show their appreciation for their rural physician educators, or preceptors.

27 We said what?

Alberta Medical Association (AMA) tracker survey measures your opinions.

3 1 What's new online?

Interim electronic medical record (EMR) Advisory Service, new Billing Corner, mid-year update on the AMA’s Business Plan and Get connected! Cover Photo:

Isabelle Colmers was part of the planning team responsible for a fantastic medical student conference in Banff. Find out more on page 6. ( provided by Marvin Polis)

More WAYS TO GET ALBERTA DOCTORS’ DIGEST We’re using QR codes to enhance your experience. Scanning this code will take you to the Alberta Doctors' Digest page on the AMA website including pdf and ebook versions. There are also QR codes embedded in a few articles in this magazine issue. Scan the codes using your smartphone or tablet device to go to the alternate content. If you don’t have a QR code reader app on your phone or tablet, download one for free from www.scanlife.com.

May - June 2014

From the Editor

Our age of anxiety Dennis W. Jirsch, MD, PhD | Editor

r. Lewis Thomas, author of The Lives of a Cell1 and The Medusa and the Snail2 said, “Worrying is the most natural and spontaneous of all human functions. It is time to acknowledge this, perhaps even to learn to do it better.”2 And worry we do: money, health, bioterrorism, nuclear fallout, spreading waistlines, fallen arches, Alzheimer’s, vague pains, climate change … you name it, the list goes on. W.H. Auden, in his 1947 book-length poem The Age of Anxiety3 coined a phrase so compellingly apt that it has endured. Mr. Auden was carrying on the work of Danish philosopher Soren Kierkegaard in the preceding century who felt anxiety represented the “dizziness of freedom”4 and was a stage on the road to one’s recognition of sin and the road to faith. Numerous theologians have, in fact, long regarded anxiety as a manifestation of man’s guilt with respect to Adam’s disobedience and so-called Original Sin. Other disciplines have their own explanations. Sociologists, for instance, reckon our worry is a reaction to the stress and the uncertainty of modern life, while existentialists regard anxiety as the price of making decisions that are relative, never absolute and made with imperfect knowledge. Sigmund Freud, of course, considered anxiety as central to the human condition with life characterized by psychic conflict and anxiety the symptom of that conflict. Others have lately leaped into the fray, with neuroanatomists and physiologists and their f-MRIs telling of wonky amygdalae or hippocampi, or other strange tracts and places. With recent discovery of the catechol-O-methyl transferase (COMT) gene5 geneticists have gotten into the act, too. The COMT gene, originally called the “Woody Allen gene” by Harvard researchers, comes in two variants with one responsible for enzymes that decay neurotransmitter dopamine slowly, the other rapidly. It’s been called “the worrier-warrior gene.”

AMA - Alberta Doctors’ Digest

Our notions about anxiety would

seem to be in a confused state and it would seem to be difficult to add to it with benefit.

Big pharma is in on things in an enormous way.6 Years ago the muscle relaxant Mephenesin was sold as Miltown, an anxiolytic that became the first pharmaceutical blockbuster, spawning Equanil and followed in the 1960s by Librium and Valium. Montreal researcher Hans Selye developed the notion of environmental and other “stressors”7 that have the potential to hurt us. The stage was set for the amine theory of depression that has led to Prozac and other SSRIs and burgeoning psychopharmacology that saw, for instance, 50 million prescriptions for Xanax in the United States of America in 2012. Drugs quite aside, a host of therapies are proposed for anxiety. These range from yoga, meditation and warm baths to cookbook-style manuals urging us simplistically to worry less, consider others, to keep moving and involved – along with quite a bit of mumbo jumbo regarding crystals, pyramids, life forces and so on. Our notions about anxiety would seem to be in a confused state and it would seem to be difficult to add to it with benefit. But Scott Stossel, successful journalist and editor of The Atlantic has brought some clarity to this imbroglio in a poignant, personal memoir. His recent book, My Age of Anxiety,8 also published in The Atlantic as Surviving Anxiety,9 provides a good window on the history of our concern with anxiety and the limitations of current therapies. Mr. Stossel chronicles a lifetime plagued with terrible worry. As a child he suffered debilitating separation anxiety and grew up with a slew of phobias that included public speaking, air travel, heights and germs, as well as full-blown panic attacks accompanied by sweating, vertigo, insomnia, stomach pains and even loss of bowel control. >

> In life-long therapy, Mr. Stossel tried everything from psychotherapy to yoga, including a pharmacopeia of licit and illicit medications that has certainly included alcohol. He’s found no complete answers. The redeeming part of Mr. Stossel’s account has to be that in spite of his ailment, he’s gone on to lead a successful magazine, and although there’s been no cure for his condition, he’s come to a more comfortable, even optimistic, coexistence with it. As Mr. Stossel puts it:9 “I do know that some of the things for which I am most thankful – the opportunity to help lead a respected magazine, a place however peripheral in shaping public debate; a peripatetic and curious sensibility, and whatever quotients of emotional intelligence and good judgement I possess – not only coexist with my condition but are in some meaningful way the product of it.” One of Mr. Stossel’s fears has been to be out of range of a bathroom and he recounts the hilarious yet agonizing tale of scurrying into a guest bathroom on the Kennedy family compound some years ago, flushing, then flooding the toilet and soiling his clothes, followed by a frantic rush to clean up with towels. Mr. Stossel ran off sans trousers to avoid detection, but returned surreptitiously to effect a further clean-up later, finally disposing of things in a nearby dumpster. The reader can’t help but be disarmed at Mr. Stossel’s candor in the face of this personal catastrophe, but the sense of humor and the humanity that allow him to be so candid are extraordinary.

The idee fixe associated with our

worrying, of course, is that by so doing we think we may gain a smidgeon of freedom, or even insight. This seldom happens.

The biologist in me reacts to Mr. Stossel's reminder of the ubiquitous and often disabling nature of our anxiety and its role in the human condition. On an evolutionary basis, with relatives that were once treed insectivores eons ago, anxiety and perpetual wariness with fidgeting would seem to be a reasonable response as our ancient ancestors became conscious, more sentient beings, aware of time and with concern for a precarious, unknowable future.

On another front, I can’t help but think our modern technical achievements, particularly our communications capabilities, have served us poorly. On a recent plane trip, waiting for news, late and uncertain of things, perhaps the perfect laboratory milieu for our pervasive angst and dread, I was struck, looking at the magazines on the newsstands, that they all seemed to offer up yet more things to worry about. How should you … take off inches from hips or thighs or midriff, satisfy a stodgy lover, have healthy children, cheap, nutritious meals and a resplendent retirement? A blizzard of common problems assailed readers, yet offered little or nothing in the way of lasting solutions. Waylaid passengers near me sent worried emails or text messages broadcasting our dilemmas as our nervous temporary community read and heard about problems, thought about them, spoke of them and broadcast them. The whole business seemed to represent a spiral of ever more worry, and one we could do nothing about. The idee fixe associated with our worrying, of course, is that by so doing we think we may gain a smidgeon of freedom or even insight. This seldom happens. We know we’re impotent regarding big problems, world conflict, climate change and such, but we can often find ourselves equally inept in the face of a maelstrom of more minor concerns. I wonder, too, whether pertimes we may become addicted to the psychic buzz of our anxiety, the adrenaline rush of feeling we’re playing Russian Roulette with one or more bullets in the gun. As I write this, there’s a new Edge publication on the newsstands, What Should We Be Worried About?10 Several hundred of our most prominent scientists and thinkers outline their unique concerns for us all, and serve up a compendium of things I never thought would go bump in this or any other night. There’s nary a thing I can think about doing for any of them. Getting back to Dr. Thomas, we are most assuredly anxious. Perhaps one day we will learn how to worry better, but in the meantime, I’d recommend Mr. Stossel’s book. Psychologist Rollo May, PhD, may have gotten it right when he said that, “One of the few blessings of living in an age of anxiety is that we are forced to become aware of ourselves.”11 Mr. Stossel’s writing rings true here. Resoundingly. We are him and he is us. Hurrah for Mr. Stossel – his courage and his humanity. References available upon request.

May - June 2014

Cover Feature What do yoga and financial management have to do with being a good doctor? Medical students find out Paras Satija | AMA

Representative, University of Alberta, Class of 2017

ver 300 medical students gathered on the first weekend in February for the 10th annual Alberta Medical Students’ Conference and Retreat (AMSCAR), held at the Banff Conference Centre. One of the key events in the pre-clerkship years, AMSCAR brings together first and second year medical students for a weekend full of sessions, events and activities all designed to teach them the necessary tools and strategies that will enable them to lead healthy lives as medical professionals. With sessions ranging from clinical skills to dancing, financial management, yoga and hiking through Banff, this event was both an informative and an unforgettable experience for attendees.

One of the key aims of AMSCAR is to foster interactions between students of Alberta’s two medical schools, presenting an opportunity for them to meet and mingle with future colleagues. Throughout the weekend, students had ample opportunity not only to network with other students, but also with medical professionals and some of Alberta’s health organizations as well.

Learning clinical skills are all part of the fun. (

provided by Katie Anker)

Students returned home with a

greater understanding and awareness of the factors that will impact their well-being.

Alberta Medical Association (AMA) President Dr. Allan S. Garbutt gave one of the keynote addresses during the event: he spoke to students about the realities of the medical profession; shared some memorable stories from his experience as a physician in rural Alberta; and highlighted the importance of maintaining a work-life balance in the future. >

AMA - Alberta Doctors’ Digest

Leading healthy and balanced lives is a key principle of AMSCAR. ( provided by Katie Anker)

Hands-on training is highly rated at AMSCAR. (

provided by Gregory Sawisky)

Other keynote speakers included Dr. Vera H. Krejcik, President, Canadian Association of Physicians with Disabilities who emphasized the importance of inclusiveness in the medical field. Dr. Jane B. Lemaire, Vice-chair, Physician Wellness and Vitality, Faculty of Medicine, University of Calgary reiterated the importance of balancing work and life in order to avoid burn-out. Rose Carter, partner with law firm Bennett Jones and adjunct associate professor, Faculty of Medicine, University of Alberta spoke to students about the importance of communication, mutual respect, trust and understanding when dealing with patients. Students were extremely impressed with the quality of speakers and also with the weekend in general. When asked about the success of the event, Isabelle Colmers, President of the AMSCAR Committee, said, “We definitely put a ton of work into preparing for the AMSCAR weekend. An exciting component we added to AMSCAR was a focus on promoting resilience, and mental health and wellness. The speakers and session presenters we brought in to address some of the many

Enthusiastic “volunteers” rolled-in to receive injections as part of the hands-on training. ( provided by Gregory Sawisky)

aspects of mental health did a fantastic job and were incredibly well received by students.” The Medical Students’ Committee added that “The weekend would not have been possible without the generous support of our sponsors, including the AMA. We are very grateful for the support they provide toward making the conference possible and financially accessible for students. We also thank all the session leaders and speakers who shared so many inspiring and creative ideas with the students, and the Banff Conference Centre for providing logistical support and a beautiful backdrop for our retreat.” Equipped with not only a fresh outlook but a variety of coping tools to enable them to take responsibility for their overall health, students returned home with a greater understanding and awareness of the factors that will impact their well-being while training to become practicing medical doctors. For more information about AMSCAR, please view the video at http://youtu.be/JzZRKvEZ6r4.

May - June 2014

Health Law Update

Chaoulli not yet enforced in Alberta

What it means for prompt access to health care Jonathan P. Rossall, QC, LLM | Partner,

n 2005, the Supreme Court of Canada confirmed that any statutory prohibition on private health insurance for medical services that would otherwise be publicly funded violated the right to security of the person, as guaranteed by s. 7 of the Canadian Charter of Rights and Freedoms. This was the landmark decision in Chaoulli v. Quebec (Attorney General) (“Chaoulli”). Yet, in Alberta, s. 26(2) of the Alberta Health Care Insurance Act is still in the books. S. 26(2) states almost a decade after Chaoulli was decided: “An insurer shall not enter into, issue, maintain in force or renew a contract or initiate or renew a self-insurance plan under which any resident or group of residents is provided with any prepaid basic health services or extended health services or indemnification for all or part of the cost of any basic health services or extended health services.”

Dr. Allen’s strategy at trial was

to rely heavily on the decision of Chaoulli as being conclusive of the argument that, where a law creates a risk to health by preventing access to health care, a deprivation of the right to security of the person is made out.

AMA - Alberta Doctors’ Digest

McLennan Ross LLP

Enter Dr. Darcy Allen (dentist) who recently took the Government of Alberta to task on this important topic. Dr. Allen suffered an injury to his lower back and his right knee in December 2007 and immediately came face-to-face with the stark realities of wait times in Alberta. Told he would have to wait six-to-eight months for an MRI of his back, he chose to purchase his own MRI to avoid the wait. He was then referred to physiotherapists and acupuncturists for treatment. He finally met with a specialist in 2009 who prescribed some medications which did not alleviate his pain. Eventually he was recommended for surgery for what was described as “further degradation and herniation of his lumbar discs,” but was told he would have to wait a further year for the requisite discogram and then a further year for surgery. Finally, he had had enough and consulted with a specialist in Montana, who was able to perform the surgery in December 2009, paid for out of Dr. Allen’s own pocket. The surgery was successful in reducing and, eventually, eliminating his pain although there was some suggestion of long-term nerve damage related to the delay. Dr. Allen sued the Government of Alberta following the surgery, claiming that the delays in treatment violated his right to security of the person as guaranteed by the Charter (much as Mr. Chaoulli had done more than 10 years previously). Dr. Allen’s strategy at trial was to rely heavily on the decision of Chaoulli as being conclusive of the argument that, where a law creates a risk to health by preventing access to health care, a deprivation of the right to security of the person is made out. In other words, once the evidence of delay in treatment was before the court, then Chaoulli gave Dr. Allen a prima facie case for his claim that the security of his person was violated. >

> Unfortunately, the trial judge did not agree with that position. Justice P.R. Jeffrey of Alberta’s Court of Queen’s Bench decided, in summary, that “… breaches of s. 7 are demonstrated by evidence and that Dr. Allen had not satisfied his burden of proof.” Dr. Allen had argued that evidence of delay gave rise to an automatic finding of a breach of his charter right. Justice Jeffrey, however, found that this argument does not lead to the conclusion that all prohibitions of private health insurance infringe the right to security of the person. Rather, he felt that any law shown to prevent access to health care creates a risk to health, which then constitutes a deprivation of the right to security of the person. The onus is always on the plaintiff to demonstrate with evidence that the law has prevented his access and that evidence simply was not placed before the court. To quote Justice Jeffrey: “Nothing on this record satisfies that burden. Dr. Allen offers only the personal opinion that the availability of private health insurance prior to his events would have provided him with timely medical care.”

In other words, while Dr. Allen had demonstrated that there were delays in his treatment, he did not provide evidence that private health insurance would have allowed him to obtain more timely care. Mr. Chaoulli, on the other hand, had done so in his trial, and that evidentiary underpinning led to his success initially in Quebec and ultimately in Ottawa. This may be a temporary speed bump on the road to the elimination of s. 26(2) of the act. Given the notoriously lengthy wait times for many procedures in Alberta, it is inevitable that another application will be before the courts in the foreseeable future. The reasoning in Chaoulli is very strong and compelling, and all it will take is the proper evidentiary foundation, demonstrating that the ability to purchase private insurance would have resulted in an injured person being able to access care through a private source, to convince a judge to strike down the section. Given this, one would think that the appropriate step for the Alberta government to take would be to accept the reasoning of the Supreme Court, amend the act, and remove s. 26(2). Unfortunately, that does not seem to be this government’s modus operandi. Reference 1. 2005 SCC 35, [2005] 1 SCR 791.

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May - June 2014

Feature

Physician disruptive behavior What it is and how you can address it constructively

others with respect, teach and model the concept of professional behavior, and take responsibility for one’s own behavior and ethical conduct regardless of the circumstances.3 This code provides a solid foundation for acceptable physician behavior.

hysicians in Alberta are increasingly aware of the impact of disruptive behavior on health care providers, patients and doctors themselves. There is growing interest in addressing the issue of physician disruptive behavior due in part to legislative and regulatory changes, and mounting recognition of the negative impact of this behavior on patient safety. As in other jurisdictions, doctors in Alberta must recognize and address physician disruptive behavior, and seek to eliminate this conduct from the behavior environment.

What is physician disruptive behavior? Disruptive behavior generally refers to inappropriate conduct, whether in actions or in words, that interferes with or has the potential to interfere with quality health care delivery.1 Examples include inappropriate words, abusive language, shaming, outbursts of anger, throwing medical instruments and use or threat of unwarranted physical force. There is usually a pattern to physician disruptive behavior, rather than an isolated incident. Disruptive behavior can also be quite subtle, such as refusing to work cooperatively with others or being chronically late for meetings, patient appointments or scheduled procedures. Disruptive behavior impacts those on the receiving end of the behavior and this can ultimately affect care provision. In the long term, disruptive behavior can lead to ineffective care, harm to patients and poorer clinical outcomes.2 A disruptive work environment can have a negative impact on communication and team functioning, and it can also damage personal and professional relationships. Not all instances of behavior that may initially seem inappropriate are actually disruptive. Much depends on the nature of the behavior and the context in which it arises. The College of Physicians & Surgeons of Alberta’s (CPSA’s) Code of Conduct requires physicians to treat

AMA - Alberta Doctors’ Digest

Some doctors wonder about how their advocacy activities may be viewed by others. Physicians can responsibly use their experience and expertise to advocate for patients and communities, and most advocacy actions by physicians are not linked to disruptive behavior. Both the Alberta Medical Association and the CPSA have spoken out in support of physicians who advocate for their patients, as long as this is done responsibly.

Complexity of medical care and changes can be contributing factors Disruptive behavior is a complex issue and its intricacies include identifying the behavior and assessing any underlying factors that may be contributing to these actions. Contributing factors may include inadequate resources, workload issues, the workplace environment, or individual physician health issues. Like other jurisdictions, the medical community in Alberta is adjusting to the complexities of health care delivery, including changes being introduced to address new transparency requirements, a heightened focus on continuity of care, evolving primary care models, and the need to enhance access for underserviced communities.

How to respond to disruptive behavior within the work setting Recognizing that the work environment should be considered when addressing provider behavior, it is appropriate for health care institutions to take an active role. Physician leaders in health care institutions can set clear expectations, model appropriate behavior, and emphasize the positive values and behaviors important to the organization. Should redress be required, the actions should be fair, graduated and proportional, and fit the >

> type and frequency of the behavior. Workplace and health issues that may impact behavior should also be taken into consideration. A tiered approach to promoting professionalism can help to manage disruptive behavior. In the case of a single incident of unprofessional conduct, a “coffee conversation” with a colleague may be all that is required, followed by documented intervention for recurring behavior. A persistent pattern of disruptive behavior unresponsive to lower level intervention may require escalation to a higher authority figure, with further documentation and an action plan. Failure to respond to the authority intervention would lead to disciplinary action.4 Both the CPSA5 and the Health Quality Council of Alberta6,7 have published frameworks and resources to

assist health care providers and health organizations in managing disruptive behavior in the workplace.

Physician leaders have a role to play The CMPA believes physician leaders can play a meaningful role in addressing physician disruptive behavior. The CMPA’s 2013 discussion paper on this topic includes recommendations that can help guide physician leaders in this effort. The recommendations are related to issues of communication, codes of conduct, counseling and intervention. Members are encouraged to access the CMPA’s discussion paper on the website at http://bit.ly/1hv4tUX. References available upon request.

Look ma, no login! Want to comment on The President’s Letter or other pages on our website, but don’t want to log into the site? Now you can! We’ve just produced a new way for you to tell us what you think or to participate in group discussions. We’ll be including this feature with President’s Letters and on other web pages in the coming months. Give it a try! For example, next time we send you a President’s Letter, click on the link at the top of the email. Scroll down to the bottom of the web page and post your comment. It’s just that easy. Take a look at our commenting policy for some common-sense advice on keeping the conversation productive. And, of course, you’ll still be able to contact the president directly by email.

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May - June 2014

Mind Your Own Business

Hot off the press!

Results of our first provincial pay survey for clinic staff positions Practice Management Program Staff

common question posed by clinic owners is, “What rate should I pay my staff?” This has been a tough one to answer given the lack of robust data available on clinic staff pay. To help answer this question, the Practice Management Program (PMP) engaged an external consultant in the fall of 2013 to develop and administer a provincial pay survey for medical clinic staff positions. The results are in. Forty-four clinics participated in the survey, representing a response rate of 43%. Surveys of this nature often have low response rates to begin with. The fact that this is the first iteration of what is hoped to be a regular product for our members positions the 43% as a successful start. The 44 participant clinics represent 378 physicians and 528 employees, the five Alberta Health Services geographic zones, and clinics of different staff sizes and community populations. The survey will provide province-wide data (as well as data “segmented” by zone, clinic size, and population size where possible) relating to: • Pay rates and cash compensation for 10 common clinic positions, including bonuses and overtime. • Pay practices such as whether or not clinics have formal pay structures in place, how clinics decide on annual increases, whether or not clinics have bonus plans, the basis of bonus payouts, and type and frequency of performance reviews. • Benefits and paid time off (including statutory holidays, vacation and sick days).

Why is this important? Many factors influence how your employees feel about their work and their workplace. Pay is one of them and perception of pay fairness is just as important as the reality of it. A 2011 study found that 25% of employees say that fair pay is the single most important thing their organization can provide. Pay programs that are anchored to the market establish a certain amount of credibility

AMA - Alberta Doctors’ Digest

right from the get-go.1 Market surveys such as ours can help you. But it’s not as simple as that. Many other factors are important in making pay decisions including your clinic’s philosophy toward pay, unique circumstances of your clinic and location, historical pay relationships, specific duties of your positions and other such factors. The core rationale of a pay plan should be internal equity, i.e., the plan should be based on the job responsibilities of each position within your clinic and how jobs relate to one another. Market data should then be layered on top of this, along with proper pay administration and employee communication to form a sound pay program. So, survey data is not the be-all and end-all. Instead, it is intended as a general market indication – a guideline. As with any survey, this data represents a sample of the entire population and caution should be exercised in data interpretation; additional caution applies when small samples are used for calculation purposes. Though it may sound complicated, our PMP consultants are available to help ensure your clinic’s pay program is on the right track and/or help you build a plan from the ground up. We can also help you interpret the survey results and understand what the data means for your clinic.

Some survey highlights The following are some tidbits from the survey results: • 16 clinics or 36% of respondents indicated having formal pay structures (i.e., wage grid with a minimum and maximum rate). • 23 clinics (52%) indicated that they provide regular across-the-board increases on an annual basis. - The median2 cost-of-living increase for the last fiscal year was 2% and is projected at 2% for the upcoming year. - The median performance-based pay increase was 3% last year and is projected at 2% for the upcoming year. >

> • 30 clinics (68%) do formal performance reviews with clinic staff. • The most commonly provided benefits are extended health care, prescription drugs and dental care. Of those clinics providing, most indicated employer contributions at 50%. • The median value of annual employer contributions to the benefits package, per covered employee, was $1,683. • Significantly more than half of the respondents indicated providing vacation and holidays beyond the minimum legislative requirements.

To find out more

We need your support

We need your help to ensure that this survey becomes a regular updated product available to members. You can help us by responding to our call for participants our next time out of the gate – most likely in 2015-16. Our 43% response rate was a great start. We want to increase our participant numbers and in so doing, the quality of data we provide to you. For questions relating to the survey report and to access the data, please contact the PMP Office at 780.733.3632 and one of our consultants would be happy to assist. References

This is just a glance – detailed survey results are available. At the time of writing, the survey report has been distributed to all participating clinics, as well as to Primary Care Network offices. The 44 clinic participants also have been offered an opportunity to participate in webinar information sessions led by Glenda Nash, PMP Consultant for this project. During the sessions, participants will be led through the report, have a chance to ask questions and participate in theoretical discussions.

1. Rasch R. Perception is Reality: The Importance of Pay Fairness to Employees and Organizations. WorldatWork Journal, Q3, 2013. 2. The median is the 50th percentile – the middle value in the data set – the value separating the higher half from the lower half. The median is a more robust measure than the average, as it is not as susceptible to outliers in the data set.

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May - June 2014

Feature

Build a panel, build a medical home Guide to Panel Identification shows you how

“P

anel” is a term that describes a group of patients who have an established relationship with a provider who they consider to be “their” physician. It’s also a key concept underlying the primary care commitment to deliver consistent, quality care. But understanding how to identify and manage those panels can initially seem daunting. That’s why the Alberta Medical Association (AMA) Toward Optimized Practice (TOP) program recently worked with stakeholders who share an interest in supporting strong patient-physician/ team relationships to develop the new Guide to Panel Identification. “Here in Alberta there are a number of organizations that work to help primary care physicians strengthen their practices and the idea of panels is really foundational to primary care improvement,” explains Doug Stich, Program Director at TOP. “This document came about because these organizations realized that we needed to have a common, consistent set of tools to help provide aligned support to primary care physicians.” TOP worked with Alberta AIM, Alberta College of Family Physicians, Alberta Health Services, AMA Practice Management Program, University of Alberta Faculty of Medicine and Dentistry, Health Quality Council of Alberta, Physician Learning Program and AMA Primary Care Alliance (Sections of General Practice, Rural Medicine and Primary Care Network [PCN] Physician Leads Executive) to develop and refine the guide. Stich notes that the guide, which helps physicians identify and establish the characteristics of their own panel, is based on the understanding that primary care physicians need to understand who their patients are in order to improve their practice. “Most physicians and patients already have a tacit understanding as to ‘I’m your doctor and you’re my patient.’ The goal now is to take it from tacit to explicit so that everyone on your team understands that relationship.” (TOP has also recently released Coordinated Approach to Continuity, Attachment and Panel in Primary Care that provides background on the concepts of panel, continuity and attachment.)

AMA - Alberta Doctors’ Digest

For Dr. Tobias N.M. Gelber, a Pincher Creek family physician and chair of the PCN Evolution Steering Committee, the new guide is an important step in helping Alberta’s primary care physicians and their teams deliver better care to patients. “It’s much more than a practical tool,” stresses Dr. Gelber. “It is also one of the first key resources that family physicians can use to build true medical homes for and with our patients. It allows us to confirm relationships and then we can build our care services to better meet the needs of our patient population.” Once the patient panel is established, confirming attachment should be no more complicated than checking demographic information. “So when patients call in, you ask if they still live at the same address and if Dr. Smith is still their doctor,” says Stich. He emphasizes that even if a patient is not attached to a specific physician within a clinic, they can still receive care. “These lists are not about excluding anyone, but rather about being able to identify additional services and supports where you can for people on your list. We know that these are ‘living lists’ that will change over time as people move away, travel or switch doctors. It may never be a perfect list, but it can be a very helpful tool for improving continuity of care for those that are on the list.” Dr. Karen J. Seigel, a Calgary family physician and part of the Calgary Foothills PCN, explains that panels can offer a critical big-picture look at what is happening within your practice. “Sometimes looking at things on a population level gives you a much better output for your efforts.” Although she acknowledges that there may be some more effort required initially to establish the panel, “it’s worth it because it will improve efficiencies and help us provide better quality care.” Local PCNs across the province can help physicians work through the development and implementation of their own panels and TOP is always willing to help. “Panels are really a small change with tremendous downstream benefits,” says Stich. “And the more we can help physicians do this, the better off we all are.” For further information, contact Arvelle M. Balon-Lyon by email arvelle.balon-lyon@topalbertadoctors.org.

May - June 2014

Feature

A brief history of our profession and the Alberta government J. Robert Lampard, MD

t is unusual for a historian to venture into the present, let alone contemplate the future. But the past does reflect favorably on Alberta’s long-standing influence on health care in Canada. 100 years of innovative policy, investment and regulation provide a template for the success of the 2013 Agreement between the Alberta Medical Association (AMA) and Alberta government – reached after lengthy, and at times rancorous, negotiations. The agreement has the potential to be remarkably constructive, if the past is any precedent. Before 1912, doctors in Canada could not move from province-to-province without another registration examination. After the 1885 Northwest Territories (NWT)/Riel Rebellion, McGill’s Dr. Thomas Roddick proposed there be a national examination and licensing system in 1899. Prime Minister Sir Wilfred Laurier agreed, providing every legislature, every provincial medical association, the Canadian Medical Association (CMA) and the Parliament of Canada approved it. Stalled, the new Alberta government included in the Alberta Medical Profession Act of 1906 a clause approving the proposal.

The past reflects favorably on

Alberta’s long-standing influence on health care in Canada.

Chagrined by the inaction, Dr. Robert G. Brett and Dr. George A. Kennedy sought to form a separate Western Canadian Medical Federation in 1909. That threat reinvigorated the CMA talks. An all-party agreement was reached in 1912 that established the Dominion Medical Council, which set an annual, voluntary, national examination.

AMA - Alberta Doctors’ Digest

In 1905, Alberta and Saskatchewan were created from the NWT. Then came the challenge: there had never been professional bodies like the AMA/College of Physicians & Surgeons of Alberta (CPSA) created in a territory which became a province. NWT Registrar, Dr. James D. Lafferty, drafted the Alberta and Saskatchewan Medical Profession Acts, then had a colleague sue him over the validity of the Alberta act. The NWT Supreme Court found the profession’s act ultra vires (illegal). The Alberta government joined the profession in the appeal to the Supreme Court of Canada. The Supreme Court found the act intra vires (or valid). In 1911, Dr. Henry M. Tory offered to have the University of Alberta (U of A) manage the provincial laboratory for the government. Approved, Dr. Tory was eventually able to recruit five teachers of pathology, including the first two deans. This minimized the direct cost to operate the faculty helping it survive two wars and the depression. So did the purchase of 5% Alberta government bonds by the U of A with the $500,000 Rockefeller grant received by the U of A in 1923 to complete the undergraduate MD program. In 1921, the U of A senate, with government approval, extended the U of A MD degree program to four years. It was the only complete program begun in Canada for 63 years (1883-1946). In a complicated four-way agreement after World War I (WWI), the university, the City of Edmonton, the province, and the federal government agreed to build an 84-bed University of Alberta soldiers annex, a wing on the Royal Alexandra Hospital (RAH), and return the Strathcona Military Hospital to the U of A as the University of Alberta Hospital (UAH). The veterans, patients, medical faculty, university, city and the province all benefited. After WWI, public health became a priority in the pre-antibiotic era. Alberta passed the first venereal disease prevention act (1919) in Canada, built the first special polio hospital (1928), passed the second free tuberculosis care act (1936), passed the first polio >

> rehabilitation act (1938), the first free cancer act (1941) and the first free maternity care plan (1944) all before oil was discovered in 1947. The highest rural postoperative mortality rate in Canada (5%) led health minister George Hoadley in 1926 to create the first specialist recognition program in Canada precipitating the formation of the Royal College of Physicians and Surgeons of Canada in 1929. Propitiously, the Alberta government guaranteed the growing UAH overdraft in 1928, requiring the minister, Dr. Warren W. Cross and deputy minister, Dr. Malcolm R. Bow, be added to the board. The UAH budget was increased by 50% through the depression. Alberta’s Hoadley Commission in 1935 defined “state medicine” as a health insurance program and proposed to subsidize it for those who could not afford it. Dr. Albert E. Archer and Dr. Donald R. Wilson recommended that doctors and hospitals be covered in the plan. CMA President Dr. Archer secured unanimous CMA support for the concept in 1943. The federal government agreed with the Alberta concept, which only failed over taxation arguments. The Dr. Archer and Dr. Wilson proposal was approved nationally by the federal government’s decision in 1957 and 1968, following the Saskatchewan doctors strike and the Royal Commission on Health Services report in 1964. The first Blue Cross plan in Canada was started in Edmonton by Dr. Andrew F. Anderson of the RAH and his colleagues in 1933. It was extended by the government across the province in 1948. In 1956, the U of A medical faculty was spending so little that its accreditation status was downgraded. The government and university injected $350,000 to increase the number of geographic full-time appointments and reverse the decision by 1959. In 1957, Ottawa introduced the Hospital Insurance and Diagnostic Services Act, with the federal and provincial governments each paying 50% of the cost. Alberta’s health minister Dr. Cross resigned over the federal government’s intrusion into a provincial jurisdiction. The 1964 Royal Commission on Health Services (also known as the Hall Commission) recommended a health resources fund to increase MD enrolment to prepare for the baby boom. Approved, the province supported

the establishment of a second faculty of medicine in the province at the University of Calgary (U of C) while the basic medical and clinical sciences buildings were built at the U of A. A number of provinces objected when Ottawa introduced universally funded medical services (Medicare) in 1968. Alberta’s health minister, Dr. Donovan Ross, resigned over this second federal intrusion into a provincial jurisdiction. In 1970, Alberta became one of the last provinces to join Medicare. The Alberta government accepted the health science center concept for training all health science students together. The Walter C. Mackenzie Health Sciences Centre opened in 1983. The Edmonton clinic extended the integration of the health sciences faculties in 2012. In 1980, medical research in Alberta was propelled onto the world stage by the Alberta Heritage Foundation for Medical Research (AHFMR). Four research buildings have been built on the U of A and U of C campuses. Medical research grants have increased almost 100-fold. In 1994-95, Premier Ralph Klein introduced substantial cutbacks to all government expenditures as well as health care regionalization. Following the release of the Barer-Stoddart report, all provincial governments slashed medical school enrolment by 10%, creating a physician shortage. Since 2000, substantial increases in physician enrolment have occurred in Canada, particularly in Alberta. After the price of oil recovered in the late 1990s, the Mazankowski Alberta Heart Institute and the Alberta Bone & Joint Health Institute were approved by Premier Klein. National acknowledgement of the decisions made in Alberta came when the premier, Honorable E. Peter Lougheed, and Dr. John E. Bradley were inducted into the Canadian Medical Hall of Fame in 2001 for starting the AHFMR. Mr. Lougheed also received the CMA’s non-physician award, the Medal of Honour, in 2002. There is an opportunity to foster the productive initiatives that have been created in Alberta under the 2013 AMA Agreement, leaving physicians at the decision-making table with the government. Based on the province’s historical record, Albertans have a right to look forward with optimism to the evolution of their health care system that puts “Patients First®.”

May - June 2014

Residents' Page

Can physician mentorship mold a future generation of leaders? Mark S. Ballard, MD | Internal

hile the evolution of medicine is always in progress, technological advances are speeding up the rate at which this change is occurring. In the last few years alone, we have witnessed many rapid developments within medicine and health care: improved Hepatitis C therapies, surgical checklists to increase operating room safety and bionic prosthetic limbs that move in response to neurologic stimulus, among many others. These advances lead to opportunities for improved patient care. Behind each of these discoveries are physicians with vision, dedication and often a willingness to play a leadership role in their fields. As physicians, we have the opportunity to play a leadership role within health care. Being able to serve well in this role requires developing strong leadership skills. As resident physicians, it can be easy to become focused solely on getting the work done, learning the practice of patient care, and maintaining the status quo; we can lose sight of the importance of other competencies like leadership. Recognizing how we practice leadership in our personal and professional pursuits and the value of mentorship within all these pursuits has the potential to improve how we practice medicine. Taking the initiative to participate in mentoring relationships and associated activities in community wellness, research, education, and advocacy can serve to enhance the future of health care delivery. Many of my colleagues already display leadership skills in their everyday lives. A common characteristic Iâ&#x20AC;&#x2122;ve noticed is my colleaguesâ&#x20AC;&#x2122; interest in and willingness to actively engage in research, education and advocacy. Resident physicians who are able to get involved in their

AMA - Alberta Doctorsâ&#x20AC;&#x2122; Digest

Medicine Resident Physician

communities are able to promote good health within those communities. For example, each year, one resident physician in my program organizes a soccer camp for children in Calgary, who otherwise would not have the opportunity to participate. This activity is not just fun, it also encourages physical activity among youth, which we know helps to reduce the incidence of diabetes and obesity. By mentoring a healthy lifestyle choice to children, we are participating in preventive medicine. Another group of resident physicians, in pathology and critical care, have demonstrated how research work in a lab under the guidance of a mentor can contribute to developing new cures for patient diseases. Their involvement in research contributed to a major breakthrough on white blood cell mechanisms of NETosis that was recently published. Leadership can also exist as collective initiatives. Together with the universities, the Professional Association of Resident Physicians of Alberta (PARA) continues to work to help resident physicians establish alternative call schedules and fatigue management plans within their programs. As these examples show, resident physicians can develop opportunities to be mentors and to learn alongside experienced mentors to improve the communities in which they live. Building relationships with preceptors offers many benefits including being able to draw from the wealth of leadership knowledge that already exists in medicine. Having shorter intervals or blocks with attending physicians can sometimes make it challenging to identify and connect with a mentor in leadership. Finding and committing to a mentorship relationship outside of regular rotations may require additional time and effort, but the skills that can be acquired make that effort worthwhile. Getting involved with a project of a preceptor offers the potential for coaching on leadership, management, administration, etc. Similarly, residents who may struggle with maintaining work-life balance can >

> rely on guidance from a preceptor who understands the challenges of finding balance and maintaining important relationships. These relationships offer an opportunity not only to diversify our skills as health care providers but also contribute to a positive work culture. In an environment where our interactions set the tone, recognizing the commitment of our mentors is important. Quality mentorship takes time. Given physicians’ many commitments to their patients, their colleagues, their families and their friends, this time is precious. While we may not be able to repay the time that is offered for our benefit, we can bestow upon these mentors our gratitude for their efforts through a verbal “thank you,” Christmas

card or nominating them for an award through the universities or PARA. Most importantly, we recognize the value of the mentorship experience by becoming mentors ourselves. When resident physicians are actively involved in their communities, education and advocacy, they are building the skills necessary to make a difference outside their own practices. It is important to recognize that to learn how to make a difference, we need guidance from those who are making a difference today. When we are able to draw from the experience of our mentors surrounding work-life balance, science and community engagement, we are actively preparing ourselves to continue shaping the future of medicine.

Register for the 87th Annual North/South Doctors’ Golf Tournament! Swing in support of Alberta’s next generation of physicians Monday, July 28 | 8 a.m. shotgun start | Red Deer Golf and Country Club Your $275 registration fee includes 18 holes, power cart, buffet breakfast, BBQ lunch, driving range and practice facility, fantastic souvenir and the opportunity to win great prizes. This stroke-play tournament is co-hosted by the College of Physicians & Surgeons of Alberta, Alberta Medical Association and the Canadian Medical Foundation to raise funds for medical student bursaries and physician health programs. All money raised will stay in Alberta.

New Medical Office Space Available In Edmonton We are looking for a Physician or group of physicians (family practice or specialists) who are looking for a newly renovated Medical Office Space. We are located in Edmonton, Alberta. The new medical office is approximately 1,800 square feet. There are 8 exam rooms and 1 procedure room in the current plan, with 2 physician’s offices large enough for 2 physicians to share. We are located in a flourishing area, not far from University of Alberta and close to Michener Park (graduate student housing) and other large family communities. Most of the clinics in the area are not accepting new patients. This is a great opportunity for a Family Practice group to come in and grow. Since the area is growing Specialist will be also be needed. Pediatrics, Internal Medicine, Cardiology, OB/GYN, would be a great asset to the area. The opportunities are endless. We are offering a very low cost per square foot. We welcome the opportunity to discuss this with you. If you are interested in looking at the space and discussing the costs, we would be happy to set up an appointment with you.

Contact: Audrey Conant | Phone: (780) 437-8818 | Email: careplusclinic@hotmail.com

May - June 2014

Feature

Know some outstanding rural colleagues? Here’s how to recognize them

tudents, patients, staff and colleagues now have a new way to show their appreciation for their rural physician educators, or preceptors.

The University of Calgary (U of C) is seeking nominations for the Rural Medicine Recognition Awards. “Rural docs are not given the recognition of the work they do,” says Dr. Douglas L. Myhre, U of C’s Associate Dean, Distributed Learning & Rural Initiatives (DLRI). “We hope that these awards recognize our long-standing rural teaching docs and their legacy.” That legacy is bound up in the future physicians these preceptors have influenced as well as the people in the communities where they practiced. In fact, the idea for the awards began with an initiative from one such rural community. When Sundre family physician Dr. Hal S. Irvine retired, the town contacted the faculty to ask for a brief presentation on his work in teaching. “His legacy deserved to be recognized going forward,” Dr. Myhre says. “That’s where it started.” Along with an award named for Dr. Irvine, there are four other categories of awards to recognize various aspects of rural practice and teaching, as well as physicians in various stages of their careers.

Early Educator Award This award will recognize U of C preceptors from any discipline in the first three years of teaching practice, located in communities outside of Calgary, who demonstrate a commitment to and enthusiasm for medical education. Nominations will be accepted from colleagues, residents and/or administration. Deadline: November 30 for presentation in February of the following year.

Dr. Hal Irvine Community Focus Award Named for the Sundre physician and former U of C Department of Family Medicine Associate Professor, this award is to honor physician preceptors in practice for a minimum of five years that have demonstrated dedication, through service and personal commitment, to improving quality of life in their community. Nominations will be accepted from community members and/or preceptor colleagues. Deadline: December 31 for presentation in May of the following year.

Dr. Ian Bennett Meritorious Service Award Dr. Ian Bennett was a long-serving family physician in Fort Macleod. Following his retirement, he continued to share his knowledge and experience with the medical community through the Alberta Medical Association’s Physician and Family Support Program, until he passed away in 2013. This award in his honor recognizes preceptors with demonstrated educational focus of over 10 years, or a single extraordinary demonstration of dedication to medical education. Nominations will be accepted from preceptor colleagues, administration, community members and/or allied health care practitioners. Deadline: November 30 for presentation in February of the following year.

Interprofessional Education Award This award is for physician preceptors or allied health care practitioners in practice for a minimum of five years in one community who have demonstrated respect and educational efforts across professions/disciplines. Nominations will be accepted from preceptor colleagues and/or allied health care practitioners. Deadline: December 31 for presentation in May of the following year. >

AMA - Alberta Doctors’ Digest

> Dr. Spencer R. McLean Peer-to-Peer Teaching Award Dr. McLean was a young orthopedic surgeon who lost his life to kidney cancer in 2013. He was a highly regarded peer teacher whose communication style was based on empathy and a sincere respect for others. This award in his honor recognizes residents in any discipline at the second year level or greater, who are nominated by other residents or family medicine based students for recognition of both educational efforts across disciplines and by demonstrating the qualities of a caring and compassionate mentor. Nominations will be accepted from resident colleagues. Deadline: November 30 for presentation in February of the following year.

How to submit a nomination

Please forward a letter outlining the merits of the nominee and how they meet the stated criteria for the chosen award to Dr. Myhre by email dmyhre@ucalgary.ca. Supporting letters should accompany the nomination reflecting different perspectives. “Hopefully the awards program encourages rural and regional physicians to continue this important work or encourages them to come forward,” Dr. Myhre says. “We can never pay them enough, so this is a way to try and recognize and honor them for their commitment.” For more information on the Rural Medicine Recognition Awards, visit the U of C DLRI website at www.ucalgary.ca/ ruralmedicine.

May - June 2014

Dr. Gadget

Digital omnivores Wesley D. Jackson, MD, CCFP, FCFP

re you one of those physicians who has a computer at the office, one at home, a laptop, a smartphone and possibly a tablet (or maybe even a wearable device)? Can’t remember which device you used when you were working on the last document? Left your laptop at the office and need to finish your work on your tablet? You may be pleased to know that you are not alone. The Epocrates 2013 Mobile Trends Report (www.epocrates. com) states: “By next year, nine out of 10 health care providers will use smartphones and nearly as many will have adopted tablets. Almost half of all respondents are ‘digital omnivores,’ defined as clinicians who utilize a tablet, smartphone and laptop/desktop computer routinely in a professional capacity.” The report goes on to predict that by the time you read this article in June, 82% of health care professionals in the United States of America will use a smartphone, tablet and a laptop/ desktop computer routinely in a professional capacity. This trend is likely very similar in Canada. The report goes on to highlight the significant functionality overlap of our devices. Our phone, often thought of as primarily a communication device, is also used to do searches or access professional resources. Tablets, often initially purchased for the consumption of electronic media such as e-books or journals, are now being used more and more to access and edit medical documents including electronic medical records. A typical digital omnivore may start a document on one device, edit or access it on another and complete it on a third device. The successful digital omnivore is a frequent and enthusiastic consumer of cloud-based services. This cloud, despite its somewhat nebulous name, consists of a physical location in which one or many servers reside, accessible by high-speed connections allowing thousands of users simultaneously. It is controlled by sophisticated software to protect security and allow

AMA - Alberta Doctors’ Digest

complex connectivity and acts something like the hard drive on your computer, with one major difference: it is accessible from anywhere.

The successful digital omnivore is a frequent and enthusiastic consumer of cloud-based services.

Consumer cloud-based services come in several “flavors.” Some, such as iCloud (Apple) or OneDrive (Microsoft) are limited to specific devices and/or applications, which contribute to the income stream of the provider. Others, such as Dropbox, Google Drive or Box, are platform agnostic, allowing access from most devices and locations. All of these provide data backup and all offer free trials of their service. Still others, such as Evernote, include cloud-based applications along with excellent data management to fulfill a specific note-taking niche in the market on most devices. Recently, Google Drive significantly slashed prices on cloud storage, which will likely push prices even lower for those who need more than the free accounts. The uses of these (and other) cloud-based services are as varied as the people who access them. Successful digital omnivores will thoughtfully determine which devices they have, how the devices will be used and how best they can be integrated into an efficient workflow to allow for synchronization, backup and ease of use. Personally, I have settled on a combination of iCloud, Dropbox and Evernote to meet my needs. I am currently working with OneDrive to see if it will offer any advantage over my favorites. Once these choices are made, the successful digital omnivore should be able to truthfully, and somewhat smugly, use the modified Chase Jarvis quote: “The best device is the one that’s with you.”

May - June 2014

PFSP Perspectives

Blunt reductionism versus fuzzy holism What place do the arts and humanities have in medical education? Vincent M. Hanlon, MD | Assessment

Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on. - “Wild Geese” by Mary Oliver1

n the PFSP Perspectives article in the March-April Alberta Doctors’ Digest, Dr. Jared D. Bly wrote about living better through empathy. He suggested three ways we might be more empathic – to increase our ability to understand and share the feelings of our patients. Give patients “a space to be.” Don’t get stuck in dichotomies; imagine “the third alternative.” Be prepared to “just listen.” To support his assertion that “empathy is an important tool in any medical toolbox,” Dr. Bly added the writings of Shel Silverstein, Carl Rogers, Gabor Maté, C.S. Lewis and Henri Nouwen. It’s noteworthy that Gabor Maté is the only physician in that group. The teaching and learning of empathy is crucial these days. Empathy is the flip side of one characteristic of burnout described as depersonalization – the “I don’t care” attitude of a physician who is losing touch with the heart of medicine. The medical literature reports that significant numbers of medical students and residents end their training less empathic than they began it.2,3 This finding is worrisome, whether one is a teacher, learner or patient. Toronto psychiatrist Dr. Allan Peterkin spoke at the Second Annual Symposium: Humanities in Health Care at the University of Calgary in March. His keynote was entitled “Keeping Reflection Fresh – How the Arts and Humanities are Invigorating Clinical Education.” In addition to being a clinician and teacher, Dr. Peterkin is the director of the Health Arts and Humanities program at the University of Toronto, and the founding editor of Ars Medica. In his interactive presentation he included a short poem, “Wild Geese,” by Mary Oliver (one of the participants

AMA - Alberta Doctors’ Digest

Physician, PFSP

read it aloud to the group). He used the poem, along with a painting, to demonstrate how poetry and visual art can be integrated into medical education (and our own learning that day). According to Dr. Peterkin, these benefits for learner and teacher include increased empathy for patients and improved powers of observation.

… successful “curricular interventions” are not about making

time and creating space in already crowded curricula. At Columbia University, it involves recasting everyone, students and faculty, as life-long learners in a humane medical enterprise.

Biosciences’ “blunt reductionism” versus the humanities’ “fuzzy holism” What place the arts and humanities should have in medical education has been debated for decades, with fluctuating levels of intensity and participation. The debate is sometimes reduced to the dichotomy that Catherine Belling neatly describes as “the blunt reductionism” of bioscience versus “the fuzzy holism” of the humanities.4 It’s a conversation that usually takes place on the margins of the medical education enterprise. Regarding the level of participation, a good illustration can be found in the fact that there were 20 to 40 people in the room for the sessions I attended at the Humanities in Health Care Symposium. It’s worth searching for one of Dr. Bly’s “third alternatives” when confronted with the overly simplistic and contentious dichotomy of concrete science or insubstantial arts. If we agree with Dr. Peterkin that >

> clinical education needs invigoration, what will that take? According to Richard Gunderman commenting on the rates of burnout among medical students, “Nothing is more needed than nourishment for the imagination.”5

The emphasis of the Royal College of Physicians and Surgeons of Canada on the “CanMEDS physician competency framework” (including competencies such as collaborator, communicator and health advocate) speaks to a broader, more contemporary understanding of what it means to be sick and what it means to be a competent physician taking care of the sick (here I’m paraphrasing Dr. Rita Charon).6 Dr. Charon, a physician and director of the Program in Narrative Medicine at Columbia University, advocates for the inclusion of both the science and the art of medicine in undergraduate medical education. She says, “In addition to reliance on one’s cognitive, computational, and logical powers, inclusion of humanities proposes the need for imaginative, affective, relational and symbolic powers as well.”

An under-utilized resource

Pantheon Verisimilus by Greg Payce. (

provided by Greg Payce)

Dr. Charon also calls for a critical re-evaluation of “reductive processes of evaluation.” She’s talking about the imperfections of randomized controlled trials to inform us of the best ways for one or more human beings to provide competent care for a fellow human being. The insights into health and illness provided by disciplines like philosophy, literature and music are a heterogenous resource that do not lend themselves to reductive quantification. Perhaps that is a reason why they are an under-utilized resource by some health professionals. Evaluation of new teaching and learning methods, objectives and outcomes in medical schools is a necessary work in progress. “The methodological minefield that stretches between any curricular intervention and the improvement of patient health is immense, and it explains the powerful trust that medical education places in tradition,” according to Catherine Belling. She might also have said that powerful trust in tradition is sometimes misplaced. According to Dr. Charon, successful “curricular interventions” are not about making time and creating space in already crowded curricula. At Columbia University, it involves recasting everyone, students and faculty, as life-long learners in a humane medical enterprise.

Wanted: senior influential clinicians For Dr. Charon, it does mean identifying “senior influential clinicians – course directors, clerkship directors, residency program directors and associate deans.” These are individuals who clearly see and model in their own lives the value of the humanities, who are growing in competence as “readers, writers, listeners, and bearers of witness to the sick.” Such a group models >

Wire cut plate by John Chalke. (

provided by Dr. Vincent M. Hanlon)

May - June 2014

> and thereby legitimizes the practice of medicine informed and enriched by the arts. Dr. Charon sees it as a more powerful instrument of change than any single course in the so-called medical humanities. Dr. Peterkin spoke about the challenges of developing such groups. They can rise and fall on the strength of the personality, passion and persistence of a few people committed to the cause. Does the same comment apply to our own physician health education initiatives? Core curricular content is desirable, as are PFSP physician health presentations at conferences and resident education half-days. In some instances these presentations are a springboard to valuable conversations and support for teachers and learners in our midst who seek better ways to live out the knowledge they already have of physician health.

the gallery, informed me that John Chalke, award-winning Alberta ceramic artist, had died suddenly earlier that week. I had taken a course in visual design in 1978 taught by John Chalke at the University of Calgary. I remember learning about chiaroscuro, greyscale images and figure-ground exercises in his class. Thanks to John I began to see the world back then in a different light, and have continued to do so throughout my career in medicine. References available upon request.

See the world in a different light On a personal note, I visited the Willock & Sax Gallery in downtown Banff while attending the March meeting of the Alberta Psychiatric Association. Susan, co-owner of

Care Plus Medical Clinic #102 Lansdowne Shopping Centre | 5124 122 St. NW, Edmonton, AB T6H 3S3 Phone: 780-437-8818 | Fax: 780-439-5557 Care Plus Medical Clinic is located in Edmonton, Alberta. Edmonton is the cosmopolitan capital of Alberta, and is known as the “City of Festivals”. Care Plus Medical Clinic is a fully equipped and fully staffed modern facility. We have 2 MOA’s, 1 LPN, and an onsite office manager. We are currently using Health Quest EMR for medical records and billing. There is no investment or administrative responsibilities, and we are offering an attractive income split. We are looking for a full time family practice physician. For more details contact the Clinic Manager.

Audreyann R. Conant, Care Plus Medical Clinic #102 5124-122 St. NW | Edmonton, AB T6H 3S3 | Phone: 780 437-8818 | Email: careplusclinic@hotmail.com

Short and tweet! Get the latest AMA news in 140 letters or less Twitter is a great way for you to get the latest AMA: • News, events and announcements. • President’s Letter and other publications. • Important information from other medical associations. How can you find us? • Already have a Twitter account? Follow us at http://twitter.com/Albertadoctors.

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Scan to go directly to the AMA's Twitter account, or visit us at http://twitter. com/Albertadoctors.

• Don’t have a Twitter account? Signing up for Twitter is fast, easy and free. Just go to https://twitter.com/. You can open an account in under a minute. Check in regularly at http://twitter.com/Albertadoctors or see the most recent tweets on the AMA website, e.g., the Twitter box on www.albertadoctors.org/media. We’ll be tweeting new items almost every day. Join us!

Feature

We said what? AMA tracker survey measures your opinions

s we work to support members, the Alberta Medical Association (AMA) needs clear information about what you think about the health care system, the 2011-18 AMA Agreement and the association. To seek out that information, the inaugural 2014 AMA Tracker Survey launched in February. This updated survey, designed to reflect the information needs of the current agreement, replaces an older version (used between 2003 and 2011 under the former Trilateral Master Agreement). “The tracker surveys are vital to AMA processes,” says AMA President Dr. Allan S. Garbutt. “They allow us to find out what members think, to gauge how well we have explained certain initiatives and to adjust our actions to better serve our members.” Survey results can also help the AMA to judge the effects of various actions on physician practices quickly and accurately. “The surveys make it possible for AMA to adjust activities around the agreement so we meet the actual needs of our members,” Dr. Garbutt notes. The survey opened February 21 and closed March 5. Responses were received from 1,100 members. The data is valid 19 times out of 20 with a margin of error of +/- 2.8%.

The story behind the results The AMA has the support of a large majority of members. At the same time, many members are feeling the pressures and continuing challenge of constant change and are concerned about the profession’s ability to lead change. The AMA needs to demonstrate value. The unprecedented nature of some of the things that the AMA is trying to accomplish creates some uncertainty for members, who expect increased clarity and understanding over time. Meanwhile, the overall health care environment is highly changeable – while some fundamental professional principles remain rock solid.

Here are some selected results. See pages 28-30 for a full data summary. • Physicians agree that the AMA is an effective advocate for members (83%) and the association keeps members well informed about news and activities (83%). Member benefits and services enjoy an 86% satisfaction rate. • Physicians gave their strongest ratings/opinions in the area of electronic medical records (EMRs) and e-health. 94% agree that patient-physician confidentiality and safeguarding of that private information remains a requirement of effective patient care. 80% agree that an integrated provincial EMR strategy (that includes seeking value from existing infrastructure) is essential for improvement of the health care system. • One of the AMA’s key objectives is alignment of how physicians practice, with the way in which they are paid and the incentives that can be built to improve access to quality care. The Tracker Survey shows overall that physicians support the objective – but they believe we have a long way to go to reach it: - 37% agreed that incentives and financial/ compensation that support physicians are (currently) aligned with the system objectives of timely access for patient care. - Family physicians (40%) were more likely than specialists (33%) to agree with the statement. - Agreement was highest in physicians new to practice (62% among first year in practice members) and lowest among those in practice 21-25 years. • In the area of fee review and relative value, 42% of respondents agree “the AMA is making progress in supporting fair allocation of compensation based on relative value.” However, almost 36% were neutral. Verbatim comments indicate that there is a lot of uncertainty about the role, mandate and potential efficacy of the Physician Compensation Committee where such matters will be discussed. This is perhaps not surprising, given the early stage of agreement implementation. >

May - June 2014

> The numbers Questions The AMA is effectively supporting the Patients FirstÂŽ vision where physicians positively influence a health system built around patients and families. The AMA is an effective advocate for physician members by providing leadership and support for their role in the provision of quality health care.

Physicians are shifting their practices to support partnering with patients in the delivery of care.

The AMA is making progress in supporting fair allocation of compensation based on relative value.

The Physician Compensation Committee process for defining and administering physician compensation is fair.

Incentives and financial/ compensation supports for physicians are aligned with the system objectives of timely access for patients to quality care.

The AMA is effectively contributing to efforts to promote system-wide efficiencies and savings. An integrated provincial electronic medical record (EMR) strategy that includes seeking value from existing infrastructure is essential for improvement of the health care system. Patient-physician confidentiality and safeguarding of that private information remains a requirement for effective patient care.

Mean 0

3.84

4.08

3.46

27.8%

4.12

AMA - Alberta Doctorsâ&#x20AC;&#x2122; Digest

93.8%

3.5%

1.9%

0.1%

9.7%

40.3% 36.1%

9.0%

2.7%

2.2%

7.4%

34.7% 35.8%

13.3%

7.7%

1.2%

7.4%

30.7% 43.6%

9.2%

4.8%

4.3%

6.3%

30.4% 34.1%

19.6%

8.1%

1.5%

8.3%

46.0% 33.7%

8.8%

2.3%

0.9%

41.3% 38.6% 12.3%

4.0%

3.0%

0.7%

59.9% 33.9%

1.4%

0.4%

0.2%

100

36.7%

11.4%

100

79.9%

0.9%

100

54.3%

2.0%

100

38.1%

34.1%

33.7%

3.50

42.1%

43.6%

3.28

4.2%

55.9% 19.0%

32.4% 50.6%

21.0% 35.8%

N/A

Neutral

100

50.1%

Strongly Disagree

17.9%

36.1%

4.52

Disagree

Agree

100

83.1%

3.07

73.8%

3.21

Strongly Agree

Category Percentages

100

4.2%

Questions Primary Care Network (PCN) Evolution toward the medical home model will improve access, quality and continuity of care. The AMA is creating and sustaining opportunities for physicians to play active leadership roles within their communities (e.g., leadership development, Many HandsTM, Youth Run Club, etc.). The AMA is effectively building and managing the partnership with Alberta Health and Alberta Health Services.

I feel well informed about the activities and news from the AMA.

Mean 0

3.68

I am able to effectively share my opinion with the AMA when an issue or change will impact me.

Physicians are being supported by the AMA in maintaining their own health and that of their families.

I am satisfied with the benefits and services provided by the AMA, e.g., insurance, continuing medical education (CME), Physician and Family Support Program (PFSP), etc.

29.4%

3.55

3.51

22% 28.8%

3.79

21.8%

3.96

86.2%

3.4%

2.9%

9.0%

40.5% 40.5%

3.6%

1.5%

4.9%

9.8%

46.2% 31.4%

7.1%

4.4%

1.1%

14.1%

3.5%

0.5%

0.1%

39.6% 28.8%

16.9%

5.1%

0.2%

18.6% 50.2% 21.8%

6.1%

1.8%

1.5%

23.3% 54.7%

16.1%

3.9%

1.0%

0.9%

31.6%

8.8%

3.2%

1.3%

0.5%

100

9.5%

100

78.1%

7.1%

22.4% 59.4%

68.9%

22.3% 34.9% 29.4%

100

49.0%

N/A

100

81.9%

4.13

Strongly Disagree

Neutral

100

56.00%

4.00

3.32

Disagree

Agree

100

49.5%

31.4%

57.2%

40.5%

I feel well informed about the news and initiatives within the Alberta health care system.

Strongly Agree

Category Percentages

100

54.7%

May - June 2014

> Who participated?

Years in practice Response

Frequency

Percent 0

Student

1.6%

Resident

1.0%

1st year in practice

2.6%

2-5 years

107

9.7%

6-10 years

137

12.5%

11-15 years

134

12.2%

16-20 years

107

9.7%

21-25 years

159

14.5%

26+ years

381

34.6%

No response

1.5%

100

My practice is primarily Response

Frequency

Percent 0

Community-based

611

55.5%

Hospital-based

441

40.1%

No response

4.4%

I have a community-based or hospital-based appointment from AHS Response

Frequency

Percent 0

Yes

797

72.5%

278

25.3%

No response

2.3%

Keep on tracking! The AMA Tracker Survey will be conducted three times a year on a go-forward basis. Results of the Tracker Survey are extremely valuable for the Board of Directors in plotting the activity and advocacy of the AMA. Thanks to all who participated! The next tracker release is planned for mid-to-late June. We will make a habit of reporting results through Alberta Doctorsâ&#x20AC;&#x2122; Digest. For further information, contact Shannon Rupnarain, Assistant Executive Director, Public Affairs, by email shannon.rupnarain@albertadoctors.org or phone 780.482.0322.

AMA - Alberta Doctorsâ&#x20AC;&#x2122; Digest

Feature

What’s new online?

Interim EMR Advisory Service

Get connected!

Although the Physician Office System Program (POSP) ended on March 31, you can now call the Alberta Medical Association’s (AMA’s) electronic medical record (EMR) helpline at 1.855.454.8400 for advice and support. You can also access many POSP resources on our website. Learn more at http://bitly/1o29f19.

The AMA has a new way to share news with members.

New Billing Corner A new Billing Corner is out! For the first time, you can access the Schedule of Medical Benefits billing changes both as a complete document and by the changes that affect your own member section. See the new issue at http://bit.ly/1dxgft5.

If you have a LinkedIn profile, search “Alberta Medical Association” to find our page. We’re posting news every day. To see us on your own daily news feed, simply click the yellow “Follow” button on the AMA page. We’re always trying to get the word out about the great things the AMA is doing – feel free to share our news with your own networks.

PHYSICIAN(S) REQUIRED FT/PT Also locums required

Mid-year update on the AMA’s Business Plan The Business Plan guides the AMA’s work each year. The 2013-14 plan has three goals: members’ financial health; physician, patient and community well being; and system partnership and leadership. Want to know how we’re doing in achieving our goals at this point in our fiscal year? Visit http://bit.ly/1kksul9.

ALL-WELL PRIMARY CARE CENTRES MILLWOODS EDMONTON Phone: Clinic Manager (780) 953-6733 Dr. Paul Arnold (780) 970-2070

May - June 2014

In A different vein

Death with and without Dignitas Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | co-Editor

here’s an old Yorkshire joke1 illustrating, perhaps, the dourness of the Yorkshire soul. The doctor visits the old man at home, confirms that he’s dying and that there’s nothing more to be done. But he suggests to the old fella’s wife that he might like one last wish. “Aye then, what would you like, Wilfred?” his wife asks. “Ee’ Ah’d luv a bit o’ the ham that’s in the larder.”

advising is something most doctors feel uneasy about. You don’t know the fine details of the case and you don’t know how the patient is perceived by the treating medical and nursing staff. You are an intrusive voice and not much good can come of it.

The face of dying has changed in the

last 50 years with the evolution of palliative treatments, which can sometimes, not always, prolong life usefully but do not eradicate the disease.

“Well you can’t have that, lad – that’s the funeral ham.” Times have changed since that story had its heyday, although it’s still trotted out from time-to-time, suggesting something universal here. The story is a reminder that death comes and goes but life goes on, including the banality of day-to-day existence. These days the patient, if dying of cancer, might be considered for a phase 1 trial of a new drug. He or she will be reviewed by the palliative care team, the family doctor being absent from the process unless personally interested in the patient – though there are still some magnificent family doctors in Alberta who act as captain of the team. But not many. Death, dying and the issue of euthanasia has risen again in Canada. Quebec’s Bill 52, seeking to decriminalise euthanasia, died on the table with the election call but was only a few days away from becoming law. This issue is back and Canadian Medical Association (CMA) President, Dr. Louis Hugo Francescutti, has called for a discussion. I agree, and since I have had experience in the terminal cancer area – though not in the equally difficult area of chronic neurological disease – here are some thoughts. In the last year I’ve been advising (from a distance) a friend whose 58-year-old sister, Trish, is facing progression of lung, mediastinal and neck nodes of a metastatic carcinoma (primary uncertain). This abscopal

Trish resembles an older Jennifer Aniston. She was always a party girl, a regular to heavy drinker, a smoker – yet careful of her appearance. She’s being managed by a private practice oncologist in Cambridge, United Kingdom, and has had radiotherapy to the neck and a course of palliative chemotherapy at reduced dose to avoid hair loss and minimize side effects. She’s had a useful temporary disease stability but the disease has now progressed. What to do? She’s not keen on second-line chemo (which I had suggested) because it’s not a “cure,” and she’s been entered into a phase 1 clinical trial by a fast-talking Australian clinical fellow – whom she took a shine to. He told her palliative chemotherapy wasn’t going to cure her so why not try a new agent in phase 1 trials. You never know (he said) it might be a blockbuster. So she’s signed up and is quite hopeful (for the moment). From a distance I suggested that the Aussie was being too glib. The likelihood of a useful response in a phase 1 trial when its objectives are dose-related toxicity and side effects were about as high as the chances of the Not Your Grandfather’s Party being re-elected to govern Alberta at the next provincial election. My friend did not understand this so I had to explain that the chances were quite low. This Antipodean resident also had a vested interest in getting her on study since his fellowship funds >

> might be coming from the company whose drug was being studied. I contacted an old friend in Cambridge – actually one of the investigators on Trish’s phase 1 trial of this new Src/ ABL inhibitor. He said, “We’ve reached a level where we see a biological effect, but no responses yet.…” What do I tell Trish who has entered the study in the forlorn hope of a complete response? I’ll say nothing. And yet from society’s perspective we need these phase 1 studies. Trish has also made it clear that she will be the one deciding when enough is enough. She has contacted Dignitas, a Swiss company specialising in euthanasia. Dignitas was founded in 1998 by a yodeller called Ludwig Minelli, a lawyer. The law in Switzerland allows non-criminal assisted suicide provided this is not motivated by self-interest. The Swiss definition of self-interest does not include some fairly hefty legal and medical fees. The group acts as a neutral party (which the Swiss are historically good at) and they are not quoted on the Swiss stock exchange. There are two medical consultations by a psychiatrist, separated by a time gap to allow you to change your mind. There may be other consults (e.g., a neurologist or an oncologist) and you have to be assessed as of sound mind. You then sign a witnessed affidavit and you’re in. Sometimes they take a video of you for legal purposes. I suspect you could purchase a copy for yourself.

… the reality is that not all patients receive this and even in those

who do receive palliative care, there can come exhaustion and a desire to end it all.

In the British papers in April this year, an 89-year-old woman was reported as having killed herself at Dignitas because she had become “totally fed up with the idiotic modern world of emails, computers, smartphones, tablets, the Internet, flat-screen televisions and supermarket ready meals” – indicating to me that she was of exceedingly sound mind.

Changing your mind Some cancer patients talk about suicide when they are in the early phases of a recurrence but back off when the reality of dying hits them and they will go the way of palliative care – which includes the judicious withholding of treatment that may prolong life. Nevertheless, knowing Trish’s personality, the Dignitas path may be the way she will take. However, many patients enroll with Dignitas as a kind of insurance that this is something they could do if circumstances get intolerable.

The politics of dying Dying these days can be a political as well as a medical process. Say that the patient is no longer able to make rational decisions. The family appears: the daughter from California who has been notably absent for most of the time, wants everything possible done to prolong life; the daughter from Red Deer (who has been appointed surrogate decision maker) wants no additional measures to prolong life; and the son from Vancouver doesn’t know what he wants. There are then family consultations with everyone but the family dog having a role advising the right course. The physician becomes an arbitrator. I doubt this is what Trish will want.

Coercion This can be overt or more likely covert and is particularly relevant in the chronically incapacitating neurodegenerative diseases. Sensitive patients may feel completely worthless when they require total nursing care and feel they can best serve society by ending their lives.

Good palliative care After several opportunities to back out, you’re given an antiemetic then an overdose of pentobarbital in juice (orange or grapefruit) and you die peacefully over the next 30 minutes. They’ve done around 1,500 assisted deaths, each costing up to $10,000. Around one-fifth of those having an assisted suicide have (like Lycurgus in Plutarchs “Lives”) “a weariness of life.” There have been problems including allegations (none proven) that the director of Dignitas, Ludwig Minelli, has received large donations from rich clients (audit of the clinic’s books has not been allowed) and that suicides have been assisted in private apartments, automobiles and in a building next door to a busy brothel. What is established is that a large number of cremation urns have been found in Lake Zurich.

The face of dying has changed in the last 50 years with the evolution of palliative treatments, which can sometimes, not always, prolong life usefully but do not eradicate the disease. In Alberta, we have excellent palliative care with devoted, expert, intelligent physicians and nursing staff. Good palliative care includes withholding any treatment that will unnecessarily prolong life as well as the appropriate use of “terminal sedation” where sedatives such as Midazolam are given to a dose level which entirely suppresses symptoms of pain and anxiety. Death generally will follow shortly after. >

May - June 2014

> Hope, treatments and spiritual approaches In the dead of night, the angst of timor mortis is terrifying. And the constant fear of dying or losing one’s mind or having chronic pain is draining. Maintaining hope in managing advanced cancer is important. But hope comes in many guises and may not be what the patient and family recognise (i.e., hope for a “cure”). It might be trying a new or different treatment approach but more importantly it could be achieving in the patient a degree of acceptance together with excellent management of symptoms. Good, experienced spiritual advisors and psychologists help achieve this state of mind, which at some point all of us will have to endeavor to achieve.

Yet despite available good palliative care ... Some expertise in delivering good palliative care is a goal for all physicians, but the reality is that not all patients receive this and even in those who do receive palliative care, there can come exhaustion and a desire to end it all. There is little support or advice available in Canada for patients wanting to end their lives of suffering in their own time. Some resort to subterfuges: taking an overdose of narcotics. This happens from time-to-time. And as a corollary to assisted suicide, the recent Rasouli case, where the Supreme Court of Canada’s split decision favoring the extension of what seems a futile continuation of preserving bodily functions at great expense to society, is highly contentious. They did suggest that decisions to end life-support should be made by an arm’s length council – the Consent and Capacity Board in Ontario. We do not have this in Alberta. Most people with whom I have discussed this case think that decisions involving expensive life-prolonging care should not be left to the family. We should consider establishing a board in Alberta to examine and advise on such cases. This board should not be an “ethics committee” type of council nor a council full of lawyers. I have found hospital ethics committees to be well meaning but often unhelpful and time-consuming in individual cases, which usually are contingent on competing medical considerations of possible life-prolonging treatment versus the treatment’s futility. However, ethics committees are useful in elaborating principles. So Trish has contacted Dignitas. The idea of a patient saying goodbye to friends and relatives, getting on an aircraft to Switzerland and returning in a box or an urn doesn’t sit easily with me, and yet it’s the only path a determined patient in Canada can take.

AMA - Alberta Doctors’ Digest

I think patients “in sound mind” who have chronic debilitating symptoms unable to be alleviated adequately should have the right to choose their death process and timing – and request assistance from a properly trained physician. The idea that this is currently a criminal offence does not sit easily with me. The principle I am following here is the right of the individual to the disposal of his or her own body. Dr. Donald Low’s recent appeal for decriminalising assisted suicide is particularly compelling. Few of us enjoy discussing death, but the joke at the beginning of this article shows that death is part of life and is a process that can be discussed with equipoise and pragmatism – at least in Yorkshire. And it’s a reminder that we’re all going to be visited by the skeleton with the scythe. The CMA has asked for a discussion. What do you think? Reference 1. I’m pretty sure this one originated in the English north country, either Yorkshire or Lancashire, but I’ve seen versions from Scotland especially featuring dying highlanders. Either way the prevailing societal approach is to face death with fortitude and humor.

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CALGARY AB MCI The Doctor’s Office™ has family practice options available in Calgary. With more than 27 years of experience managing primary care clinics and eight locations, we can offer you flexibility with regard to hours and location. We provide nursing support and electronic medical records. We’ll move your practice or help you build a practice. Walk-in shifts are also an option. All inquiries will be kept strictly confidential. Contact: Margaret Gillies TF 1.866.624.8222, ext. 133 practice@mcimed.com EDMONTON AB Evansdale Medical and Northgate Medical Clinic are recruiting partand full-time family physicians/ general practitioners to join our dynamic team. They are walk-in and appointmentbased clinics. We are growing and busy; clinics are in north Edmonton with friendly, supportive and outgoing staff. Our clinics offer pleasant working conditions within a well-equipped modern facility and electronic medical records in each room. Contact: T 780.707.3595 or 780.782.1893 northgateclinic@yahoo.ca EDMONTON AB Urban Medical Clinic in vibrant southeast Edmonton is a new state of-the-art medical clinic that is rapidly expanding. The clinic uses TELUS PS Suite electronic medical records. Our team currently includes two

family physicians and we are part of Edmonton Southside Primary Care Network with full-time nurse and dietician. We have 8,000 patients registered. The clinic is growing and we are recruiting part- and full-time physicians. Competitive overhead for long term commitments. We have eight examination rooms, one procedure room and one specially designed wheelchair room. Contact: Dr. Oshean Naidoo onaidoo@telus.net or Dr. Dhanakodi Rengan drengan@telus.net T 780.757.9545 EDMONTON AB North Town Medical Centre is looking for part- and full-time family physicians and specialists to join our team. North Town Medical Centre is a multidisciplinary clinic with three family physicians, two specialists and two chiropractors. The clinic is in a strip mall with plenty of free parking, close to medical imaging, pharmacy and laboratory. Modern well-equipped facility with highly trained staff allow for no administrative burdens, electronic medical records, no hospital on-call, plenty of examination rooms, offices for physicians and competitive fee split. Flexible schedule can accommodate physicians who are looking to pick up extra shifts or a new physician wanting to open their practice to new patients. If interested in knowing more regarding this great opportunity, please contact us. Contact: Dr. Hassen Taha T 780.905.0027 or Dr. Ataher Mohamed T 780.298.2986 thamad73@yahoo.com >

May - June 2014

> EDMONTON AB Two positions are immediately available at the West End Medical Clinic, unit M7, 9509 156 Street. 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 west Edmonton. The physician income will be based on fee-for-service with an average annual income of over $300,000 and overhead fees are negotiable. The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines. Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 westendmedicalclinic@gmail.com EDMONTON AB Beverly Medical Clinic is a new state-of-the-art medical clinic that is rapidly expanding. Our team currently includes three family physicians, two internists and a pediatrician. The clinic is growing and needs more dedicated family physicians as one of the physicians is planning on slowing down. Competitive overhead for long term commitments; 75/25% split. We have 10 examination rooms, one treatment room and one specially designed pediatric room. Contact: Dr. A. Elfourtia or Dr. Z. Ramadan T 780.756.7700 C 780.224.7972 EDMONTON AB Ellerslie Medical Centre in southwest Edmonton is seeking part- and full-time physicians. The busy clinic is in a prestigious and fast-growing community which has a high public demand for family physicians. The physician income will be based on fee-for-service with an average annual income of over $300,000. The

AMA - Alberta Doctors’ Digest

physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guideline. Contact: Walid 11140 Ellerslie Rd SW Edmonton AB T6W 1A2 T 780.884.4124 walid@ellersliemedicalcentre.com EDMONTON AB The Chokka Center for Integrative Health is currently seeking a partor full-time psychiatrist (ideally a registered physician with the College of Physicians & Surgeons of Alberta) to join our multidisciplinary team in an executive clinic setting. Contact: Floyd Dunphy Director of Business Development 780.465.5749, ext. 110 fdunphy@chokkacenter.com EDMONTON AND FORT MCMURRAY AB MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic each have 10 examination rooms and Alafia Clinic with four examination rooms are looking for six full-time family physicians. A neurologist, psychiatrist, internist and pediatrician are required at all four clinics. Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton. Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray. The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines. The physician income will be based on fee-for-service with an average

annual income of $300,000 to $450,000 with competitive overhead for long term commitments; 70/30% split. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records (paper free) and member of a primary care network. Full-time chronic disease management nurse to care for chronic disease patients at Lessard, billing support and attached pharmacy are available at the Lessard and West Oliver locations. Work with a nice and dedicated staff, nurse available for doctor’s assistance and referrals. Also provide on-site dietician and mental health/ psychology services. Clinic hours are Monday to Friday 8:30 a.m. to 8:30 p.m., Saturday and Sunday 10:30 a.m. to 5 p.m. Contact: Management Office T 780.757.7999 or T 780.756.3090 F 780.757.7991 lessardclinic@gmail.com FORT McMURRAY AB Part- or full-time family physician wanted to join an existing walk-in ready clinic. Wonderful staff, flexible hours and schedules, great northern incentives and offer low overhead percentage. Contact: Dr. Loretta Roberts T 780.370.8425 roberts.loretta@ymail.com HIGH RIVER AB Family physician needed to join a vibrant practice with four friendly and supportive colleagues to cover departing physician’s patient panel of mainly women and children. The clinic has been newly renovated and offers full electronic medical records. Hospital privileges, low-risk obstetrical clinic, emergency room and operating room assist shift available; optional but encouraged. Contact: Dr. Bonnie Bagdan T 403.422.4296 bbagdan@me.com >

> HIGH RIVER AB Rural family physicians are invited to join active teaching practices in High River. Opportunities in three different, fully computerized clinics with a collegial group of doctors enjoying a great professional, supportive relationship. Practice opportunities abound at the local hospital with 32 acute-care beds, low-risk obstetrical group, community cancer clinic, active emergency room and two surgical suites, supported by anesthesia, obstetrics/gynecology, visiting surgeons, CT and ultrasound. Live in a picturesque, growing community 30 minutes from Calgary and the Rocky Mountain Foothills with an abundance of recreational opportunities for the active individual. Great opportunities for family as well. Contact: Dr. Stephen Finnegan T 403.601.5470 sp.finnegan@nucleus.com RED DEER AB Excellent practice opportunity in a pleasant, modern and well-equipped facility. Family practice and walk-in component, no investment, no administrative burden, no on-call, if you wish you may apply for hospital privileges. Obstetrics are optional, flexible hours and schedules, excellent emergency room and specialist coverage at hospital. Fee split is 75/25. Contact: Dr. Tony Ford T 403.342.2040 C 403.848.1388 docford@shaw.ca SHERWOOD PARK AB Well-established, busy and recently expanded clinic in Sherwood Park with five family physicians is seeking one to two part- or full-time physicians. Clinic is in a professional building with laboratory and X-ray on site. Primary care network family practice nurse support and excellent staff. Full electronic medical records and competitive fee split. Contact: T 780.464.9661 lorrainehosford@gmail.com

Physician and/or locum wanted CANMORE AB The Bow Valley Medical Clinic is hiring part-time, full-time or locum physicians who enjoy steady and interesting work. Office hours are 9 a.m. to 5 p.m., Monday to Friday, no on-call, hospital privileges are available. Excellent staff, electronic medical records, full hospital with emergency and on-call coverage. One full time and two part-time doctors currently working, but plenty of work for another full time or two part-time physicians; huge practice. Contact: Cassie Hall Office Manager T 403.609.2136 EDMONTON AB Summerside Medical Clinic and Edge Centre Walk-in Clinic require part-time and full-time physicians. Locums are welcome. The clinics are in the vibrant, rapidly growing communities of Summerside and Mill Woods. Examination rooms are fully equipped with electronic medical records, printers in all examination rooms and separate procedure room.

We have an excellent and knowledgeable support team, supportive colleague base, competitive 70/30 split and fully integrated electronic medical records. All staffing and administration support is provided. The clinic is connected to the Red Deer Primary Care Network and has several health care professionals collaboratively working with family physicians. Contact Dr. Hopfner joseph.hopfner@amgrd.ca

Practice Wanted CALGARY AB I am a family doctor looking to take over any physician/clinic owner who is relocating or retiring. I would also consider buying a medical building or a retail condo where medical is a permitted use. Contact: Dr. D. Das T 403.585.6840 drddebasish@gmail.com

Contact: Dr. Nirmala Brar T 780.249.2727 nimmi@theplaza.ca RED DEER AB Associate Medical Group was established in 1946 and is one the largest full-spectrum family medicine clinics in Red Deer. Associate Medical Group offers a diverse practice and is currently seeking part- and full-time physicians, as well as locums, interested in seeing patients in a busy walk-in environment and/or an office practice. Hospital in-patient care and an obstetrical practice are also available. The walk-in clinic and downtown office are in high-traffic retail locations which generate large income potential with generous financial splits. A pharmacy is located at both locations and the laboratory and hospital are located within minutes.

May - June 2014

Space available EDMONTON AB Private, professional mental health office space available at 10443 85 Avenue. Lovely heritage house setting in Old Strathcona. Waiting room, free parking, basic business services and mental health colleagues included. Space available is 200 sq. ft., main floor, soundproofed and unfurnished. Rent is $1,350 per month. Contact: Dr. Morhaliek T 780.431.1777 EDMONTON AB Bright and new, general practitioner and family practice looking to rent out one office space and two examination rooms. Rent would include use of staff and waiting room. Medical Imaging Consultants (MIC) and DynaLIFE Dx in the same building; across the street is a hospital. Contact: Danielle Sieswerda T 587.523.6334 tmedcentre@gmail.com

Lot has naturally clean rocky beach and nice slope to the lake. Close to “The Village” near Mameo with all its facilities. Ideal for a quality home at the lake. Contact: Dr. John Marko T 780.434.0057

for sale COMMON SHARES Rare opportunity. Selling my common shares in an innovative medical services company Imagine Health Centres, operating in Calgary and Edmonton. Novel model, multiple revenue streams including family practice clinic, pharmacy, physiotherapy, nutraceuticals as well as real estate. Accredited investors only; please inquire for further information. Contact: athiagar@gmail.com

Conference Practice available EDMONTON AB Looking for a general internist to take over a part-time internal medicine practice with room for expansion. Office is shared with a second physician with proximity to the Royal Alexandra Hospital and very experienced staff. Contact: Jim Kutsogiannis 601 Hys Centre 11010 101 St Edmonton AB T5H 4B T 780.450.0453

Vacation Property for Sale PIGEON LAKE AB Grandview Beach, 190 ft. treed lake-front lot for sale on 0.58 acres in developed, exceptional community.

AMA - Alberta Doctors’ Digest

PAIN SOCIETY OF ALBERTA 8TH ANNUAL CONFERENCE “PERSONS IN PAIN: PRACTICAL CUTTING EDGE MANAGEMENT” BANFF CONFERENCE CENTRE BANFF AB SEPTEMBER 26-27 Pre-conference Mainpro-C course, “Managing chronic non-cancer pain: Assessment, treatment and responsible prescribing,” Friday, September 26, $195 includes lunch and coffee breaks. Conference, Friday, September 26, 8 p.m. to 10 p.m.; wine and cheese, and view the exhibits. Saturday, September 27 sessions, 8 a.m. to 5:30 p.m., $150 includes wine and cheese on Friday, Saturday breakfast and lunch. Early bird deadline is August 31, price increases to $225 after August 31. For more information and registration forms, contact: www.painsocietyofalberta.org

Courses CME CRUISES WITH SEA COURSES CRUISES • Accredited for family physicians and specialists • Unbiased and pharma-free • Canada’s first choice in CMEatSEA® since 1995 • Companion cruises FREE ALASKA GLACIERS July 4-11 Focus: Renaissance in primary care XVIII Ship: Celebrity Solstice August 16-23 Focus: Second annual McGill CME cruise Ship: Zuiderdam MEDITERRANEAN July 19-26 Focus: Mental health 2014 Ship: Celebrity Equinox September 8-19 Focus: Caring for the aging patient Ship: Celebrity Infinity BERMUDA August 3-10 Focus: Primary care CME: With the Ontario Medical Association Ship: Celebrity Summit DANUBE RIVER September 11-21 Focus: Cardiology, nephrology and medical-legal Ship: A-Rosa Stella (exclusive charter) JAPAN AND CHINA September 28-October 12 Focus: Clinical pearls in medicine Ship: Celebrity Millennium CANARY ISLANDS October 2-13 Focus: Musculoskeletal navigator CME: With MSK Courses of Canada Ship: Independence of the Seas >

INDIA AND SRI LANKA November 26-December 9 Focus: Adventures in medicine Ship: Azamara Quest CARIBBEAN NEW YEAR’S December 28-January 4, 2015 Focus: Endocrinology, psychology and dermatology Ship: Allure of the Seas FIJI AND SOUTH PACIFIC January 16-30, 2015 Focus: Rheumatology and infectious diseases Ship: Oosterdam ANTARCTIC AND SOUTH AMERICA February 3-24, 2015 Focus: Explorations in medicine Ship: Seabourn Quest

Services

NETREGISTER CORPORATION

CEREBRAL MEDICAL TRANSCRIPTION SERVICES

We do incorporations for physicians including general and professional corporations for individual doctors or a large practice. Done fast! We can meet with you at your clinic. Starting at $385 flat. We also do notarizations/commissioner of oaths for out-of-province and country documents.

Hate voice recognition software and long turn-around time? Cerebral Medical Transcription Services is an experienced and passionate Edmonton-based transcription company offering local and global service without the nuisance of voice deciphering software. Convenient online payment and stat transcription available. Pay per character. Contact: info@cerebralmedical transcriptionservices.ca www.cerebralmedicaltranscription services.ca CLINICAID

EASTERN CARIBBEAN March 14-22, 2015 Focus: Primary care update Ship: Independence of the Seas

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TAHITI AND TUAMOTUS March 18-25, 2015 Focus: Geriatrics, physician health Ship: Paul Gauguin

Contact: TF 1.888.686.8560 info@clinicaid.ca www.clinicaid.ca

HAWAIIAN ISLANDS April 20-May 1, 2015 Focus: Improved patient care Ship: Celebrity Solstice

DOCUDAVIT MEDICAL SOLUTIONS

For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

Retiring, moving or closing your family or general practice, physician’s estate? DOCUdavit Medical Solutions provides free storage for your paper or electronic patient records with no hidden costs. We also provide great rates for closing specialists. Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com

Contact: Netregister Corporation T 780.425.8788 austin@netregister.com www.netregister.com RUTWIND BRAR PROFESSIONAL ACCOUNTANTS With an established medical PC clientele, we are able to efficiently and effectively meet all of your financial needs. Our services include PC incorporations, tax planning specifically designed for physicians, their families and their PCs, as well as full accounting services. Contact: Rutwind Brar Professional Accountants T 780.483.5490 F 780.483.5492 rbadmin@rbpa.ca www.rbpa.ca

Display or Classified Ads To Place or renew, contact:

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

May - June 2014

Make incorporation part of your total wealth management strategy. All in one Expert Office. Financial Planning and Advice

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Let’s talk about incorporation. Call 1 800 267-2332 or learn more at md.cma.ca/ incorporation

The MD ExO service provides financial products and guidance to eligible clients, delivered through the MD Group of Companies (MD Physician Services Inc., MD Management Limited, MD Private Trust Company, MD Life Insurance Company and MD Insurance Agency Limited). MD Physician Services is owned by the Canadian Medical Association. Incorporation guidance limited to asset allocation and integrating corporate entities into financial plans and wealth strategies. Professional legal, tax and accounting advice regarding incorporation should be obtained in respect to an individual’s specific circumstances. Banking products are offered by National Bank of Canada’s Partnership Branch through a relationship with MD Management Limited.