September/October 2012
THE ALBERTA DOCTORS’
Alberta
set to lead
in academic
medicine
An enduring mystery A brief history of multiple sclerosis
Patients First®
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Volume 37, Number 5
From The Editor
Zoobiquity Connecting with the biosphere can help you understand health Dennis W. Jirsch, MD, PhD Editor
I had a eureka moment some years ago. My Shih Tzu broke from me in the alley on a snowy evening and ran pell-mell into the side of a passing car. Ka-boom. After a few minutes the animal emerged, a little breathless, but not much worse for wear. When I examined her though, there were bowel sounds above one hemi diaphragm. Diagnosis: ruptured diaphragm. Fifteen hundred bucks and an operation later, Mugsy was good as new. My eureka had to do with my recognition that this was pathophysiology I’d seen in human blunt trauma. Zoobiquity: What Animals Can Teach Us About Health and the Science of Healing 1 goes further than that. The title melds the Greek “zo” for animal with the Latin “ubique,” for everywhere. Authored by a University of California Los Angeles physician and an Atlantic editor, it’s an engaging book that examines the continuum of disease in animals and man. As Dr. Rudolf Virchow put it: “Between animal and human medicine there is no dividing line – nor should there be. The object is different but the experience constitutes the basis 2
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of all medicine.” The commonalities of disease in animals and man would have been a no-brainer for Charles Darwin. And Dr. William Osler, one of Virchow’s students, is revered as a father of both veterinary and human medicine. It’s something, however, that we need to learn and re-learn. Tumors, for example, are common in all animals. Sharks, contrary to popular belief, get cancer. Dogs have a 60% risk of dying from the disease and osteosarcoma, prostate and squamous cell cancers are common. Cats get leukemia and lymphoma. There are papilloma virus induced genital cancers in sea lions, dolphins and whales. Cancers have been described in fruit flies and cockroaches.
We’ve benefited from this larger view, including ourselves in the animal kingdom. The limb-sparing technique that surgeons use to save osteosarcoma afflicted teenagers from amputation was pioneered by veterinary oncologist Dr. Stephen Withrow working with dogs. Dr. Philip Bergman, another veterinary oncologist, has treated melanoma-afflicted dogs with antibodies to human tyrosinase. The antibodies seem to attack canine tyrosinase with successful palliation of the animals, and the technique may work in humans. If cancers are ubiquitous, infections are too. Many animal infections are transmitted sexually, and Zoobiquity describes dolphins with penile and cervical warts, koalas with chlamydia, baboons with herpes, rabbits with syphilis, house flies with genital fungus. The list goes on.
Breast cancers are found in cougars, kangaroos, llamas, sea lions, beluga whales and ferrets. The notorious BRCA 1 gene mutation exists in animals, as well as man. In a Swedish study the presence of the mutation rendered English Springer Spaniels four times more likely to develop canine breast cancer.
The ability of infections to change behavior is especially interesting. Physicians recognize hydrophobia associated with human rabies, for instance, but there are compelling examples in animals. Male crickets infected with a certain parasite sing differently and are more attractive to mates. Female moths infected with the H z-2V virus produce more sex hormones. Male swamp weed beetles infected with a sexually transmitted mite become more sexually assertive. The trypanosomal equine disease dourine seems to enhance stallion libido, and a sexually transmitted disease of deer puts animals in perpetual heat.
Years ago, dead beluga whales began showing up in the St. Lawrence River and exhibited a long list of breast, intestinal, utero-ovarian and bladder cancers related to aluminum smelter toxins, DDT, PCBs, PAHs and heavy metals. Zoobiquity invites us to regard animals as the proverbial canaries in our collective coal mines as we continue to degrade our world.
A survey of sexual behavior across the animal kingdom reveals all the behaviors, both accepted and deviant, that are seen in humans, with oral, anal, group sex, and even necrophilia in frogs and mallard ducks. Foreplay behavior is common too, with stroking, neck-biting, vulvar licking and ear-tonguing seen in many species. Forced sex occurs too, as well as
“convenience polyandry,” in which females, fatalistically perhaps, endure the advances of a persistent male. On the other hand some beetles have sliding chitinous plates they use to occlude vaginal openings, preventing penetration. Rats, cats, sows and guinea pigs signal sexual receptivity with arched backs, possibly explaining our enduring fascination with high-heeled shoes and the consequent lordosis. Many aroused ungulates, cats and rodents exhibit a characteristic grimace called a flehmen, and the asymmetric raising of the upper lip involved brings to mind the provocative facial mannerisms of Billy Idol, Mick Jagger and Elvis Presley. Obesity may be the epidemic of our time but animals have not gone unscathed, with 25-40% of cats and dogs affected, suffering too with associated diabetes and cardiovascular problems. There are accordingly diets for pets (Catkin’s diet!) and we speak of portly ponies, chubby fish and even overweight birds called perch potatoes. Overeating may relate to evolutionary urges for protein and sugar in the face of plenty. Considering our animal brethren enlarges the discussion though. Possibly germane to humans is the notion of infectious obesity, with seven viruses and a
The easy way to get online We’re using QR codes in a few articles in this issue. Scan these codes using your smart phone or tablet device to view online content. Scanning the code above will take you to the Alberta Doctors’ Digest page on the AMA website.
prion implicated in obesity in lions, chickens, horses and bats. Eating disorders aren’t restricted to humans either. Binge eating, secret eating and food hoarding are common. Regurgitation and reingestion – seen in gorillas, chimps, dolphins, whales, vultures and caterpillars – have been considered a response to environmental stressors. Thin sow and wasting pig syndromes may be homologues of anorexia nervosa in humans. Adolescence across species has commonalities too. Risk taking and impulsivity propel adolescent birds out of nests, hyenas out of dens, and are much visible in dolphins, elephants and horses. Evolution seems to provide an opportunity to practice social behavior in relative safety revealing the connections we might see among pre-adult salmon swimming in schools, sparring young elephants and a swarm of teenagers at movies or the mall. Nor are animals immune from self-injury. Humans have “cutters” and self-mutilators who ingest spoons or pull out hair. In the animal world we find feather-picking disorder and incessant licking called acral lick dermatitis seen in canines. Such instances of “grooming gone wild” are attributed to stress, isolation and boredom while similar human
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maladies are ascribed to sexual abuse or personality disorders. It may be a stretch, but the prevalence of piercings and tattoos has been considered part of this continuum. Are we alone in our predilection for drugs? Not so. Zoobiquity describes opium intoxicated wallabies, drunken monkeys and cedar waxwings, bighorn sheep addicted to psychoactive lichen, and a cocker spaniel addicted to licking toads. Researchers find opiate and cannabinoid receptors everywhere: mammals, birds, amphibians, fish, mussels and sea urchins. Our addictive potential may stem from our ancient, shared past. Zoobiquity’s conclusions are clear. We and our evolutionary confreres are closer than we think with similar illnesses and common vulnerabilities. Our connections are both ancient and deep, extending from “body to behavior, from psychiatry to society.” The call then is for larger thinking, for new collaborations with veterinarytypes and with biologists. Equally, the call is for a new humility: our health and that of all living things – the biosphere – are connected in ways we are only beginning to realize. Reference 1. Bowers K, Natterson-Horowitz B. Zoobiquity: What Animals Can Teach Us About Health and the Science of Healing. Alfred A. Knopf, New York, 2012.
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If you don’t have a QR code reader app on your phone, download one for free from www.scanlife.com. Alberta Doctors’ Digest
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New name. Renewed commitment. Total heart health. Cardiology Consultants has a new name - TotalCardiology. • Donald A.N. Meldrum • Robert N. Lesoway • Jim L. Hansen • Tim G. Prieur • Neil G. Filipchuk • Patrick T.S. Ma • Frank P. Spence • J. Peter Giannoccaro • James A. Stone • James M. Cohen • Sandeep G. Aggarwal • Ronak S. Kanani • Grant L. Peters • Tim S. Boyne • Hamid S Banijamali • Doris Basic • Andreas Westib • Hamid R. Habibi • Mustapha Kazmi • Ilias Mylonas
With our new name, we renew our commitment to patient-centred care that reflects our core values of respect, excellence, innovation, teamwork and collaboration and sustainability. We provide total heart health care delivering comprehensive cardiology services in 3 locations in Calgary: Our brand new state-of-the-art Cardio-Diagnostic Centre at 2891 Sunridge Way NE (Yellow Pages Building) where we offer: • Cardio-diagnostic tests: - Myocardial Perfusion Imaging Stress Tests - Exercise Stress Test - Echocardiogram - Carotid Doppler/Ultrasound - Holter Monitor Rapid Access Chest Pain Clinic (RACPC) at 2891 Sunridge Way NE (Yellow Pages Building) where we evaluate patients experiencing chest pain syndromes in a dedicated chest pain clinic setting. Clinical Care Centres in Bridgeland at 803 – 1st Avenue NE, Yellow Pages Building and South Tower Medical Building (Foothills Hospital): • Clinical Consultation for general cardiology • Tele-consultations with Cardiologist • ECG interpretation services – by Cardiologists Cardiac Wellness Institute of Calgary (CWIC) in the Talisman Centre 2225 McLeod Trail south for: • Cardiac Rehabilitation • Wellness and Prevention Screening Visit us online for our new one page Diagnostic Requisition and our Tele-Consultation Requisition for consultation by phone. To learn more about TotalCardiology please visit our website or call us at 403 571 8600.
totalcardiology.ca
TABLE OF Patients First ® Patients First ® is a registered trademark of the Alberta Medical Association.
The Alberta Doctors’ Digest is published six times annually by the Alberta Medical Association for its members. Editor: Dennis W. Jirsch, MD, PhD Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Editor-in-Chief: Marvin Polis President: R. Michael Giuffre, MD, MBA, FRCP, FRCPC, FACC, FAAC President-Elect: Allan S. Garbutt, PhD, MD, CCFP Immediate Past President: Linda M. Slocombe, MDCM, CCFP
CONTENTS
DEPARTMENTS 2 12 16 19 20
27 Health Law Update 32 Mind Your Own Business 34 Letters and Corrections 37 From the Editor
PFSP Perspectives Web-footed MD In a Different Vein Classified Advertisements
Residents' Page
FEATURES 6 Alberta set to lead in academic medicine
Physicians and the health care system will benefit.
9 "What physician advocacy is all about" Emerging Leaders grants support medical students and residents to help junior high students and refugees.
11 Renew your AMA/CMA membership now 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 November/December issue deadline: October 17
Continue to receive important benefits.
11 Tweet, tweet!
What the AMA's Twitter account offers you.
13 Five minutes, better bariatric surgery referrals Video podcast helps you understand issues of the obese.
14 An enduring mystery The opinions expressed in the 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 the Alberta Doctors’ Digest. Advertisements included in the Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.
A brief history of multiple sclerosis in Canada 1850 - 1950.
21 Annual North/South Doctors' Golf Tournament Large turnout, record-breaking contributions for medical student bursaries.
22 Scrutinizing primary care networks How would Alberta’s auditor general make PCNs better?
25 Wastes fraught: pass the audit, not Alberta Health Services’ waste management draws auditor general’s attention.
© 2012 by the Alberta Medical Association Design by Backstreet Communications
Cert no. XXX-XXX-000
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. Alberta Doctors’ Digest
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C o ve r F ea t u r e
Alberta set to lead
in academic medicine Physicians and the health care system will benefit Dr. Ronald J. Bridges Senior Associate Dean, Clinical Affairs, Faculty of Medicine, University of Calgary
Dr. Dennis Y. Kunimoto Vice-Dean, Faculty Affairs, Faculty of Medicine & Dentistry, University of Alberta
Dr. Rowland T. Nichol Associate Chief Medical Officer,
The current landscape: AARPs For more than a decade, Alberta has been recognized nationwide as a leader and innovator in academic medicine and the development of academic alternate relationship plans (AARPs). Today, the province is home to 10 AARPs at the University of Alberta and the University of Calgary that involve the departments of internal medicine (including cardiology and neurology), neurosurgery, family medicine and pediatrics. Collectively, they involve approximately 57% of faculty members with full-time academic appointments and 10% of those with clinical appointments.
Physician Work force, Compensation & Workspace, Alberta Health Services
A new provincial framework will change the face of academic medicine in Alberta. Building on the successes of current academic alternate relationship plans (AARPs), the provincial AARP (P-AARP) is a further integrated approach that will involve more disciplines and provide stability as academic medicine continues to grow and evolve. In this article, representatives of some of the main stakeholders involved in the development of the P-AARP share their thoughts on why this is the logical next step in the future of academic medicine, how it strengthens the health care system, and what to expect over the next year. 6
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AARPs, and the people they involve, have made tremendous progress in advancing innovation and the four pillars of academic medicine: clinical service; education; research; and administration/leadership. From attracting and retaining family physicians and specialists to enhancing the quality of Alberta’s medical education, AARPs have demonstrated great value in delivering results for our health care system. In a survey of 135 AARP members in Calgary, physicians said the AARP had a positive impact on their ability to spend more time with patients with complex needs (63%), implement innovations (64%) and provide interdisciplinary care (56%). However, the implementation of AARPs in Alberta has not extended
beyond the original 10 plans. In fact, only eight out of the 30 clinical departments at the University of Alberta and the University of Calgary have AARPs. This limits opportunities to plan on a province-wide basis, and the department-based model leads to inconsistency across existing plans. While we have made tremendous progress with AARPs, we realize that more needs to be done to ensure continued success. A provincial approach – supported by the development of a single health region and the Alberta Academic Health Network (a partnership among the University of Alberta, the University of Calgary and Alberta Health Services [AHS]) – will help us move forward and re-establish Alberta’s competitive advantage in academic medicine.
A new provincial approach: P-AARP A principles framework for a new provincial AARP was approved by Alberta’s minister of health in December 2011. Developed collaboratively by the faculties of medicine, AHS, Alberta Medical Association (AMA), government and academic physicians, the framework lays out principles that will guide the development of policies and details of the provincial plan. Ultimately, the plan will provide opportunities to: • Establish and achieve commonly defined and agreed guiding principles across AARPs around the areas of governance, compensation, membership, workforce planning and service.
As we move forward, we want • Deliver province-wide disciplinebased coordination, planning and program delivery integration and optimization involving primary and specialist care. • Secure Alberta’s competitive advantage in academic medicine and mitigate intra-provincial competition through a common compensation principles framework. • Increase capacity to address new proposals from other departments and specialties. All of this work will leverage knowledge gained from more than 10 years of developing and implementing AARPs.
Current status and next steps At the time of writing, the various stakeholders are working to develop detailed internal policies and procedures as they relate to: • Governance – promoting transparency and accountability in decision-making. • Workforce planning – creating an integrated, evidence-based approach that is driven by the health needs of Albertans. • Accountability – establishing common accountability information systems and service-specific metrics.
to ensure that the P-AARP supports physicians in the work that they do. After all, the real driver of success is not the plan itself, but the people who make it all happen.
Much of this work is being carried out by committees under the P-AARP governance structure, involving the AMA, government, AHS, faculties, current AARPs and interested departments. We anticipate that a formal arrangement will be finalized by April 1, 2013. Once in place, the P-AARP will be voluntary and open to academic physicians who hold a license to practice in Alberta and an AHS medical staff appointment, in addition to other eligibility criteria. More specific information regarding membership in the P-AARP will be finalized and released shortly, so please stay tuned.
Final thoughts
• Compensation – striving for transparent, competitive, consistent compensation for members of the P-AARP that incorporates recognition and risk.
Academic medicine is an integral part of the future of our health care system. In recognition of this, AARPs were developed and have made tremendous progress over the years. We believe now is the time to harness this progress, and promote collaboration and integration of academic medicine at a province-wide level. In doing so, we can strengthen the coordination of academic and clinical programs across the province. This is what the P-AARP hopes to achieve.
• Transition planning – developing transition schedules and assessing the impact of P-AARP principles on existing AARPs.
We welcome your thoughts. Please email info@albertapaarp.ca. For more information, visit www.albertapaarp.ca.
• Financial management – allocating resources based on clinical and academic priorities and demonstrating value for money.
The AMA and the P-AARP The AMA has had an ongoing role in the funding of AARPs through the former trilateral master agreement, and expects to maintain this role in the P-AARP. Currently, the AMA is involved in the P-AARP governance structure as a member of the P-AARP Steering Committee, established to oversee the development of the P-AARP and set its future strategic direction. The engagement and involvement of physicians will be crucial to the success of the P-AARP. The AMA will continue to provide input on matters pertinent to Alberta physicians, particularly from the individual perspective. In addition, the AMA is planning to develop materials and supports to assist academic physicians who are considering joining the P-AARP. For more information, contact Verlin R. Gwin, Senior Advisor, Policy and Negotiations, AMA, by phone 780.482.0318, toll-free 1.800.272.9680, ext. 318 or email verlin.gwin@albertadoctors.org.
What is an AARP? In Alberta, an academic alternate relationship plan (AARP) is much more than a compensation model for physicians. Rather, it is a complex and sophisticated accountability and funding framework that brings together multiple stakeholders including government, the two universities with faculties of medicine, AHS and the AMA. Through a contractual arrangement, an AARP pools multiple revenue sources into a single-funding envelope to support the delivery of academic medicine. Members of an AARP receive contractual payments that compensate them for all pillars of their work at a level comparable to clinical rates. This arrangement removes financial barriers that may discourage participation in non-clinical work, encourages innovation, and enhances integration across clinical and academic domains.
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F ea t u r e
“What physician advocacy is all about” Emerging Leaders grants support medical students and residents to help junior high students and refugees Refugee health and advocacy
Future physicians are wasting no time using their skills, passion and initiative to improve the health of others. Thanks in part to the Alberta Medical Association’s (AMA’s) Emerging Leaders in Health Promotion grant program, two Calgary-based projects have left a lasting impression on two very different groups. One project focused on promoting sun and skin safety to junior high school students. The other helped refugee patients better navigate the Canadian health care system. Those involved showed meticulous planning, implementation and evaluation skills to make their respective projects a success.
“We chose junior high school students because they focus more on their appearance and are interested in asserting their own independence in decision-making,” said Dr. Shoimer. “Also, at this age, teens may start using tanning beds to enhance their appearance for their junior high graduation.”
Sun and skin safety awareness
“I wanted to help because I enjoy teaching and interacting with kids,” said Mr. Guo. “The project provided me an experience in advocacy and education in dermatology.”
“There have been many times while traveling when I was surprised by our ability to connect with people whose lives seem like a million worlds apart from our own,” said Ms Lim, now in her third year of studies. “As physicians or physicians-in-training, we should always strive to relate to our patients, no matter their background.”
Over a period of six weeks, the medical students visited numerous schools and spoke to more than 1,500 students. They also spoke to a local high school’s graduating class. The response was very positive, and many of the participating schools have requested a repeat presentation for next year.
According to Ms Lim, Calgary receives approximately 1,300 new refugees every year. She believes this figure alone indicates a need for “culturally competent and socially accountable physicians,” especially because there are unique challenges that affect this group – health determinants, migration experiences, language and culture, to name a few. To this end,
Nothing frustrates resident physician Dr. Ilya Shoimer more than knowing that many incidents of skin cancer could have been prevented with precaution and proper care. “A lot of people aren’t aware of the risks and detrimental effects of ultraviolet radiation,” said Dr. Shoimer, now entering his second year of residency at the University of Calgary (U of C). “The fact that people put themselves in danger and not even know it really pains me as a dermatologist-in-training.” Along with a group of like-minded dermatology residents at the U of C, Dr. Shoimer decided to reach out to junior high school students in the Calgary area. Using a short PowerPoint presentation riddled with “eeew” – inspiring images of skin damage and overly-tanned celebrities as well as various hands-on activities, the group planned to spread the message on sun and skin safety to 1,000 students.
To carry out their mission, Dr. Shoimer and his resident group recruited eight medical students who would volunteer their time and present to the different schools. U of C medical student Danny Guo was eager to help.
Having worked in countries like Haiti, Nepal and Uganda as a health care volunteer, U of C medical student Rachel Lim has a personal connection to those coming from developing countries to seek a new life in Canada. Her project brought together medical students to provide assistance with refugee patients as they navigate through the Canadian health care system for the first time.
For Dr. Shoimer, organizing this project took his leadership skills “to the next level.” “I had to interact with medical students, oversee the project, and coordinate between students, school staff and the AMA,” said Dr. Shoimer. “I was able to enhance my project management skills, and I think these are important skills to have as a physician leader.”
University of Calgary medical students.
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she suggests that cultural competency and advocacy training should start right at medical school. Rather than waiting for this to happen, Ms Lim’s group decided to take action and apply their skills at the Calgary Refugee Health Clinic (CRHC), operated by Calgary Catholic Immigration Services. “I thought the best way to promote better health outcomes involved medical students gaining firsthand exposure to the unique health issues and barriers to care within the refugee population,” added Ms Lim. The main objective for the participating students was to meet refugee patients and assist them in finding family physicians. After obtaining health records and medical histories under the guidance of a supervising physician, the students helped refugee patients in their search for a family physician and accompanied them for their first visit to the physician’s office. Dr. Annalee Coakley was one of the supervising physicians at the CRHC and served as a mentor for the project. She was impressed by the knowledge and interest displayed by the medical students. “The medical students were great to work with,” said Dr. Coakley. “I got great feedback from the refugee patients – they appreciated that the students would take time to listen to their medical histories and the stories they had to share.” All participating medical students attended a training session before working with refugee patients. The training included a presentation on refugee health given by a physician from CRHC and a cultural competency workshop given by a hospital ethicist. Students also completed an internet-based training module 10
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focusing on refugee experiences and a self-assessment quiz prior to their initial visit. These materials were provided by a similar student-led initiative at the faculty of medicine, University of Ottawa. “Training was very important because communicating with a refugee patient can be pretty daunting for a medical student,” said Ms Lim. “Not only are there language barriers, but there are also cultural differences and often highly sensitive information being disclosed during the patient interview.” Over a period of two months, 15 medical students were able to interact with more than a dozen refugee patients. For Ms Lim, leading this project opened her eyes about the importance of physician advocacy and leadership. She was also inspired by the recent action taken by physicians across Canada to protest the cutbacks to the Interim Federal Health Program, which provides health benefits to refugees.
“Their efforts showed medical students what physician advocacy is all about.” This is a continuation of our series profiling the eight projects that received the 2012 AMA Emerging Leaders in Health Promotion grant. For more information about the program, visit www.albertadoctors.org/emerging-leaders.
Are you — or do you know — a medical student
or resident physician interested in developing a health promotion project? The 2012-13 Emerging Leaders grant application is now online!
Visit www.albertadoctors.org/ emerging-leaders for eligibility information and the application form. The application deadline is November 1.
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F ea t u r e
Renew your AMA/CMA membership now Continue to receive important benefits It’s time to renew your Alberta Medical Association/Canadian Medical Association (AMA/CMA) membership. The membership year begins October 1.
Membership forms and information packages were mailed in September. They will vary depending upon member category and may include the following:
Continue to receive AMA/CMA benefits and services, plus information about Negotiations 2012 and other issues important to physicians.
• Letter from the AMA president.
Renew via one of the following methods: • Online (log on to www.albertadoctors.org). • Mail your completed membership form to the AMA. • Fax both pages of the form to 780.482.5445.
• @ your service membership guide. • Membership form. • Medical Liability Reimbursement Administration Policy.
Membership questions? Contact AMA Membership and Benefits Team Leader Kirsten M. Sieben at 780.482.0323, toll-free 1.800.272.9680 ext. 323, or email kirsten.sieben@albertadoctors.org.
• Continuing Medical Education Administration Policy.
Scan to find out how you can join or renew your membership, or visit www.albertadoctors.org/ membership.
• Postage-paid return envelope.
Tweet, tweet!
What the AMA’s Twitter account offers you On August 13, we posted our firstever tweet on the new Alberta Medical Association (AMA) Twitter account! 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. Signing up for Twitter is fast, easy and free. Just go to https:// twitter.com/. You can open an account in under a minute.
• Don’t have a Twitter account? Check in regularly at http://twitter. com/Albertadoctors or see the most recent tweets on the AMA website, e.g., the Twitter box on https:// www.albertadoctors.org/media. We’ll be tweeting new items almost every day. Join us! Scan to go directly to the AMA’s new Twitter account, or visit us at https://twitter.com/ Albertadoctors.
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Health Law Update
Using social levers to reduce risk of medical misadventure and litigation Jonathan P. Rossall, QC, LLM Partner, McLennan Ross LLP
The education sessions at this year’s Canadian Medical Association annual meeting in Yellowknife, Northwest Territories, focused largely on health equity and particularly the social determinants which influence and guide the delivery of health services in the north. There was a special lecture on this topic by Sir Michael Marmot, MB BS, MPH, PhD, FRCP, FFPHM, FMedSci, FBA, an internationally acclaimed expert on the topic. Sir Michael explored six “domains” in his talk, commenting on the progress on each, both in his native country and internationally: • Giving every child the best possible start in life. • Education and lifelong learning. • Employment and working conditions. • Minimum income for healthy living. • Healthy and sustainable communities. • Social determinants approach to prevention. In my view, the six domains also feature prominently in the delivery of legal services in the medical-legal
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context in Canada’s isolated communities. The overall thesis is that the traditional delivery of health care is largely reactive rather than proactive. Because social determinants play heavily into the likelihood of the development of certain health issues, by addressing issues such as poverty, education, employment, healthy living and so on, many chronic health problems can be prevented or at least minimized. In the same vein, it is my view that these social determinants influence the culture of litigation in the north. Traditionally, when assessing trends in litigation (and specifically medical-legal
Social determinants play heavily into the likelihood of the development of certain health issues. By addressing issues such as poverty, education, employment, healthy living and so on, many chronic health problems can be prevented or at least minimized.
actions) we tend to look south. Litigation in the US is big business and one of the curses of having an undefended border is the seepage of litigation trends into Canada. However, the experience in the north, in my view, is quite different. It’s safe to assume that residents of Canada’s north are subject to at least the same risks of medical misadventure as the rest of Canada. In fact, Sir Michael Marmot would suggest that because of the social inequities, the northern population is exposed to a greater risk. However, statistically the number of lawsuits commenced in the north (per capita) is likely far less than in the larger, urban regions. I think this has to do with many of the factors Sir Michael identifies with health inequity. Education, social determinants, poverty and in fact geography all play a role in determining responses to perceived malpractice or inappropriate conduct on the part of physicians or other health care providers. Litigation in the north is as expensive, if not more so, than in the south. In addition, the indigenous people in the north tend to be much less confrontational by nature, more amenable to reconciliation or mediation and less likely to litigate. And the challenges posed by the vastness of the space and the comparative lack of resources make the prospect of commencing and maintaining lengthy and expensive lawsuits even more daunting. Those same challenges weigh heavily on
health care providers involved in litigation, many of whom reside in distant locations and are far-removed from the actions which form the subject matter of a lawsuit. Physicians, and those representing them, would likely argue that discouraging litigation is not a bad thing – that resolving differences through mediation or other
non-litigious means is a win for all parties involved. One does question, however, whether these societal factors are producing fair results for those injured through the inadvertence or negligence of a health care provider. One could also argue that by addressing and adopting Sir Michael Marmot’s six domains in the delivery
of health care, many of the diseases or afflictions which may otherwise give rise to medical misadventure will be eliminated or reduced, thus reducing the risk or frequency of litigation as well. All of which serves to underline the complexity of doing medical-legal business in Canada’s north.
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Five minutes, better bariatric surgery referrals Video podcast helps you understand issues of the obese Struggling through a lifelong battle with obesity often leads to a myriad of other health problems including heart disease and diabetes. Your patients are increasingly looking to you to help them find the answer, and for many patients, bariatric surgery is their last hope. “For the right patient, bariatric surgery is a real life saver,” says Dr. Chris J. de Gara, Professor of Surgery at the University of Alberta and Director of the Bariatric Revision Clinic at the Royal Alexandra Hospital. In October 2011, the Physician Learning Program (PLP) and Bariatric Program team at Weight Wise Adult Weight Management Clinic undertook a quality improvement project to examine bariatric referral protocols and related communication practices that promote surgical and medical referrals for bariatric surgery. This project was part of the wider provincial five-year obesity management initiative of Alberta Health Services.
As a result of information gleaned in this project, a five-minute video was created to enhance referrals of appropriate patients for surgical intervention. The video addresses certain misconceptions surrounding bariatric surgery by conveying the following messages: • Bariatric surgery is not an easy way out of obesity. • Bariatric surgery is not dangerous. • Bariatric surgery is a necessary and effective procedure because it achieves and sustains substantial weight loss compared to exercising and dieting. • Bariatric surgery is an effective procedure for treating and/or preventing a number of co-morbidities (Type II diabetes, high cholesterol, hypertension, sleep apnea, joint disease, cancer). • Bariatric surgery is an important part of an overall approach to obesity management.
The bariatric surgery video is one of hundreds of podcasts that make up the PLP resource library available to members of the Alberta Medical Association (AMA). It can be found on the PLP website at: http://www. albertaplp.ca/bariatricsurgeryreferral.
About the Physician Learning Program The PLP is an AMA-sponsored benefit stream program administrated collaboratively between the University of Alberta and University of Calgary. PLP is a physician-driven program designed to help physicians self-assess their current clinical needs and access high-value learning resources to meet those needs. The program achieves these ends by analyzing aggregated provincial data and the physician’s own practice-specific data. PLP provides physicians with feedback on their data to help them identify perceived and unperceived learning needs from which to target their learning. Using a variety of tools, including data analysis, podcasts, province-wide assessment projects and assisted individual studies, PLP creates an invaluable resource for physician learning. As physicians access and apply these resources, patient care and outcomes will be improved. Alberta Doctors’ Digest
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An enduring mystery A brief history of multiple sclerosis in Canada 1850-1950 Dr. Aravind Ganesh RECENT GRADUATE, UNIVERSITY OF CALGARY
This article was developed from the course work and student’s research project at the University of Calgary (U of C) History of Medicine and Health Care Program. It was presented at the Calgary History of Medicine Days conference in 2011. It was also presented at the special history of neuroscience workshop held for students at the Banff Centre for the Arts, as part of the first joint meeting of the International Society for the History of the Neurosciences and Cheiron – the International Society for the History of the Behavioral and Social Sciences (June 22, 2011). Both conference events were supported through the Alberta Medical Foundation. Similar to the series of three student papers in 2010, this contribution is an abbreviated version of one of the Dr. Margaret M. Hutton Lectures held at the Alberta Medical Association’s annual general meeting in Calgary on September 24, 2011. Multiple sclerosis (MS) is a chronic and debilitating demyelinating disease of the central nervous system, affecting close to 2.5 million people worldwide. The medical profession’s quandaries with MS as a distinct disease entity may be traced back to 1849, with the early description of Hirnsklerose (“brain sclerosis”) by the German pathologist Friedrich Theodor von Frerichs (1819-85). The century following the emergence of this clinical entity has been described by Hans Lassmann 14
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(b. 1949), neuropathologist at the University of Vienna, as a “golden centenium” for the evolution of medical understanding of MS. Although Canada has one of the highest prevalence rates for MS in the world, there is a paucity of historical explorations of this era.
MS likely had victims in Canada as in the rest of the world, long before the first descriptions emerged from the French and German neurological schools. One documented case that raises a strong suspicion of MS is that of a 19th century trader with the Hudson’s Bay Company at its York Factory post.
Early Canadian occupations with MS cases MS likely had victims in Canada as in the rest of the world, long before the first descriptions emerged from the French and German neurological schools. One documented case that
raises a strong suspicion of MS is that of William Brown (b. 1790), a 19th century trader with the Hudson’s Bay Company at its York Factory post, who began experiencing progressive leg weakness, gait difficulty and visual problems in 1811, to the point that he was forced to return to Scotland to be cared for by his family and died within a few years. It was in the wake of Jean-Martin Charcot’s (1825-93) work in Paris that three cases of “insular sclerosis” of varying severity were presented by Dr. William Osler (1849-1919) in 1880 before the Medico-Chirurgical Society of Montreal. These cases appear to be the first reported cases of MS in the English-speaking Canadian literature. Osler’s approach closely matched the leading trends of the period, be it the detailed clinical descriptions for each case, his diligent use of autopsy to identify the distinctive pathological features of the disease or his consideration of general paresis. With regard to the broad and confusing differential diagnosis, Canadian neurologists were vulnerable to the same diagnostic challenges as their European and US-American contemporaries, being forced to rely entirely on clinical features, details of the neurological examination and sometimes even post-mortem findings. Reflecting the American trend of psychiatric and cognitive symptoms being relegated to the realm of psychiatry, there is however virtually no discussion of MS neuropsychiatric aspects in English Canada between 1850 and 1950.
Nevertheless, Canadian physicians appear to have stayed abreast of contemporary European and US-American developments – such as the Romberg test for dorsal column pathology and postural instability, the deep tendon reflexes with the Babinski sign, the Argyll-Robertson pupil, and the Wassermann Reaction for syphilis – and thereby became more adept at differentiating MS from its mimics. Canadian neurologists appear to have been actively involved in the critical appraisal of these newly emerging technologies with respect to their clinical utility, as exemplified by the 1910 Canadian Practitioner and Review.
Etiological theories about MS were internationally discussed In considering the historical epidemiology, the Canadian literature matches the international trends during this era, with most cases involving young male patients. In the rare examples where a diagnosis of MS was considered for a female patient, it seemed that the alternative contemporary diagnosis of hysteria may have been typically favored, suggesting that the improved diagnosis of female patients with the evolution of neurology as a specialty may be tied with the apparent increase in the prevalence of MS in the late 20th century. The historical manuscripts also reveal the fascinating etiological theories for MS discussed in Canadian medicine, with two major camps – favoring infectious and toxic etiologies. Despite their day-to-day clinical struggles in accurately diagnosing MS, Canadian physicians appear to have been undeterred in their enthusiasm in seeking answers as to why their patients were suffering from this mysterious disease. Attempts at treatment were just as varied and intriguing, ranging from non-pharmacological and pharmacological therapies, to invasive
surgeries like nerve-stretching. While some physicians revamped clinical approaches to also confirm their diagnoses, as with Samuel West’s use of iodide of potassium, the evidence for most treatments was sparse at best. Canadian physicians appear to have been keenly aware of the extant quackery in the medical profession, as evidenced by a 1900 article in The Maritime Medical News, which remarked that “incurable diseases are as babies in [the quack’s] hands, and locomotor ataxia, multiple sclerosis, and epilepsy are his favourite bait.”
The postwar period as a new era for MS research The end of the Second World War may be seen as the beginning of a new “therapeutic era” in neurology. Patients with syphilis received the prospect of definitive curative treatment through
the mass production of the first antibiotic agent penicillin, discovered in 1928 by Dr. Alexander Fleming (1881-1955). Following the discovery of the neurotransmitter dopamine in 1957, the ability of injected l-dopa to improve akinesia in Parkinson patients was first demonstrated in 1961, leading to the development of oral levodopa later in the decade. Finally, academic research into the antiviral activity of interferons in the 1950s set the stage for the use of type I interferons for the treatment of MS in the 1970s, offering tangible hope for the first time in history. Yet even with our clearer characterization of MS and confounding entities in the modern era, the diagnosis of the disease remains a challenging issue. References available upon request.
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Mind Your Own Business
Are your employees fully engaged in your practice? Learn how to get there from here PMP Staff
“Engagement” has become a very common term in discussions about employee satisfaction and retention. Do you understand what engagement means? Do you understand what it means to your employees? According to Wikipedia, an engaged employee is one who is fully involved in and enthusiastic about his or her work, and thus will act in a way that furthers the organization’s interest. Engagement is distinctively different from employee satisfaction, motivation and organizational culture. Engaged employees often mean improved patient care, increased employee retention, a more satisfying work environment and a healthier bottom line. The questions you need to ask are whether your employee communication strategies are engaging employees, or are they merely informing them. Have you created a two-way dialogue, or are you simply pushing information in their direction? Are your communication strategies encouraging and supporting employees to change behaviors and attitudes, or are you finding – no matter what – your employees’ level of engagement stays exactly the same? Employee engagement encompasses a shared understanding of the issues that affect business, and that understanding 16
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leads to changes in employees’ attitudes and behaviors. Unless employees truly understand the issues and make a meaningful connection between their jobs and those issues, their attitudes and behaviors will not change. They need to understand that their success and success of the practice are linked.
with employees, you have an opportunity to be creative and craft how you connect with and reach them. One of the ultimate purposes in employee communication is to lead to the “Aha!” moment. This is the moment when employees have the required information, “get it” and understand they have the ability to do something about it.
Employee engagement
But before your employees “get it,” you as their employer, supervisor or boss need to help them and do your part. Do you know what motivates your employees? Do you understand what they know, and don't know, about your practice? Are you aware of what they don't like about their workplace or job? Do you know how they serve your patients or clients?
encompasses a shared understanding of the issues that affect business, and that understanding leads to changes in employees’ attitudes and behaviors.
Typically, three things need to happen to achieve engagement. • The employee has to understand the issue. • The business issue has to personally mean something to the employee. • The employee must feel that he or she contributes to solving the issue or improving the practice. There are many ways to encourage engagement. When communicating
The first step to building improved employee engagement is to understand how your employees think, act and feel. Engaging employees is a continuous journey that requires ongoing commitment. Consider and follow these four steps to help you build a stronger connection with and understanding of your employees. Doing so will help build their engagement and connection to your practice: • Inventory – list the methods you are currently using to communicate with employees and identify the frequency, intended audience and whether they are one-way or two-way communication vehicles.
One of the ultimate purposes in employee communication is to lead to the “Aha!” moment. This is the moment when employees have the required information, “get it” and understand they have the ability to do something about it.
» If the communication method allows for employees to give their feedback, ask questions or participate in important discussions, then it is likely that tool is more engaging and therefore, effective. This isn't to say that there is no place for a one-way information letter or email from the head of your organization or practice. The key is making sure you have the opportunity for ongoing dialogue with your employees. » If you don't have any communication tools that provide that opportunity, think about creating some. Hold a town hall meeting with staff. Have lunch with them. Create small working groups to brainstorm solutions to a practice issue. Create a blog and ask your employees questions and ask for their input. Build areas on your intranet where employees can contribute content. • Focus group – create an atmosphere where you can ask employees about their thoughts
on the practice and its clients. Focus groups are a good format as they allow you to explore issues further and sometimes discover issues that haven't been considered in management meetings. Ask employees about the practice and how it serves patients and identify if there are gaps in what you think, your patients think, and what your staff think. Don’t shy away from a professional facilitator who can be very helpful in taking your team through the process. • Create the plan – once you have the outcomes from the focus group, you can begin designing employee communication strategies that engage employees. You should have a clear understanding about what employees know and what the facts are, and the gap between the business facts and the staff perceptions. • Follow through – make sure you follow up on what you heard in your employee focus group. It is important to show your staff that you "heard" them, and respond
accordingly. Identify one of the issues your employees touched upon and build a strategy with them to address or resolve it. Even if you cannot or choose not to act on certain ideas, acknowledge that they have been heard and considered. Keep in mind if you have never engaged your employees in a meaningful way and they are used to communication being top-down only, it may take some time for them to be convinced you really mean it and openly participate. You may need to persevere and build credibility one step at a time by acting on their feedback and suggestions. It is worth it. Over time, active employee engagement can result in positive changes which will lead to improved functioning of your clinic and a more satisfying environment for you, your staff and your patients. The Practice Management Program is available to assist in a number of areas related to the effective management of your practice. For assistance, please contact Linda Ertman at linda.ertman@ albertadoctors.org or phone 780.733.3632.
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Letters and Corrections The following is a clarification from Dr. Arnold J. Voth regarding his letter in the May/June Alberta Doctors’ Digest. In his original letter Dr. Voth indicated that for general internists, it requires “$30,000 (a very lean operation) to $100,000 or more a year to maintain our offices.”
Addendum I have just discussed the figures I used for office overhead with a few colleagues who laughed at me because my figures were much too low. They find it inconceivable that anyone could possibly run an office for $30,000 a year and most would feel $100,000 is difficult. This is true. The office overhead in my own office for rent and wages alone would be somewhat over $100,000. By the time the other incidentals are added in, it is probably closer to $130,000. So realistically that figure should probably be revised to give a range of $75,000 to $150,000 for one physician.
The Alberta Medical Association (AMA) welcomes open letters and comments about Digest articles and suggestions for future topics. Please contact Daphne C. Andrychuk, Communications Assistant, daphne.andrychuk@albertadoctors.org, or write her c/o Public Affairs, Alberta Medical Association, 12230 106 Ave NW, Edmonton AB T5N 3Z1. The association reserves the right to publish and/or edit all letters.
Correction The article regarding the membership survey in the July/ August issue of the Alberta Doctors’ Digest indicated that 50% of members do not read the President’s Letter. That should have read “Only 50 members said they do not read the President’s Letter.”
Yours sincerely, Arnold J. Voth, MD LMCC, FRCP (CAN), FACP Edmonton AB
Flu Shot Clinics All Co-op pharmacies will be hosting in-store complimentary flu shot immunizations. Sign up in advance as space is limited. By appointment only. All individuals must live, work or go to school in Alberta, must be nine years of age or older and must show Alberta Health Care card to be eligible for flu shots.
Visit calgarycoop.com/pharmacy for clinic dates.
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Residents’ Page
Putting “family medicine” back into family physician residency training Dr. Lindsay M. Jantzie Family Medicine Resident Physician
Canadian family medicine residency programs are in the midst of a major transition. At the national level, medical school and residency curricula are being refocused to more firmly center in family practice. In March 2011, the College of Family Physicians of Canada, the national residency accreditation body, released recommendations on the future of family medicine training, and introduced the new Triple-C Competency-based Curriculum. The three C’s consist of comprehensiveness, continuity of both education and patient care, and experiences centered in family medicine. These curriculum priorities align well with the Future of Medical Education in Canada – Postgraduate Recommendations. They seek to ensure we train doctors to meet societal needs by focusing on developing family doctors who have significant experience in family practice settings outside of academic health science centers. I am very proud to be a part of Calgary’s Family Medicine Residency Program, which is quickly emerging as a leader in curriculum transformation in its implementation of these changes. As a family medicine resident physician, my education is unique. Compared to other programs where resident physicians spend the majority of training time in the context of 20
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their own specialties, at present, the majority of my training does not occur within the context of family medicine. Most of my learning is completed in a rotation-based format where the bulk of my experiences are on off-service rotations in specialties such as medicine, pediatrics, obstetrics, etc. On average, a family medicine resident physician has only eight months of training devoted to family medicine. This time is usually broken up into one- or two-month blocks. This model was based on the core belief that family physicians need to know a little bit about everything; however, as a result of the rotating model, I spend most of my training away from family practice and family physician preceptors and mentors, in environments that are often highly focused on areas of practice that may not always be relevant to my future practice. There are times when I struggle with this traditional training model, because it fails to recognize the core strength and experience of family practice – continuity of care. One of the skills that must be developed in a successful family practice is the ability to build ongoing relationships with patients and families and manage the complexities within these relationships. When I am on an off-service specialty rotation, my experiences with patients tend to be different – much more transient than what I wish to have when I am a fully licensed practicing physician. All too often in the current training model, I am unable to establish enduring relationships with my patients. In the context of a family medicine practice, these enduring relationships afford me with the opportunity to
One of the skills that must be developed in a successful family practice is the ability to build ongoing relationships with patients and families and manage the complexities within these relationships.
learn about my patients’ response to illness over time, the natural history of their disease, and the impact that illness has on their spirit. An ongoing relationship has benefits for my patients as well. A sustained relationship of trust and mutual respect enables them to raise concerns and feel comfortable divulging private information and asking important questions that might otherwise go unasked. Through repeated interactions, I am beginning to be able to recognize significant changes in my patients just from speaking with them. Recognizing a patient’s affect and body language is becoming just as important as the clinical findings in my examination. A major focus of Calgary’s new Urban Family Medicine Program (which began for all new first-year resident physicians on July 1) is continuity of education and patient care. In the new curriculum, resident physicians primarily experience family practice, rather than extended exposure to
other specialties, as is the case in the traditional model. These resident physicians will spend the majority of their training in the family medicine clinic (at least two full days per week). They take responsibility for a panel of patients and, over their two years of training, will be able to foster continuing relationships with these patients. The goals and outcomes of training and curricular elements are fully planned and overseen by family medicine educators who understand the needs of their family practice patients, and are able to ensure that
resident physicians are prepared to meet those needs. In addition, because the primary teachers in the new curriculum are family physicians and a small core group of primary preceptors is expected to follow each resident physician for their two years, we can build a feedback process that is increasingly continuous, constructive and consistent. As a co-chief resident for the University of Calgary’s Urban Family Medicine Program, I am excited to be a part of this evolution and I look forward to watching how these changes unfold. Not only do some of
the changes affect my own education, I am also playing a role in shaping the experience of new family medicine resident physicians! I believe this transformation in training and learning fundamentals will only make the discipline of family practice stronger. In the long term, stronger family medicine programs will benefit all Canadians. New graduates will enter practice with a well-developed sense of professional identity, a clear understanding of patient-centered care and the ability to provide care in diverse environments for all Canadians.
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Annual North/South Doctors’ Golf Tournament Large turnout, record-breaking contributions for medical student bursaries The Alberta Medical Association (AMA), along with the College of Physicians & Surgeons of Alberta (CPSA), hosted the 85th Annual North/South Doctors’ Golf Tournament, July 23 at the Red Deer Golf and Country Club. The event included breakfast, golf, lunch and prizes. More than 100 participants came together for the event, making it the biggest turnout to date. As a result, more than $40,000 was raised for medical student bursaries. That brings the total bursary funds raised for students to $994,500 since 2001. Thank you to all of the participants. More so, congratulations for making the 2012 record-breaking contributions to the medical student bursaries achievable!
Top: Drs. Patrick M. Pierse, David W. Bond, Robert T. Kruhlak and A.A. Carlos Menezes (l to r) make a quick stop at the 10th hole snack shack.
See you in 2013!
Bottom: Marilyn Elliott (l) and Crystal Pelton of tournament sponsor MD Physician Services arrive at Hole #2 for a chance to win $50,000 in the hole-in-one contest.
Dr. William J. Dickout is the lucky raffle winner of a Sun Mountain golf cart.
(
courtesy of the CPSA.)
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Scrutinizing primary care networks How would Alberta’s auditor general make PCNs better? For his July 2012 report, Alberta Auditor General Merwan Saher turned the sights of his office on primary care networks (PCNs). As he wrote, “the objective of the audit was to determine whether the Department of Health has systems to demonstrate the value that Albertans are receiving from the public’s investment in primary care networks. We examined: • “Whether the department has systems to ensure PCNs, individually and overall, are achieving the objectives of the PCN program. • “Whether Alberta Health Services (AHS) has systems to meet its responsibilities under the PCN program.” What did he find? The auditor general reported good value in primary care networks – and strongly recommended that PCNs receive more support to become even better in the future. Not surprisingly, then-AMA President Dr. Linda M. Slocombe read the report with keen interest. She shared her reaction with members in a July 5 President’s Letter. “The report,” she wrote, “shows Mr. Saher’s good understanding of PCNs – their successes and their challenges – and the value of investing in primary care. It also speaks to the need for greater accountability. The report, therefore, can serve as a reference and guide as Alberta’s primary health care continues to evolve with additional investments by government.”
PCNs: A pat on the back The auditor general complimented those involved with the PCNs, saying 22
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that his investigation found “many examples of positive outcomes and good practices by individual service providers, management and staff at PCNs and AHS, as well as the department.” For example, one story cited involved “a recent independent study (that) compared 75,000 diabetics receiving treatment in a PCN with 75,000 diabetics not receiving their treatment in a PCN … care within a PCN was associated with a 20% reduction in the rate of admissions to hospitals and visits to emergency departments for diabetes-specific conditions.”
PCNs: Need more support The auditor general “found weaknesses in the systems of accountability and centralized support for the PCN program.” He made it clear that PCNs could have been more successful with the appropriate support from Alberta Health. “The department assigns patients to PCN patient panels but does not proactively inform the physicians, the PCNs or AHS which patients have been assigned to the PCN physician panels.” Alberta Health should “proactively inform Albertans which primary care network they have been assigned to, and what services are available through their PCN.” Alberta Health “has a wealth of health data that would be very useful to PCNs in planning and evaluating their services, but does not have systems to share this data with PCNs or help them analyze it.” For example, PCNs need information about which Albertans have chronic diseases, and about “immunizations
and patients who require and have received screening services.”
Family care clinics: Look before leaping The auditor general provides guidance and a caution for the government about its plans to set up 140 family care clinics (FCCs). Mr. Saher noted that: “As with the PCN program, all major initiatives in primary health care need clearly defined expectations and systems to measure and report performance. As the FCC initiative goes forward, the department needs to consider the issues discussed above to determine the systems it will require to ensure FCCs are duly accountable and have adequate support to ensure their success.”
Auditor General’s Report July 2012 Excerpts from the report Summary The first Primary Care Network began operations in 2005. The program has grown steadily since its inception. As of this April, there are 40 PCNs operating in the province, involving over 2,600 family physicians and more than 600 full-time equivalent other health care providers in delivering primary health care services to 2.9 million Albertans. The Department of Health expects to spend more than $170 million on the PCN program in 2012-13 and has provided over $700 million in funding to date. Why it is important to Albertans The significance of the PCN program goes far beyond the direct funding the department provides to it. PCNs are a critical link that operationally
connects family physicians with AHS in the delivery of primary health care services. High-quality primary health care is critical for prevention of acute illness and for effective and efficient management of chronic disease. By focusing on health promotion and disease prevention, primary health care can help identify disease at its onset and reduce the subsequent severity of an illness. This can produce better health outcomes for Albertans and reduce the demand on more expensive acute care services. What we examined The objective of our audit was to determine whether the Department of Health has systems to demonstrate the value that Albertans are receiving from the public’s investment in primary care networks. We examined: • Whether the department has systems to ensure PCNs, individually and overall, are achieving the objectives of the PCN program. • Whether Alberta Health Services has systems to meet its responsibilities under the PCN program. We performed two concurrent audits – one at the Department of Health and one at AHS. The reason for presenting them in one report is that both entities have significant roles with respect to PCNs, and these roles must be coordinated for the program to succeed. What we found We found significant weaknesses in the design and implementation of the accountability systems for the PCN program. Our overall conclusions are as follows: • The department and AHS do not have systems to evaluate the
PCN program and demonstrate that their current efforts are bringing the province-wide benefits envisioned for this initiative. • Albertans are not informed that they are assigned to a PCN, and PCNs do not have the names of those the department has assigned to them. PCNs know only the total number of patients assigned and the amount of funding they receive. This limits patients’ ability to engage in decisions about their own health care, and impairs PCN program planning and accountability. • Opportunities to create province-wide systems to support and improve the PCN program have been missed by both the department and AHS. • System weaknesses at different levels within the PCN program have resulted in poor compliance oversight for the program overall. • Although we found weaknesses in the systems of accountability and centralized support for the PCN program, we observed many examples of positive outcomes and good practices by individual service providers, management and staff at PCNs and AHS, as well as the department. PCN context The current state of the PCN program must be viewed in the context of challenges the program has faced since its inception. The following history provides some context for the progress of the program: • The PCN program was the first systematic effort in Alberta to bring the department, regional health authorities and family physicians together at the operational level in primary health care.
• During the eight years (2003–11) that the Trilateral Master Agreement was in effect, the department, regional health authorities (later AHS), and the Alberta Medical Association were considered equal parties in making decisions about the PCN program. This need for consensus created challenges in aligning the parties’ interests to achieve the common objectives of the PCN program and measure its success. • To get the initiative started, sacrifices were made around system design, controls and performance measurement. The department and regional health authorities expected to overcome these limitations and gaps as the PCN program matured. • From the start, the daily operations of PCNs were placed under the control of family physicians, with regional health authorities participating mainly at the governance level on PCN boards. • Effective April 1, 2009, AHS took over from the nine regional health authorities as a 50% joint venture participant in all PCNs. AHS had to combine the different structures inherited from the regional health authorities into a provincewide approach to its PCN responsibilities. Subsequent reorganizations within AHS have further changed the processes between AHS and the PCNs. • With the expiry of the Trilateral Master Agreement on March 31, 2011, the department has sole authority for all financial matters related to the PCN program, with input from AHS and the AMA through an interim advisory committee that has representation from all three parties. Alberta Doctors’ Digest
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What needs to be done? We made the following four recommendations to the Department of Health and one recommendation to Alberta Health Services: Recommendation – department’s accountability for the PCN program We recommend that the Department of Health: • Establish clear expectations and targets for PCN program objectives. • Develop systems to evaluate and report performance of the PCN program.
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Recommendation – AHS accountability for PCNs
Recommendation – department’s support to the PCN program
We recommend that AHS within the context of its provincial primary health care responsibilities:
We recommend that the Department of Health improve its systems to provide information and support that the PCNs and AHS need to achieve PCN program objectives.
• Define goals and service delivery expectations for its involvement in PCNs. • Define performance measures and targets. • Evaluate and report on its performance as a PCN joint venture participant. Recommendation – engagement and accountability to PCN patients We recommend that the Department of Health proactively inform Albertans about which PCN they are informally assigned to, and what services are available through their PCN.
Recommendation – department’s oversight of PCNs We recommend that the Department of Health improve its systems for oversight of PCNs by: • Obtaining assurance that PCNs are complying with the financial and operating policies of the PCN program. • Ensuring PCN surplus funds are used in a timely and sustainable manner. http://www.oag.ab.ca/files/oag/ OAGJuly2012report.pdf
F ea t u r e
Wastes fraught:
pass the audit, not Alberta Health Services management of waste material draws the auditor general's attention In his July report, Alberta Auditor General Merwan Saher examined “whether Alberta Health Services (AHS) has effective systems to manage its health care waste materials handling and disposal.” “Health care waste materials” include both biomedical and chemical waste. The auditor general found weaknesses in the way AHS deals with these materials. He found no evidence of actual harm being done, but made strong recommendations for improvement. As he told the Edmonton Journal (July 5, page A4): “If you ask me, ‘Do we have evidence that there are actual human health risks and actual environment risks that we observed, and that AHS’s reputation has been damaged so far by incidents?’ the answer is no, but that’s what a risk is all about. “You identify risks and then you put in place cost-effective systems to manage the risks. So we’re simply saying that there is a real risk and the system is not there to manage the risks. And if you don’t put the systems in place, you continue to leave yourself exposed to something nasty happening, and that’s what Albertans should be concerned about.” AHS responded to the report and recommendations by saying the
organization has already been working with the auditor general’s office. AHS wants to deal with the concerns Mr. Saher identified and will be working on new policies and processes to close the gaps.
Auditor General’s Report July 2012 Excerpts from the report Why it is important to Albertans The cost of health care waste materials management is not high in relation to AHS’s total annual budget of more than $10 billion. However, the potential risks associated with health care waste materials are significant, including: • Human health risks such as infection or injury from direct contact with biomedical waste by patients, health care workers, visitors, cleaning staff, waste collectors, processors and recyclers. • Environmental risks (ground, air and water contamination) – health care waste materials may contain substances that are infectious, toxic, radioactive, flammable, explosive, corrosive or otherwise harmful if not safely disposed of. • Reputational risk – health care waste incidents may raise fears, aesthetic concerns or loss of confidence in the health care system.
What we found We found weaknesses in AHS’s systems to manage health care waste materials. Our key findings include the following: • AHS has not assigned responsibility for oversight of the management of health care waste materials at all AHS sites that generate these materials. • AHS has not fully standardized health care waste management procedures across its sites. • AHS does not have adequate controls to ensure waste disposal services have been performed before it approves vendor invoices for payment. • AHS’s current agreements with contracted service providers do not provide adequate assurance that AHS’s service standards for health care waste materials management are being met. What needs to be done? We made the following four recommendations to AHS: Recommendation – oversight at AHS waste generating sites We recommend that Alberta Health Services establish systems for overseeing the management of health care waste materials at all AHS sites that generate these materials.
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Recommendation – waste handling policies and procedures at AHS sites We recommend that Alberta Health Services improve the handling and disposal of health care waste materials at its sites by: • Standardizing health care waste materials handling policies and procedures across sites. • Establishing processes to monitor and enforce facilities’ compliance with health care waste materials handling policies and procedures.
• Ensuring chemical waste hazards are remediated promptly. • Pursuing more opportunities to reduce, reuse and recycle materials that could enter the health care waste stream. Recommendation – contract management for disposal of health care waste at AHS sites We recommend that Alberta Health Services take steps to improve its contract management processes for health care waste by: • Requiring sites to verify services have been received before
approving vendor invoices for payment. • Developing risk-focused systems to monitor health care waste management for purposes of controlling volumes and costs. Recommendation – health care waste at contracted health service providers We recommend that Alberta Health Services assess its risk related to health care waste produced by contracted health service providers and ensure contract provisions manage that risk. http://www.oag.ab.ca/files/oag/ OAGJuly2012report.pdf
F ea t u r e
New this month at albertadoctors.org Tips and new stuff for you Website feature focus: My Favorites One of the fastest ways to find your way around the new Alberta Medical Association (AMA) website is to use the search feature (top right on every page of the website). If you want to find a specific document or piece of information, using search is definitely the best way to go. But what if you have documents or information that you use all the time? Instead of searching for them every time, you can create your own mini-version of the site – a “My Favorites” list. Creating a list of your most visited pages is easy. 1. Log on to the website: • Go to the gold “Member Sign-in” box at the top right of the site. 26
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• Enter your AMA member number and website password. If you need help logging in, please visit Login help (https:// www.albertadoctors.org/ feedback/login-help). 2. Create your favorites list! • As you move around the site, you’ll see a gold “Add to favorites” bar at the bottom of every web page you visit. • To create a favorite, simply click on the bar. • Click on the blue link to “My AMA” at the top left of the website to see your favorite web pages listed in alphabetical order. • Now, whenever you log on to the “My AMA” page, just click
on a favorite’s link to go directly to that web page. • Follow the same process to add more favorites at any time. For a guided tour of the AMA website and its many features: • Visit https://www.albertadoctors. org/feedback/how-to-use-thiswebsite or • Scan the QR code below with your smartphone (for instructions on how to scan QR codes, see page 3 of this magazine).
PFSP Perspectives
A leader in the movement
toward a healthier culture of medicine Vincent M. Hanlon, MD PFSP ASSESSMENT PHYSICIAN
Perspectives are changing at the Physician and Family Support Program (PFSP). Dr. Dianne B. Maier, recipient this summer of the Canadian Medical Association (CMA) Physician Misericordia Award for her outstanding contributions to physician health, retired as director of PFSP in January. While Dianne enjoys her retirement, the work of the program that flourished under her years of empathic leadership continues. Dr. Teresa E. Brandon is our interim clinical director. New assessment physicians have joined our team as others have retired or redefined their work priorities. PFSP’s activities in the area of physician health education are also in transition. Dr. Elizabeth M. Monaghan (pfsp@ albertadoctors.org) took over as PFSP’s education coordinator in July. We are revisiting our education mandate as the number of requests for presentations increases year by year.
Big Country Hospital in Oyen AB. All facilities across the province need to cultivate the health of their own workers — not just the patients inside the building. ( by Dr. Vincent M. Hanlon)
The PFSP Annual Report 2011 (https://www.albertadoctors. org/pfsp/annual-report [login required]) includes a list of the 75 presentations done by 29 different speakers – PFSP staff, contractors or sponsored speakers – at more than
50 educational events, retreats and conferences attended by nearly 3,000 physicians, residents or medical students. New and recurring topics include the healthy workplace, resilience, work-life harmony, fatigue management, effective communication, stigma and mental illness, mindfulness and career transitions.
PFSP’s education and health promotion agenda The philosophy underlying our education initiatives is four-fold. 1. We do presentations. At the invitation of curriculum advisors, residency program directors, retreat organizers and conference planners, PFSP helps to infuse physician health content into under- and post-graduate medical education and participates in a range of Continuing Medical Education/Continuing Professional Development/CanMEDS activities and conferences. 2. Information by itself is not enough. No matter how compelling the evidence, it is often insufficient to motivate behavioral change. Patients remind us of that every day. Access to reliable up-to-date information is the first step. How we respond to it, and are transformed by it, are important next steps. 3. Improving physician health across the profession requires more than individual efforts at self-improvement. More than once I’ve been told by residents when discussing fatigue management or work-life balance that PFSP messages need to be shared with their program directors – which we do. Physician health is a shared responsibility that requires cultivating a network of advocates and champions among our health care partners – the faculties of medicine and organizations like Alberta Health Services, College of Physicians & Surgeons of Alberta, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association and Canadian Medical Association. This work never ends. Physician self-interest is at work here but it should be seen in context of the interdependence of our organizations and ultimately, the health of patients. 4. We facilitate informal conversations on health and wellness through Diane Bird, our PFSP project manager. Diane, along with other support staff, took Alberta Doctors’ Digest
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our PFSP booth to 13 educational events in 2011. From it they conducted surveys for the addressing stigma initiative, and distributed our latest health promotion materials, welcoming more than 2,000 visitors to the booth along the way. Diane and the booth are the visual emblem that many colleagues identify with PFSP.
We do not think ourselves into a new way of living, but we live ourselves into a new way of thinking.
Not long ago I attended a presentation by Dr. Jane B. Lemaire on the meaning of support. What are the ways in which we as individuals can support or help someone in difficulty? Dr. Lemaire described three different kinds of support, a classification which is relevant to understanding our own health needs or those of a colleague. 1. Emotional support. Call this part “being there.” It is the attentive listening to the story of someone in distress – being present to a friend, a patient, a colleague. 2. Informational support. Providing information and suggesting courses of action are forms of informational support. Sharing knowledge and giving advice are familiar territory for physicians, although we may be more comfortable giving than receiving.
enough. They need to take root during all stages of medical education (or preferably before) so they can be practiced across the career span.
Ongoing evaluation Timely and thoughtful assessment of our education efforts is indispensable, just as it is in the practice of clinical medicine and the teaching of trainees. We ask for, receive, and act on formal evaluations from participants at the majority of our presentations, and from conference organizers’ feedback. The PFSP Advisory Committee at its spring meeting reiterated a need to continue traditional face-to-face
3. Instrumental support. This is the “action” part of support. It might involve accommodating a colleague’s request for a call-schedule change, volunteering some of your non-medical expertise, or inviting someone for coffee when it’s not convenient for you. Helping someone may require going that extra kilometer. We should examine our attitudes to physician health in a similar fashion. To what extent do we engage emotionally with our personal health issues (and share those feelings) as distinct from analyzing them? And how are we best able to convert an understanding of our health priorities into salutary daily practices? One of PFSP’s primary educational roles is to be a catalyst – to turn what many participants at our sessions identify as “common knowledge” and “common sense” into common action. Richard Rohr, director of the Center for Action and Contemplation says, “We do not think ourselves into a new way of living, but we live ourselves into a new way of thinking.” Articulating wellness strategies is not
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Münster: Germany’s bike friendly city 2011. Improving physician health across the profession requires more than individual efforts at self-improvement. ( by Dr. Vincent M. Hanlon)
physician health presentations with large and small groups, in addition to tele- and video-conferencing, and the use of electronic and print media. Unfortunately these kinds of assessments do little to evaluate any permanent change in attitudes or behaviors wrought by our educational activities. We continue to look for better quantitative and qualitative instruments with which to measure the long-term effectiveness of our efforts.
Important physician health education events on the horizon: 1. AMA-BMA-CMA International Conference on Physician Health. October 25-27, Montreal. 2. Healing and Treating Trauma, Addictions & Related Disorders. November 28-30, Edmonton. 3. Canadian Conference on Physician Health. November 15-16, 2013, Calgary.
Which way to the future? What is the best way to proceed as we organize our master timetable and engage in another year of presentations? Here are some of PFSP’s key objectives for the educational year ahead: 1. Manage the form and content of our presentations in creative ways. We present topics designed to inform, challenge and motivate participants. We try to emphasize interactive elements over the didactic, include evidence where it exists, and make practical suggestions pertinent to daily life. 2. Endeavor to model the best physician health programs in our work, including proven pedagogical methods to maximize adult learning. 3. Clarify how PFSP can best use web-based and social media platforms in our educational initiatives. ePhysicianHealth.com, “the world’s first comprehensive, online physician health and wellness resource,” has been available for three years. Albertadoctors.org has recently been redesigned. How do we make online physician health material credible, dynamic and worth five or 10 minutes of your daily visits to cyberspace? 4. Determine the optimum balance between online and offline education endeavors. Location is everything. Or is timing everything? The 1.877.767.4637 helpline provides 24/7 access to our clinical services. In some ways, the more complicated logistical task is preparing and making a relevant presentation at the right time and place to a group with mixed needs and expectations. At the end of the day, clinical service and educational outreach are complementary parts of a physician health program that endeavors “to be a leader in the movement toward a healthier culture of medicine.” (PFSP Annual Report 2011)
Please call PFSP toll-free at 1.877.SOS.4MDS (1.877.767.4637) 24 hours a day, 7 days a week, 365 days a year.
Physician and Family Support Program
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AMA Physician Locum Services®
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Locums needed. Short-term & weekends. Family physicians & specialists.
Contact:
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Web-footed MD
Canadian Medical Association
– Stat!Ref J. Barrie McCombs, MD, FCFP
Canadian Medical Association cma.ca In this issue, we’ll look at Stat!Ref, another of the clinical resources available on the Canadian Medical Association (CMA) website. To get started, log onto the CMA website then click on “Clinical Resources/K4P” at the top of the page. A link to Stat!Ref is located in the menu on the left side of the Clinical Resources page.
Stat!Ref home page You will first be requested to accept the terms of their End User License. Links to textbooks are listed on the left-hand side. Links to other tools and resources are displayed in boxes in the center of the page.
Training center The Training Center is the best place for new users to start. It provides a brief introductory video tutorial and printable “quick guides.” Additional user information is available from the Help link on the upper right of every page.
Search window To search all available resources at once, enter a search term in the
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window at the top of the page. The Advanced search feature allows you to customize your search.
Your preferences Some tools are not activated until you use the “Your Preferences” link to identify your medical specialty and select options for what information you will find useful. Creating a preferences file also allows you to flag a particular document as a “favorite” so that you can return to it quickly.
Textbooks Stat!Ref offers subscriptions to more than 300 medical textbooks and resources. The CMA subscribes to only those listed on the left side of the Stat!Ref home page. Click on a title to display its table of contents. The current subscriptions include resources in Family Medicine, Pediatrics, Internal Medicine, General Surgery, Psychiatry, Oncology and Infectious Diseases.
Tool boxes Several resources are available from “tool boxes” in the center of the Stat!Ref home page. To view the resource, click on the logo in the middle of the box. To minimize or maximize any box, click on the blue bar containing the title.
Anatomy TV This is a suite of 3D interactive models of human anatomy. Intuitive controls allow the user to zoom, rotate and peel away layers. A wealth of supporting
media, MRIs, X-rays, movies and animations are also included.
MedCalc 3000 MedCalc 3000 provides a wide array of pertinent medical formulae, clinical criteria sets and decision tree analysis tools.
ACP PIER PIER (Physicians' Information and Education Resource) is a collection of over 400 evidence summaries published by the American College of Physicians.
AHFS-DI This is a drug information resource from the American Hospital Formulary System. It is available from the same box as ACP PIER. As with other American drug resources, the drug indications and dosages may differ from what appears in the Canadian Compendium of Pharmaceuticals and Specialties.
Favorites If you have created a preference account, you can attach “sticky notes” to a paragraph. The text in the sticky note is displayed in the Favorites box and provides quick access to the information.
Evidence alerts This box displays recent alerts that match the criteria you have set up in your preferences account.
Medical news feeds
Mobile application
Log out
This box displays medical news items that match the criteria you have set up in your preferences account.
A box on the home page gives links to information about access to Stat!Ref using mobile devices. This feature may not be available to CMA members.
As for other CMA clinical resources, please use the Log out link on the Stat!Ref home page when you are finished. This frees up the resource for other members.
Stedman’s medical dictionary Double-click on any word in a document to display the definition from the Stedman Dictionary. Direct access to the dictionary is available from the Stedman’s toolbox.
APhA
Time out If you use Stat!Ref for extended periods, you may encounter a window asking you to enter a user name or password. To restore access, return to the CMA website and log in again. This issue has been reported to the CMA librarian.
Your comments and suggestions are welcome. Please contact me: bmccombs@ucalgary.ca T 403.289.4227
Drug newsletters from the American Pharmacists Association (APhA) are available in this box.
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In A Different Vein
Here’s mud in your eye Taking a ride to conquer cancer Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Co-editor
The best travel stories are about discomfort, lost passports and wallets, nasty immigration officials or sweaty nights in flea-blown hotels. And since you’re all weary of Alberta Health Services (AHS) expense scandals and fat pensions for bureaucrats, here’s a bit of a travel story – a bicycle ride at the end of June. This was the optimistically named Ride to Conquer Cancer 2012 for which some had rashly volunteered to stoke-up funds for the clinical research unit at the Tom Baker Cancer Centre. Willem, our team captain, gave a rousing speech at 8:30 a.m. on the Saturday and more than 2,000 of Alberta’s FLOWERS OF THE FOREST wheeled their velocipedes out of Spruce Meadows, bikes oiled and name labels hanging from the top tube so cheerleaders could give a personal cheer as we swooped into a pit stop or puffed up a hill. “Yeh, Dave … woo-hoo … nearly there.” Grey clouds threatening, we breezed past the Edmonton Cross Cancer Institute team who were gasping up the first main hill, unaccustomed to the altitude. We waved to them sportingly. 34
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Riding in the rain. (
supplied by Dr. Alexander H.G. Paterson)
The rain started two hours later at High River and for the first day’s ride of 125 kilometers it seemed worthwhile to try to keep dry. But by Sunday I had surrendered, deciding to enjoy the trickle of water down the back of the neck, the damp in the groin and the wet seeping into the shoes. Throughout the two-day ride, especially when pedaling up alps upon alps with spray in the face, I nursed my wrath (to keep it warm) at AHS for failing to support and understand the importance of clinical trials in oncology. I urged my bike up the hill wishing that the little group ahead was a peloton of AHS bureaucrats … er … “vice-presidents” that I could shoulder into the ditch. It’s true – these reprehensible thoughts come to one at times of physical stress.
Biking tip #1: Even though wet and cold, keep up the fluid intake to avoid dehydration. Think dark thoughts to keep the adrenaline flowing. It was a hard slog west on Highway 24 to the Cowboy Trail in light rain which evolved into a downpour for the grind south to Chain Lakes. Dark clouds obscured the Rockies. A thunder storm rumbled to the west. The threat of a lightning storm stimulates gluconeogenesis, although by then I was convinced my saddle had dropped off and I was sitting on the saddle post. Biking tip #2: Keep the pudendal vasculature flowing and the levator ani relaxed. Because of the inevitable proctalgia, every 500 meters stand up on your pedals and if no one is within ear-shot, let out a grunt: “Ooof…” – like top tennis players do while serving.
There should be a special roasting grill in hell for the person who invented roadside rumble strips. For a cyclist, accidentally going over these is like a dental drill grinding into one’s ischial tuberosities.
A woman and a boy came up:
Every so often one passed a glum rider at the side of the road with a flat tire – yes there’s sympathy and perhaps even a shout of “Need any help?” but then a short burst of schadenfreude: Thank God it’s not me who has the flat.
I churlishly refused a hand-up. When you do something stupid you don’t want any help emphasizing your stupidity. It’s human nature. Rising from the mud I looked like an Elizabethan theatre actor portraying night and day.
Coming into Chain Lakes there was a crowd of on-lookers and cheerleaders roped in for the event. I cruised in Lance Armstrong style with a handlebar salute. “Well done Alexander … woo-hoo….” It was the same crew that was at the lunch stop. They were just doing their job. “Watch the mud. It’s slippery,” shouted an older man. I smiled. As the bike slowed in the squishy mud, I did the slick Charleston movement with the feet to unclip the shoes from the pedals. The right shoe came out fine but my shoes were looser than I thought and – panic – the left shoe did not release. The bike slowed to a stop in the deepest part of the mud. It’s a helpless feeling when you know gravity is real and something bad is going to happen – please, not in front of all these people. It was like that National Geographic movie where the antelope is being chased by the lion and there comes the point when the antelope realizes the game is up and he collapses to the ground and lets the lion sink its teeth into his neck. It was pointless to struggle. I made a slow left-hand side pitch into the mud and lay there like the antelope. I was glad of the helmet – it saved me getting a full facial mud pack even though some say it’s good for the skin.
“Hey, my son did something like that, didn’t yuh Brandon.” Brandon looked about 12-years-old.
Biking tip #3: Oh, forget it. It was now pouring rain which helped wash down my night side. I parked the bike. A soaking wet seat tomorrow was 12 hours away. Tent A63 was at the furthest corner of the tent area. Sloshing along in the mud between the rows of tents like Slum Dog Millionaire in a Bombay monsoon, I located the tent, threw in my bag and took out my new air mattress. “It inflates itself, mate,” the young Aussie had said at Mountain Equipment Co-op. I waited for the magic to happen, gave up and inflated it by mouth, cursing all young Australians.
There were showers in long trucks. The shower was hot but of limited volume requiring a slow turning of the torso as if on a barbecue spit – glorious and warm with the spray on the front, cold behind. Back in the tent the rain hammered on the canvas. “If I get up in the night I’m heading right,” said Dave, my tent mate. We agreed we were not going all the way to the biffy in the middle of the night. In World War I trench mates looked after each other’s feet by massaging them. We did not do that. No cases of trench foot were reported to the medical orderlies. We pushed in our ear plugs to the battering of rain and slept. Well, it was hardly like a night at Passchendaele – no trench foot, shells, bullets, lice or compo ration – but there was mud and a feeling of no escape, ever, from the damp and wet. Sunday morning was misty at 5 a.m. with low-lying cloud and drizzle. The campsite was waterlogged. The rows between tents had mud up to the ankles. “Anyone got sunblock?” shouted a wag.
By now the rain had settled into a steady reliable downpour. Some riders wandered around wrapped in silver foil looking like Christmas tree decorations. Supposedly this keeps you warm. Others had their feet cased in plastic bags to keep the mud out. Many gave up on shoes and squelched around in bare feet. Rain water poured off the edges of the canvas tent. The whole area was a mud pit. Our team sat in the marquee chatting and drinking wine. The band played. I suppose it was like Woodstock in 1969 with Country Joe and the Fish on stage although there was no public copulation.
Nature called – and it’s amazing how a trouble-free bowel movement can perk one up. It’s also amazing how sleeping bags are always much larger than the holding bag they came in especially when being rolled up in a wet tent. Yesterday’s gear was still sopping. I walked bare foot for breakfast, slithering in the mud. Putting on wet socks over muddy feet and squeezing into soaked bike shoes was a low point. I settled onto the spongy bike seat and set off in the mist and drizzle with the 2,000 other riders for a fun up-hill grind. A crazy cement truck roared south down the Cowboy Trail. Alberta Doctors’ Digest
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“It’s Batman,” said a kid.
“Random drug testing for truck drivers,” I shouted into the spray. Clusters of supporters along the route held encouraging signs “You Can Do It!” and “Only 90 kilometers to go.” After two hours of being passed by Tour de France types and athletic Valkyries shouting “On your left,” we reached Longview – Clint Eastwood country. At Turner Valley we had a pleasant ride through the empty golf course until I felt a tap on my helmet. Someone wanting to pass? No. Hailstones. Loud thumping music announced the lunch stop. The cheerleaders at the entrance to the lunch stop were wet and weary but managed a low volume: “Alex, Alex, Alex, yeah…” Now north to Millarville. The Bow River had overflowed its banks and police waved us through a flooded road junction. My yellow plastic cape flapped in the wind. It was still needed for the rain but was becoming a hindrance. “Yuh c’d fly across, buddy,” said a roadside half-wit.
Biking tip #4: Ignore this type of comment. Focus on your spin rate. Try for 60/minute. I had hoped the cape would act as a spinnaker wafting me east along Highway 22X with an extra couple of effortless knots. Perversely, the wind was now from the east. Even going downhill required pedaling to the cracking of the yellow cape. The only athletic medal I ever won was third prize in the under-10 sack race at school. But cycling into the Spruce Meadows grounds you could hear the loudspeaker announcing each rider. My inner champion, long dormant, perked up. My back-up car drew alongside and the mechanic leaned out and fine-tuned my rear brake (OK, kidding). I put on pace, rounded the bend, entered the arena and crossed the finish line giving a dignified wave to the crowd. For a fleeting second, hubris reigned, one understood the feeling of walking up the 18th fairway on the final day of the Open, being handed one’s putter and doffing the cap or swishing to a stop after completing an Olympic skiing slalom.
Top: The writer enjoying the bike ride. Bottom: The campsite at Chain Lakes. ( supplied by Dr. Alexander H.G. Paterson)
The ride raised $8 million for cancer research. We made $95,000 for our clinical research unit. But then I saw a boy, maybe 15 or 16 years old, head resting on his handlebars. He’d arrived just in front of me. He wore a yellow t-shirt. On the back, carefully sewn on with black letters were the words: “This is for you Mom.”
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EVOLUTION OF MEDICAL CENTRES
Classified Advertisements Physician wanted CALGARY AB Med+Stop Medical Clinics Ltd. has immediate openings for part-time physicians in our four Calgary locations. Our family practice medical centres offer pleasant working conditions in well-equipped modern facilities, high income, low overhead, no investment, no administrative burdens and a quality of lifestyle not available in most medical practices. Contact: Marion Barrett Med+Stop Medical Clinics Ltd. 290-5255 Richmond Rd SW Calgary AB T3E 7C4 T 403.240.1752 F 403.249.3120 msmc@telusplanet.net CALGARY AB Celebrating more than 30 years of excellence in serving physicians, MCI The Doctor’s Office™ has opportunities in northwest Calgary for both family practice and walk-in shifts. We’ll move your practice or help you build a practice. We offer flexible hours and schedules, no investment, no financial risk, no leases to sign, and no administrative or human resource burdens. MCI Medical Clinics (Alberta) Inc. provides quality practice support in nine locations throughout Calgary. Contact: Margaret Gillies TF 1.866.624.8222, ext. 433 practice@mcimed.com EDMONTON AB Family clinic immediately requires a part- or full-time physician to replace departing physician. Two-doctor office, fully computerized, affiliated with Edmonton Southside Primary
Care Network. Excellent location near Southgate, beautiful offices, excellent and experienced long-term staff. Contact: T 780.940.3865 srurms@telus.net EDMONTON AB Two specialists with a well-established practice in north-central Edmonton are seeking a full-time physician or two part-time physicians, preferably specializing in internal medicine or cardiology to take over one vacant office in our larger leased space. Office features include spacious shared entry and waiting area, front-desk space for clinic nurse or assistant, ample free parking for patients, handicapped access, elevator and secure underground staff parking. Electrocardiogram facilities are available on-site, use of which is negotiable. Successful tenant will be prepared to take over proportional share of all office expenses. Contact: Catherine catherinem@live.ca EDMONTON AB The Capilano Medical Clinic is looking for a full-time general practitioner. Clinic hours are Monday to Friday, 8:30 a.m. to 5 p.m. This multidisciplinary primary care network facility is in the mature Forest Heights neighborhood at 7905 106 Avenue. Contact: heidi.schurman@capilanomed.com
CMWC is looking to add two full-time family or walk-in physicians to a well-established, high patient volume, family practice relocating to a brand-new site. New grads are welcome. Physicians would have their own office plus two (minimum) examination rooms. This is an ideal opportunity to quickly build your own practice with all the benefits of a group practice with friendly support staff and allied health professionals. CMWC is affiliated with Edmonton North Primary Care Network, offers electronic medical records, flexible hours and a 70/30 split plus incentives. Contact: Ramadan Hochaimi Administrative Director T 780.907.3472 castledownswellness@gmail.com ST. ALBERT AB Salvus Family Medical Clinic is looking for a part- or full-time general practitioner to join our well-established family practice. We offer pleasant working conditions in a well-equipped modern paperless clinic along with a professional team of physicians and support staff. Our clinic has a strong working relationship with the attached pharmacy and is within walking distance to the Sturgeon Community Hospital and medical imaging/ laboratory facilities. Contact: Dr. Robert Hauptman T 780.460.4682 C 780.233.7070 medcare1@telusplanet.net
Physician and/or locum wanted EDMONTON AB Family/walk-in physicians needed for Castledowns Medical & Wellness Centre (CMWC).
CALGARY AND EDMONTON AB Is your practice flexible enough to Alberta Doctors’ Digest
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fit your lifestyle? Medicentres is a no-appointment family practice with clinics throughout Calgary and Edmonton. We are searching for superior physicians with whom to partner on a part-time, full-time and locum basis. No investment and no administrative responsibilities. Pursue the lifestyle you deserve. Contact: Cecily Hidson Physician Recruiter T 780.483.7115 chidson@medicentres.com
EDMONTON AB
Companion cruises FREE.
Summerside Medical Clinic requires part- and/or full-time physician(s). Locums are welcome. The clinic is in the vibrant, rapidly growing community of Summerside. Examination rooms are fully equipped with electronic medical records, printers in all examination rooms and separate procedure rooms.
CARIBBEAN
Contact: Dr. Nirmala Brar T 780.249.2727 nimmi@theplaza.ca SLAVE LAKE AB
CALGARY AND EDMONTON AB Imagine Health Centres (IHC) Ltd. is currently looking for family physicians to join our dynamic team in part-time/ full-time/locum positions in both Calgary and Edmonton. Limited walk-in shifts may be available. Physicians will enjoy no hospital on-call, paperless electronic medical records, friendly staff and industryleading fee splits. IHC are multidisciplinary family medicine clinics with a focus on health prevention and wellness. Come and be a part of our team which includes physicians, physiotherapists, massage therapists, fitness trainers, nutritionists and pharmacists. IHC prides itself in providing the very best support for family physicians and their families in and away from the clinic. Health benefits and full financial/tax/accounting advisory services are available to all IHC physicians. There is also an optional and limited time opportunity to participate in ownership of our innovative clinics. If you are interested in learning more about our exceptional clinics, please contact us. All inquiries will be kept strictly confidential. Contact: Sumiko Yip T 780.716.8585 (direct) Toll-free: 1.855.550.5999 info@imaginehealthcentres.ca 38
Alberta Doctors’ Digest
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Slave Lake Family Medical Clinic is urgently looking for a full-time family physician to work clinic and on-call hospital schedule. Paperless clinic, Netcare available. Urgently need locums to work Monday to Friday, 8:30 a.m. to 4:30 p.m. Contact: Daniel Payne T 780.849.2860 (office) T 780.849.4009 (home) danielsl@telusplanet.net
Space available ST. ALBERT AB Medical professional space available for lease. The Sierras of Inglewood complex offers 2,319 sq. ft. of main floor medical professional space. The corner unit has great exposure and the building is off St. Albert Trail. The space for lease is beside the Sturgeon Community Hospital and other medical professional resources and offices. Ample parking, large windows and proximity to the medical community make it a great space for any medical tenant. Contact: Mike Keating T 780.969.3028 mike.keating@colliers.com www.collierscanada.com/6626
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For sale EDMONTON AB Spectacular custom-built 3,200 sq. ft. house directly facing the gorgeous North Saskatchewan River in lovely Riverdale. Country living in the middle of the city; within walking distance to downtown, LRT, Royal Alexandra and Glenrose Rehabilitation hospitals. The stunning family home has four bedrooms, three bathrooms, fireplace, atrium, great room and double-detached garage on a large lot. Contact: hkamm@yahoo.com
Services ACCOUNTING AND CONSULTING SERVICES EDMONTON AB Independent consultant, specializing in managing medical and dental professional accounts, to incorporating PCs, full accounting, including payroll and taxes, using own computer and software. Pick up and drop off for Edmonton and areas, other convenient options for rest of Alberta. Contact: N. Ali Amiri, MBA Financial and Management Consultant Seek Value Inc. T 780.909.0900 F 780.439.0909 aamiri.mba1999@ivey.ca www.seekvalue.ca DOCUDAVIT MEDICAL SOLUTIONS 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 FIRST ECHELON COMPUTER SOLUTIONS Edmonton and area computer repair. Free initial assessment and estimate. Having computer problems? We’re the solution. First Echelon is a computer repair and maintenance company that specializes in on-site repairs. If you have a computer problem that is interrupting your work or leisure, give us a call and a trained technician will come to you and get your PC in working condition. Visit our website for more information. Contact: T 780.293.5905 askeith@first-ecs.net www.first-ecs.net RECORD STORAGE & RETRIEVAL SERVICES INC. RSRS is Canada’s leader in medical records storage and scanning services since 1997. Free services for closing primary care practices. Physicianmanaged and compliant. TF 1.888.563.3732, ext. 221 www.recordsolutions.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
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