Crowfoot Village Family Practice

www.cvfp.com

Enhanced care for Type 2 Diabetes • Menopause — the Basics • The Importance of Vaccination • The CVFP Proactive Care Program •

Providing comprehensive family medicine services Crowfoot Village Family Practice

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• Physiotherapy • Health Care/Insurance Massage Therapy Motor Vehicle Accidents • Orthotics • Authorized WCB Provider • Acupuncture

Specializing in Spinal Braces Computer Designed & Graphite Foot Orthotics Knee, Ankle, Elbow & Wrist Braces All aspects of Prosthetic Care Ken Moghadam C.O. (c) Director Cascade Orthotics Ltd. & Cascade Prosthetic Services Steve Scott C.P. (c) Director Cascade Prosthetic Services 2636 Parkdale Blvd. NW, Calgary, AB West of Crowchild on Memorial Appointments Recommended

Reliable, RepRoducible and MeasuRable Results Your Northwest Calgary Clinic

403-241-1600

Fax 403-241-1647 205-60 crowfoot crescent n.W. Open Monday - Friday 7:00 am - 8:00 pm Saturday 9:00 am – 1:00 pm

403-283-7872

Get your vaccinations

at

today.

IT’S EASY!

Many vaccinations offered.

Flu, shingles, meningococcal, pneumonia, Human Papillomavirus (HPV) and more.

• Convenient services on a walk-in or appointment basis.* • Vaccination services available for businesses and other organizations.

• See Pharmacy for details. Fee for service. * Age restrictions do apply. Available vaccinations vary by location.

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Suite 210, 600 Crowfoot Crescent NW Calgary, Alberta T3G 0B4 Phone: 403-239-9733 Fax: 403-241-8112 After hours patients call: HealthLink at 403-943-LINK (403-943-5465) ww.cvfp.com

Contents We are thrilled!...................................................... 3 CVFP Physicians................................................... 4 Enhanced care for Type 2 Diabetes.............. 7 Why does my baby cry so much..................... 8 Doctor, I’d rather take a Natural Product....10 An IUD - Contraception....................................13 Menopause — the Basics...................................14 Making the decision to stop driving.............16 Frequently Asked Questions...........................16 The importance of Vaccination......................17 Chasing the fountain of youth........................18 Proactive Care at CVFP...................................19 Cover photo: The Crowfoot Village Family Practice staff on their 2012 retreat

Project Manager Art Director Publisher

We are thrilled to be bringing you the fifth annual edition of the CVFP Magazine!

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rowfoot Village Family Practice is a progressive multidisciplinary group that uses a Patient Based Funding Model to deliver primary health care in northwest Calgary. The model was developed initially as a pilot project in 1999 in conjunction with the Government of Alberta.

How does the model work?

• I n contrast to the traditional Fee for Service (FFS), our practice is provided with a monthly payment for each registered patient (based on age and gender).

•T he team is enhanced by a number of co-located health professionals (see graphic below). The model emphasises access and patient centred care.

• We are able to ensure that patients are seen by the most: – appropriate multidisciplinary health team member, working to full scope of practice, for the – appropriate service, whether that be by phone or by fax, email, individual visit, or grou p session at the – appropriate time

The Patient Care Team – The Medical Home: The Results

• Increased Access to Care: The average panel size (patients per physician) at CVFP is 1700 patients as compared to the average size of a panel in Alberta - 1200.

• We provide same day appointments for any urgent requirements and our patients have access to the team of professionals, not just the family physician. CVFP Physicians provide more than one service per visit which results in fewer patient appointments overall.

• As of December 2012, we now serve more than 24,000 patients in NW Calgary! This means 1 in 45 people in Calgary is a CVFP Patient!

• Improved Clinical Outcomes: A 2009 study conducted by the Health Quality Council of Alberta demonstrated the proportion of services provided by outside visits decreased from 21% to 8% suggesting better 24/7 coverage of patient issues and greater continuity of care. The study also demonstrated that CVFP Patients have:

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13% fewer Emergency Department Visits 17% fewer Hospital Admissions

• Significant Reduction in Cost to the Healthcare System: The improved clinical outcomes and reduced impact on ED visits and hospital admissions results in a marked reduction of acute care costs.

A second survey conducted in 2012 by the Health Quality Council of Alberta demonstrated that as compared with the Foothills Primary Care Network and Alberta Health Services Calgary Zone, patients of Crowfoot Village Family Practice need less frequent office visits, are seen by specialists less often, and lower rates of emergency department visits and admissions. Finally, CVFP patients who are admitted to hospital have an overall shorter length of stay.

—By Dr. Chris Bockmuehl Crowfoot Village Family Practice

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CVFP Physician Profiles Dr. Kristine Bertsch

Dr. Kristine Bertsch was born and raised in Calgary, and after her undergraduate studies at the University of British Columbia and medical school at the University of Alberta, she returned to Calgary. She completed her residency at the Crowfoot Village Family Practice in 2010, and was the chief resident in her final year. Now, in addition to her family practice at Crowfoot Village Family Practice, she also works with the Northwest Maternity Group delivering babies at the Foothills Hospital. In the fall of 2012, she and her husband welcomed a new baby boy to the family. In her spare time, Dr. Bertsch and her husband enjoy hiking, running, cross-country skiing, and anything else that will get them out in the mountains!

Dr. Chris Bockmuehl

Dr. Bockmuehl was born in Switzerland and lived there, and in Germany until age 12, before emigrating to Vancouver. He completed medical school in Calgary in 1989 and his family medicine residency in Vancouver and Williams Lake in 1991. He returned to Calgary and practiced in the Southwest until joining CVFP in August of 2007. He is a fellow of the College of Family Physicians of Canada and a Clinical Assistant Professor at the University of Calgary. Dr. Bockmuehl is married and has two teenagers at home. He plays cello and electric bass in a church band and occasionally enjoys flying the friendly western skies as a private pilot. He is distraught at the recent necktie ban by numerous international governing bodies. Please forgive him any Windsor knot relapses in which you may discover him.

Dr. Zoe Chan

Dr. Chan was born in Prince George, British Columbia and raised in North Vancouver, British Columbia. After obtaining her Bachelor of Arts at Simon Fraser University, she worked at the Vancouver Coastal Health Authority for a year. Afterwards, she went on to obtain her medical degree at the University of British Columbia. She completed her Family Medicine training at the University of Calgary. She brings with her a wide range of experiences: from 10 years of working with children at her local library; to working as a contraceptive counselor at Planned Parenthood; to building aqueducts in Costa Rica; to starting a clinic in Nepal. When she’s not working, she enjoys travel, reading, movies, painting, cooking and spending time with her husband and daughter.

Dr. Ted Jablonski

Dr. Ted Jablonski was born, raised and trained in Winnipeg (B.Sc. Med., MD 1984 – University of Manitoba, CCFP, FCFP) and has taught and practiced family medicine in rural Manitoba, Northern Saskatchewan and Northwestern Ontario before moving to Calgary in 1998. Ted is also a clinic associate at the Men’s Sexual Health Clinic at the Southern Alberta Institute of Urology (in the Rocky View Hospital) and does consultant work in sexual and transgender medicine for Southern Alberta. He joined CVFP at the end of 2010, bringing his large community practice along. Ted continues to moonlight as “dr j”, a multi-instrumentalist, singer-songwriter who has 6 indie CD releases. He is married to Monique and has two very independent “adult kids”. He successfully ran, cycled and spoke across Canada in the Fall of 2010 to raise awareness of Seasonal Affective Disorder (SAD) and inspired action to overcome it.

Dr. Kathy Johns

Alberta born and raised, Dr. Kathy Johns graduated from the University of Alberta Medical School in 1992. She completed her Family Medicine Residency at the U of A in 1994 and completed her Emergency Medicine Certificate in 1995 as Chief Resident. Returning to her home town of Calgary, she practiced Emergency Medicine at the Foothills and Peter Lougheed Centres from 1995 to 2006, with active participation in the STARS Air Ambulance Service, the PARTY Program, the EMS liaison committee and the teaching of medical students and residents. Returning to her family medicine roots, she joined CVFP in May 2006 and loves coming to work!

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CVFP Physician Profiles Dr. Michelle Klassen

Dr. Michelle Klassen joined CVFP in 2010 after completing her medical degree and residency in family medicine at the University of Calgary. She also has a Ph.D. in molecular virology and viral vaccine design from the University of Saskatchewan and a Certificate in Adult Education from Dalhousie University. Outside of CVFP, Dr. Klassen enjoys spending time with her husband, Brian, and their teenage daughter, Rachel. Dr. Klassen can often be found at home cooking, reading or learning a new skill, at Canada Olympic Park at the luge track or in Canmore enjoying all that the mountains have to offer.

Dr. Reid McLean Wiest

Dr. McLean Wiest completed his family medicine training in Calgary in 2002. Before joining CVFP as an associate, he worked as a locum in over 90 physician offices in the Calgary area. Dr. McLean Wiest has been happily married to Beth since 1997, when they decided to try something romantic by combining their two “maiden names” (i.e. he was “Wiest”, she was “McLean”). They are devoted Christians and parents to two boys and a girl. They also direct and perform with a choir called Harmony Through Harmony, which seeks to develop young adult leaders, build community, expand worldviews and fight for justice for the oppressed (check out www.HarmonyThroughHarmony.com). Dr. McLean Wiest also enjoys composing music, playing squash, skiing, fly fishing, cooking and travel.

Dr. Jessica Orr

Dr. Orr officially joined CVFP as an Associate Physician in 2010. After graduating from the University of Alberta Medical School, Dr. Orr moved to Calgary to complete her Family Medicine Residency. When not working, she is busy with her adorable children, Ben, Savanna and Alyssa.

Their favorite outings are the zoo, science centre and parks. She is 6’1” which isn’t tall compared to her husband, Chris, who is 6’ 10”. Together, they built a customized house to accommodate their height. Dr. Orr also enjoys teaching children’s Sunday school, painting, scrapbooking, camping, hiking and chocolate.

Dr. Karyn Richardson

Dr. Karyn Richardson joined CVFP in 2010 after completing her medical degree and residency in family medicine at the University of Calgary. She also has a BSc in neuroscience and a law degree from the University of Calgary. Outside her medical practice, she is kept busy with her three young children and their activities. She is a keen mountain biker, runner and skier, and enjoys sharing her passion for the outdoors with her husband, children and friends.

Dr. Karen Seigel

Dr. Seigel grew up in Ottawa and completed a Master’s of Epidemiology and her medical degree at Queen’s University in Kingston. She came to Calgary in 2002 to complete her family medicine residency. She has been practicing in northwest Calgary since 2004 and looked forward to joining CVFP. Aside from seeing patients, Dr. Seigel is the Physician Lead for Population Health with the Calgary Foothills Primary Care Network. She enjoys being involved in research and is also a member of the Southern Alberta Primary Care Research Network. Outside of work, she enjoys playing her violin and photography, and loves spending time with her husband and two young kids.

Crowfoot Village Family Practice

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CVFP Physician Profiles Dr. Wendy Stefanek

Dr. Wendy Stefanek has practiced with CVFP since 2004 when she graduated from Family Medicine at the University of Calgary. Dr Stefanek is beginning to expand her practice to include teaching clinical clerks and residents. Her time outside of the office is spent trying to keep up with her very active daughters, and her husband, an avid athlete. Her other interests include renovating her 100 year old house, running the occasional 10k and reading for her book club.

Dr. Rick Ward

Dr. Ward has been a partner at CVFP since 1988. His professional interests include preventative cardiology, chronic disease management, psychiatry and sexual medicine. Besides his activities with CVFP, Rick has a clinical appointment with the Faculty of Medicine at the University of Calgary where he is a Clinical Assistant Professor. He is actively involved through the U of C with teaching at CVFP and developing educational programs for family physicians across Canada.

He is married to Cindy, whom he met while an undergraduate at the University of Guelph; they have two sons. His hobbies include travel, fishing, reading and spending time at his recreational property on Vancouver Island.

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Enhanced Care for Patients with Type 2 Diabetes

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n 2011, CVFP began a project in partnership with the Merck Care Elements team to look at enhanced care for patients diagnosed with type 2 diabetes. The Care Elements Program is designed to support primary care delivery through work with clinics to optimize use of resources both internal and external, identifying care gaps in order to deliver care more effectively to a specific patient population.

• Has the patient had a blood pressure recording within the past 12 months?

• Does the patient have an LDL recorded within the past 12 months?

• Is the patient on a statin?

• Is the patient’s HbA1c higher than 9?

• Is the patient’s smoking status recorded?

What is Type 2 Diabetes?

Your body gets energy by making glucose from foods like bread, potatoes, rice, pasta, milk and fruit. To use this glucose, your body needs insulin. Insulin is a hormone that helps your body control the level of glucose (sugar) in your blood. Type 2 diabetes is a disease in which your pancreas does not produce enough insulin, or your body does not properly use the insulin it makes.

If you have type 2 diabetes, glucose builds up in your blood instead of being used for energy. Over time, high blood glucose levels can cause complications such as heart disease, kidney problems, nerve damage and erectile dysfunction.

Type 2 diabetes is a progressive, life-long condition; over time, it may be more difficult to keep your blood glucose levels in your target range. Fortunately, good diabetes care and management can prevent or delay the onset of these complications.

These are very important clinical indicators that tell us how well a patient’s diabetes is managed. Now that this has been collected, we can review the data for each physician and team within our clinic to determine some simple interventions we can do with our patients to ensure their diabetes management is optimized. This may include group classes on management of diabetes with lifestyle (diet, exercise); ensuring patients who do not have recently recorded values are assessed and these clinical indicators are up to date and noted within the patient record; and specific interventions if we have patients identified whose values are not at the optimal clinical target.

How the Care Elements Program is helping patients Our healthcare team has now developed a registry, or database, of patients who have been diagnosed with type 2 diabetes. The registry contains important clinical information about each patient including:

CVFP will be working with the Merck Care Elements team through the spring of 2013 to analyze the data now collected and determine appropriate interventions for this patient group. A second review will be done in April of 2012 to evaluate the impact on diabetic care in the clinic and interventions that have had an impact on clinical care and outcomes will be permanently implemented across the clinic.q —By Shauna Wilkinson Executive Director Crowfoot Village Family Practice

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Why Does My Baby Cry So Much? – Understanding Colic in Infants B

abies are said to have colic when they cry or fuss excessively in the newborn period, which causes distress to the parent and often leads them to seek medical attention.

It affects about 20% of newborns, and has various definitions.

The strict, traditional definition is intense crying episodes for at least three hours per day, on at least three days per week, for at least three weeks; during these episodes the infant frequently tenses its muscles, is red-faced and might appear to be in pain, and is inconsolable. The colicky episodes tend to be in the evening. Colic can also be defined more loosely, to include newborns who seem excessively fussy and require frequent, prolonged, and complex parental soothing

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(rocking, carrying, car rides, etc) to prevent intense crying.

Colicky babies also seem to have more trouble falling asleep and sleep less overall than babies who don’t have colic.

Colic usually starts at 2-4 weeks old, peaks at 6-8 weeks, and resolves by 3-4 months old.

The cause of colic is unknown despite decades of research.

There are many suggested causes, and parents should be wary of any person who claims to know the cause, or the treatment, of colic. It is intensely distressing to be a parent of a colicky infant, especially because it remains poorly understood and without an effective treatment. Parents are often concerned that there is something wrong medically

with their child, or they attribute the colic to gas or a dietary intolerance. To ensure this is not the case, the family physician will ask questions and examine the baby to rule out medical causes such as gastroesophageal reflux, milk protein intolerance, or anal fissure. Usually, a cause for colic is not found.

Colic improves spontaneously, and often suddenly, which is why many parents often find a ‘cure’- the treatment they were trying the week that the colic improves seems to have miraculously ‘cured’ the colic. Be wary of this. A large and extensive body of scientific research has not been able to find a cure for colic, so it is currently clear that one does not exist. Giving a baby any type of medication, whether prescription or natural supplement or homeopathy, is not without risk, and is unlikely to help in colic. For breastfed infants, breastfeeding should be continued; and if the infant is formula-fed it is unlikely that formula changes will improve colic.

For parents, the key to surviving colic is to try and stay calm and continue trying to soothe the baby even if nothing seems to work. Even two hours of crying can seem like an eternity for parents, so enlisting support from family and friends to allow parents to take a break is very important. It is normal for parents to feel overwhelmed by a colicky infant, and it is okay to lay the baby down in their crib and take a ‘time out’ from the crying when needed.

Studies show that when babies with colic reach one year old, they are not different than babies who did not have colic. Colic does not have long-term implications, and does not affect intelligence, personality, or health. However, colic can have long-term negative effects on family stress levels, and on the infant’s sleep habits. It is important for parents of a colicky infant to educate themselves on healthy sleep habits for infants and children to support the development of proper sleep habits for their baby after the colic resolves. An excellent book to consider is ‘Healthy Sleep Habits, Happy Child’ by Marc Weissbluth.

The Author Dr. Kristine Bertsch, MD CCFP works with the Northwest Maternity Clinic, a group of family physicians providing lowrisk obstetrical care at the Foothills Hospital. q References Roberts, D., Ostapchuk, M., & O’Brien, J. (2004). Infantile Colic. American Family Physician. Vol. 70/No. 4: 735-740.

Turner, T., & Palamountain, S. (2012). Evaluation and Management of Colic. UpToDate Inc. Retrieved from http://www.uptodate.com/contents/ evaluation-and-management-of-colic?source=related_link Turner, T., & Palamountain, S. (2012). Clinical Features and Etiology of Colic. UpToDate Inc. Retrieved from http://www.uptodate.com/contents/ clinical-featuresandetiologyofcolic?source=search_result&search=colic&sele ctedTitle=1%7E145#H22 Weissbluth, M. (2003). Healthy Sleep Habits, Happy Child. 3rd Edition.

Ballantine Books. New York.

“WHY DO I HAVE TO PAY FOR SERVICESI THOUGHT HEALTH CARE IN CANADA WAS FREE?”

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everal times a day, patients comment to staff and physicians about charges for services. The fact is, many services provided to patients are not covered by Alberta Health and Wellness. As many of you who are small business owners recognize, we must recover the cost of these services to continue to run our practice.

The most common examples include notes for insurance companies or employers to cover sick time, physiotherapy, massage therapy and orthotics. Each note requires staff and physician time, documentation and charting, and responsibility for any future inquiries. While it may seem like a small task for an individual patient, each team prepares at least ten of these notes daily, with each requiring about ten minutes of staff and physician time. This represents over 1300 hours of work yearly - about three full days of clerical time weekly! It is clear why we need to charge for these services.

Prescription refills by phone are another convenience for patients which are not covered. Your physician provides a prescription that should last until you need to be seen again (or one year, after which all prescriptions expire). When a pharmacist requests a prescription refill, your physician reviews your chart to see if it is appropriate, and may ask a nurse or clerical staff member to call you for required followup. We originally tried to include this as part of our service, but received over 800 requests a month! Once the charges were introduced, patients made an effort to keep track of their prescriptions and get them when in for an appointment, making the process much easier.

If you have concerns about any charges, please address these with your doctor. Our staff follows office policy set by the physician group. While recognizing that exceptions are sometimes required, staff members are unable to make exceptions without asking the physician. We ask that you support and respect their role in collecting these fees.

The most efficient way for the Crowfoot practice to provide these services is for patients to pay an annual fee which includes the services they use. We encourage you to purchase a yearly package on our website at cvfp.com; it supports our practice and makes life easier for everyone. q

Crowfoot Village Family Practice

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Doctor, I’d Rather Take a Natural Product….

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ccording to a 2010 survey, 73% of Canadians stated they have used a natural health product (NHP). NHP, also called “complementary” or “alternative” medicines, include: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines (i.e., Chinese and Ayurvedic or East Indian medicines), probiotics, and other products like amino acids and essential fatty acids. NHP are used and marketed for numerous health reasons. A few commonly used NHP will be reviewed.

GLUCOSAMINE Glucosamine, most commonly used in the form of glucosamine sulfate, is a natural compound found in healthy cartilage. Glucosamine supplements are derived from chitin, a substance found in the shells of shrimp, lobsters and crabs.

Evidence/Use Glucosamine is commonly used for the treatment of symptoms of osteoarthritis, particularly of the knee. The current evidence is highly inconsistent, with many of the most recent studies failing to find a significant benefit. Inconsistent evidence suggests that glucosamine supplements might relieve symptoms of osteoarthritis. According to positive trials, glucosamine acts more slowly than conventional treatments, but eventually produces approximately equivalent benefits. There are two studies that reported glucosamine can slow the progression of osteoarthritis, but these were funded by a major glucosamine manufacturer.

However, recent studies have been less promising. In these studies, glucosamine failed to show any meaningful 10 Crowfoot Village Family Practice

taken once a day is another option.

improvement in symptoms. One study even examined the effects of stopping glucosamine after patients were taking it for 6 months. The study found that patients, who unknowingly stopped using glucosamine, did no worse than those who stayed on it. The reason for these disparate findings is unclear, but may be related to study design, glucosamine product or severity of osteoarthritis. In terms of combination products with methylsulfonylmethane (MSM) or chondrotin, these products have not been shown to work any better than glucosamine alone.

Side Effects and Precautions Glucosamine has not been associated with significant side effects.

Some possible side effects include: abdominal pain, constipation, flatulence, headache, and heart burn. There is one case report of an allergic reaction to a glucosamine/chondroitin product, causing an exacerbation of asthma.

Glucosamine has been shown to be safe in multiple clinical trials lasting up to 3 years.

Interactions Possible interactions include drugs that increase the risk of bleeding like aspirin, warfarin, clopidogrel, ibuprofen, naproxen, herbs or supplements with similar effects (like arginine, kava, ephedra, vitamin E).

Dosing A typical dosage of glucosamine is 500mg 3 times a day. A 1,500mg dose

Bottom Line It is okay to try glucosamine, but find a product that contains only glucosamine sulfate as some of the combination products can lead to dosing issues.

If there is no effect after 8-12 weeks, stop it and save your money.

SAW PALMETTO Saw palmetto is a low-growing palm tree found in the West Indies and in coastal regions of the southeastern United States. The tree grows 6 to 10 feet in height and has a crown of large leaves. The berries are used in herbal remedies.

Evidence/Uses Studies on saw palmetto for treating symptoms of benign prostatic hypertrophy (BPH) are inconsistent and contradictory. Some studies have shown that it improves symptoms such as frequent urination, painful urination, hesitancy and urgency; but some studies have shown no better effect than placebo. A meta-analysis (a study of a bunch of studies) of all saw palmetto studies suggests that saw palmetto might modestly reduce nocturia (going to the washroom in the middle of the night) and some measures of BPH symptoms compared to placebo; but it might not improve other measures of BPH symptoms or measures of peak urine flow. The reason for these confusing and inconsistent research findings is not clear. Differences may be due to different study methodologies, different patients, different symptom measurement methods, and differences in the saw palmetto products used.

Research shows significant variation in the chemical composition of commercially available saw palmetto extracts which might explain different study findings.

Side Effects and Precautions The adverse effects of saw palmetto are generally mild and comparable to placebo. Dizziness, headache, and gastrointestinal complaints such as nausea, vomiting, constipation, and diarrhea are the most frequently

reported adverse effects. Other side effects reported in clinical trials include asthenia, loss of libido, ejaculatory disorders, and postural hypotension.

Saw palmetto has been safely used in clinical studies lasting up to a year.

Interactions Theoretically, saw palmetto might increase the risk of bleeding when used concomitantly with drugs such as: aspirin, clopidogrel, ibuprofen, naproxen, warfarin and others as it

has been reported to prolong bleeding time. Saw palmetto may also interfere with contraceptive drugs as it might have antiestrogenic effects.

Dosing For BPH, 160mg twice daily or 320mg once daily of a lipophilic extract containing 80% to 90% fatty acids has typically been used in clinical trials.

Bottom Line Many of the saw palmetto studies are small, short-term, and of poor quality. Larger, higher-quality and more reliable studies appear more likely to show no beneficial effect of saw palmetto. Overall, it appears that saw palmetto does not offer significant benefit for symptoms of BPH. Any benefits are modest at best.

BLACK COHOSH Black cohosh is a tall perennial herb originally found in the northeastern United States. Native Americans used it primarily for women’s health problems.

PERSONALIZED SUPPORT AND SERVICES: • Custom Meds Compounding • Diabetes Care Centre - reviews, classes and products

• Accu-Pak® Blister Packaging • Free City-Wide Delivery • Immunization and Injections

SCAN ME! “As your Medicine Shoppe pharmacist, I do more than just fill your prescriptions – I help you make sense of the bigger health picture.

I take the time to get to know you, understand your health needs, and get actively involved in improving your well-being.”

– Randy Howden, B.Sc. Pharm, CDE

P. (403) 455-9939 Crowfoot West Business Centre #11 - 600 Crowfoot Crescent N.W. Calgary, AB Located just downstairs by The Crowfoot Village Family Practice

www.medicineshoppecrowfoot.ca

Evidence Black cohosh’s main use is for the treatment of menopausal symptoms.

The evidence remains incomplete and inconsistent. This may be associated with the considerable variability in the preparations used in clinical trials. The most consistent evidence is with an extract standardized to contain 1mg triterpene glycosides, calculated as 27-deoxyactein, per 20mg tablet. Some evidence shows that it significantly reduces menopausal symptom indices and hot flash frequency compared to placebo. Studies using non-commercial black cohosh extracts have been mostly negative. There is conflicting evidence about whether black cohosh reduces hot flashes in breast cancer survivors. More studies are needed in this area as safety is unknown.

Side Effects and Precautions Black cohosh seldom produces any side effects other than occasional mild gastrointestinal distress. Other potential adverse effects include: rash, headache, dizziness, weight gain, feeling of heaviness in the legs, cramping, breast Continued page 12 Crowfoot Village Family Practice

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Continued from page 11 tenderness, and vaginal spotting or bleeding. Safety in those with severe liver or kidney disease is not known.

Black cohosh has been safely used in some studies lasting up to a year; however, most studies have lasted only up to 6 months.

Interactions Theoretically, taking black cohosh with hepatotoxic drugs (drugs that may affect the liver) or supplements (such as amiodarone, carbamazepine, isoniazide, methotrexate, kava, niacin, red yeast, and many others) might increase the risk of liver damage. Black cohosh may alter the way the liver breaks down or metabolizes certain drugs. Patients receiving cisplatin chemotherapy should also avoid black cohosh.

Dosing The most commonly used dosage of black cohosh is 1 or 2, 20mg tablets twice daily of a standardized extract.

Bottom Line Black cohosh may be modestly effective for reducing hot flashes and other symptoms of menopause, but doubts remain.

ST. JOHN’S WORT St. John’s wort is the more common name for the plant species Hypericium perforatum, and is also known as Tipton’s weed, chase-devil, or Klamath weed. Hypericium perforatum is an upright perennial with small, ovate leaves and terminal clusters of star-shaped yellow flowers 1.5cm acrossi.

Evidenceii St. John’s wort extracts are more effective than placebo in the treatment of mild depression. St. John’s wort is likely as effective as low-dose tricyclic antidepressants (TCA), and likely as effective as the selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Taking St. John’s wort extracts improves mood, decreases anxiety and somatic symptoms, and decreases insomnia related to mild depression. Short-term response rates to 12 Crowfoot Village Family Practice

St. John’s wort appear to be between 65% and 100%; however, long-term, the response rates appear to be lower (60% to 69%).

Side Effects and Precautions St. John’s wort is usually well tolerated. Side effects can include insomnia, vivid dreams, restlessness, anxiety, agitation, irritability, gastrointestinal discomfort, diarrhea, fatigue, dry mouth, dizziness, and headache. St. John’s wort can also cause skin rash, paresthesia, and hypoglycemia. Insomnia can often be alleviated by decreasing the dose or taking St. John’s wort in the morning.

Interactions The list of medications that St. John’s Wort interacts with is several pages long and is beyond the scope of this article. St Johns Wort interacts with many classes of medications by enhancing an enzyme system in the body that eliminates drugs in the body. This leads to faster elimination of medication from the body and a resulting decrease in effect. Please talk to your pharmacist or physician before taking St. Johns Wort.

Dosing For mild depression, most clinical trials have used St. John’s wort extract standardized to 0.3% hypericin content. Doses are most commonly 300 mg three times daily. Doses of 1200 mg daily have also been used Bottom Line Since St. John’s wort has not been shown to be more effective or significantly better tolerated than conventional antidepressants, and may cause many drug interactions. St. John’s wort might not be an appropriate choice for many patients, particularly those who take other conventional drugs.

CONCLUSION While NHP are generally safe, they are not risk free. Risk may include: manufacturing problems, unproved claims, interactions with prescription medications or other NHP, and unwanted side effects or reactions. Most NHP have not been studied in pregnant or lactating patients, and thus cannot be

recommended. Looking for a product with a natural product number (NPN) in Canada or the USP-verified mark on U.S. labeling can help reduce some risk.

It is advisable to discuss your medications and NHP with your pharmacist and physicians to help ensure the potential benefits outweigh the risks. q References

Ipsos Reid. Natural health product tracking survey; 2011. Report no. POR 135-09; HCPOR-09-25. www.hc-sc.gc.ca/dhp-mps/ prodnatur/index-eng.php (accessed July 23, 2012).

Health Canada. (n.d.). Drugs and health products: About natural health products.

Retrieved Aug 15, 2012 from http://www.hc-sc. gc.ca/dhp-mps/prodnatur/about-apropos/conseng.php Natural Medicine Comprehensive Database.

(2012).

Glucosamine Sulfate.

Retrieved Aug 15, 2012 from http://naturaldatabase. therapeuticresearch.com/nd/Search.aspx?cs=C HA~CEPDA&s=ND&pt=100&id=807&ds=&name= Glucosamine++(GLUCOSAMINE+SULFATE)&se archid=36567477 Natural & Alternative Treatments. (2012).

Glucosamine. Retrieved Aug 15, 2012 from http:// therapy.epnet.com.hinc.lib.ucalgary.ca/nat/nat. asp Natural Standard. (2012). Glucosamine Slufate. Retrieved Aug 15, 2012 from http:// www.naturalstandard.com.hinc.lib.ucalgary.ca/ databases/herbssupplements/all/glucosamine. asp Natural Medicine Comprehensive Database.

(2012). Saw Palmetto. Retrieved Aug.13 from http://naturaldatabase.therapeuticresearch. com/nd/Search.aspx?cs=CHA~CEPDA&s=ND&p t=100&id=971&fs=ND&searchid=36567477 Natural Medicine Comprehensive Database.

(2012). Black Cohosh. Retrieved Aug 15, 2012 from http://naturaldatabase.therapeuticresearch. com/nd/Search.aspx?cs=CHA~CEPDA&s=ND&p t=100&id=857&fs=ND&searchid=36567477 Natural & Alternative Treatments. (2012).

Black Cohosh. Retrieved Aug 15, 2012 from http:// therapy.epnet.com.hinc.lib.ucalgary.ca/nat/nat. asp Natural Standard. (2012). Black Cohosh.

Retrieved Aug 15, 2012 from http://www. naturalstandard.com.hinc.lib.ucalgary.ca/ databases/herbssupplements/all/blackcohosh. asp i Royal Horticultural Society (2012) St Johns Wort, Retrieved Aug.13, 2012 from RHS Plant Selector Hypericum perforatum / RHS Gardening ii Natural Medicine Comprehensive Database.

(2012). St Johns Wort. Retrieved Aug 13, 2012 from http://naturaldatabase.therapeuticresearch. com/nd/Search.aspx?cs=CHA~CEPDA&s=ND&p t=100&id=329&fs=ND&searchid=37062620

—By Amy Pham, BSc. Pharm, ACPR, CDE and Esmond Wong, BSc Biology BSc Pharmacy CDE

An IUD…Contraception that is Effective and Forgettable!

T

he most commonly used methods of contraception used by Canadian women today (in order from highest to lowest are: condoms, oral contraceptives, male/female sterilization, and the IUD (1). However, the most effective methods rank quite differently.

A good way of comparing the effectiveness of contraceptive methods is to look at the number of unintended pregnancies for every 1000 women, during the first year of use. The numbers of unintended pregnancies were: • condoms 150 • oral contraceptives 80 • IUD (copper intrauterine device) 8 • IUS (hormonal intrauterine system) 1 • female sterilization 5 • male sterilization 1.5 What exactly is an IUD? IUD stands for “intrauterine device” and there are two main types. The copper IUD is a T-shaped device that contains copper. The hormonal IUD is a T-shaped white, plastic device that contains the hormone levonorgestrel. This is a hormone similar to progesterone, a sex hormone that is produced naturally by the body (4). Both have the same dimension as a 2 dollar coin. These devices are inserted inside the uterus (3). An IUD can be inserted or removed by a physician or nurse practitioner in the office. Two threads may be felt in the vagina, so a woman can check herself to ensure that the device is still in place.

How does an IUD work?

The hormonal IUD contains levonorgestrel and is released slowly over time. Levonorgestrel prevents ovulation and also implantation of a fertilized egg. It also acts on the lining of the uterus to reduce the normal monthly build up and thickens the cervical mucus making it difficult for sperm to pass through the cervical canal. (3, 4) The IUD can be left in place up to 5 years. The copper found in the IUD acts by decreasing the motility and viability of the sperm. Ovulation is not effected. The copper IUD essentially acts as an intrauterine spermicide (1). The copper IUD can be left in place up to 10 years depending on the brand used (3).

What are the advantages of IUDs? Both types of IUDs are highly effective and convenient methods of contraception. Both are reversible, with a rapid return to a woman’s usual level of fertility. (1) Women often make the comment: “I forget that I even have an IUD”. Both contain no estrogen and can be used by women who are breastfeeding or who smoke. An additional benefit of the hormonal IUD is that it often leads to decreased menstrual pain (5) and a decreased amount of blood loss each month.

(4) The hormonal IUD is frequently used to treat women with heavy menstrual bleeding, that has no apparent cause. (4) Some women using the hormonal IUD eventually find that their periods stop altogether.

What are the disadvantages?

Both types of IUD may fall out (6% for the hormonal IUD) (6), most typically occurring soon after insertion. Both carry a risk of uterine perforation (0.16 %) during the insertion, and a risk of ectopic pregnancy (less than 0.26%) (5). The hormonal IUD may cause weight gain and other hormonal side effects such as acne, depression, headache, and breast tenderness (5). Most women report these side effects as being much less severe as compared to other hormonal-type contraceptives, since the devices act directly on the uterus. Also, in the first three to six months, women might experience frequent spotting in addition to their periods (4). The copper IUD may increase menstrual bleeding or menstrual cramping (2). Neither device protects against sexually transmitted infections and barrier methods such as condoms are encouraged for prevention.

Who is the appropriate candidate for an IUD? The 31 year old who is breastfeeding and has three children, who says she doesn’t want any more kids? The 45 year old woman with heavy and painful periods? Or, the 20 year university student, with no immediate plans to start a family?

Actually, an IUD would be an excellent choice for all three of these women. They could all experience the benefits of contraception that is effective and forgettable! q References

(1) Grimes, D. Today’s Intrauterine Contraception… Not your Mother’s IUD. Bayer Healthcare Pharmaceuticals.

(2) Society of Obstetricians and Gynaecologists of Canada & the Foundation of the Promotion of Sexual and Reproductive Health (Second Ed.).

Choosing a contraceptive that’s right for u. www.sexualityandu.ca (3) Bayer HealthCare Pharmaceuticals. The Smart Mom’s Guide to Birth Control After Baby: Choices, Challenges & You. (4) Bayer HealthCare Pharmaceuticals. Mirena: Levonorgestrel-releasing intrauterine system. Patient Information.

(5) Society of Obstetricians and Gynaecologists of Canada. Birth Control Options poster. www.sexualityandu.ca (6) UpToDate (2012). Management of problems related to intrauterine contraception.

—By Wendi Walcer NP, MSN Adult Nurse Practitioner

Crowfoot Village Family Practice would like to thank Bayer Health Care for their collaboration on this initiative. www.bayer.com

Crowfoot Village Family Practice

13

MENOPAUSE – THE BASICS 1. WHAT IS IT? You are considered to be menopausal when you have ceased to menstruate for a period of one year, due to cessation of ovarian function. This usually happens between 40-59 years of age (average age = 51). This hormonal change may result in various symptoms, ranging from subtle to severe.

Premature menopause can sometimes occur; however, that is outside of the scope of this article.

2. WHAT ARE THE SIGNS AND SYMPTOMS? Symptoms vary from individual to individual in type, duration, and severity.

Symptoms may be pronounced or subtle and can include any of the following: Menstrual irregularities, mood swings/irritability, sleep disturbance, hot flashes, memory/cognitive issues, decreased libido, fatigue, vaginal dryness, hair loss, loss of skin elasticity, loss of pelvic floor tone resulting in urinary incontinence, weight gain, loss of bone density resulting in osteoporosis.

3. WHAT ARE THE TREATMENTS? Symptoms may be managed with hormone replacement therapy (HRT). This consists of estrogen or estrogenprogesterone combinations. There are many forms of delivery 14 Crowfoot Village Family Practice

of hormone replacement therapy (HRT)–oral medications, patches, vaginal tablets/creams, skin creams.

Some women seek treatment of specific symptoms without hormonal medication – eg - antidepressants for mood, sleep medications for sleep disturbances, pelvic floor physiotherapy for incontinence issues, and so on.

Bone health/prevention of osteoporosis is part of treatment and should include adequate calcium intake (1200-1500mg daily) and vitamin D intake (1000U daily), as well as regular weight-bearing exercise.

Various alternative remedies exist in addition to traditional HRT, such as herbal remedies (limited evidence for effectiveness), lifestyle modifications (regular exercise, proper diet, weight management, smoking cessation, symptom trigger avoidance), and bio-identical HRT (more on this below!)

4. INVESTIGATIONS YOU MAY NEED Most women can be diagnosed as menopausal or perimenopausal based on their symptoms alone. Your doctor may do certain blood tests to rule out other contributing factors, such as blood counts, thyroid tests, and occasionally blood hormone level testing. Hormone levels may not correlate with symptoms, so measured levels do not necessarily guide

treatment. Salivary hormone levels may not be accurate, as they may not reflect circulating hormone levels.

Other tests might include pelvic ultrasound to rule out sources of irregular menstrual bleeding and bone density testing, if at risk. Further investigation may be required, depending on results of these basic tests.

5. WHAT ARE THE RISKS OF HRT? The decision to take HRT should be individualized for each patient. Thorough past medical and family history, as well as lifestyle, should be considered in the evaluation of each woman considering HRT. Risk vs. benefit of HRT should be weighed, and the lowest effective dose to control symptoms should be used, for the shortest duration possible.

The longer HRT is used (particularly if used beyond five years), the more risk increases for the development of gynecologic cancers (breast, endometrial, ovarian) and clotting (deep vein thrombosis, pulmonary embolus, stroke, heart disease, etc.)

This clotting risk is increased in women who smoke, are obese, have high blood pressure/ high cholesterol, or who have positive family history of clotting, stroke, or coronary artery disease.

HRT is contraindicated in the setting of active or previous gynecologic cancers, unexplained vaginal bleeding, preexisting liver disease, known clotting disorder, and smokers who are at high risk for cardiovascular disease.

Bio-identical compounding is often based on saliva tests, which do not necessarily correlate with symptoms. Batches may vary in composition and quality, resulting in uneven treatment. Bio-identical hormones are also expensive compared to “regular” HRT options.

7. ALTERNATIVE HERBAL REMEDIES There is some evidence for the use of black cohosh to give short term relief of menopausal symptoms, gingko balboa for memory issues, valerian root/melatonin for sleep disturbance, and St. John’s Wort for depression. There is little evidence to support the use of ginseng , DongQuai, and evening primrose for the treatment of menopausal symptoms.

8. WHEN TO CONSULT YOUR DOCTOR If your menopausal symptoms are not manageable, talk to your doctor about the options.

If you have been without periods for one year and subsequently have vaginal bleeding, you need investigations to rule out endometrial cancer and should consult your doctor immediately.

If you have menstrual irregularities, do not assume it is just due to menopause – discuss with your doctor as to whether you need some testing.

If you are taking HRT and are diagnosed with any kind of clotting disorder, cardiovascular disease, gynecologic cancer, or liver disease, speak to your doctor about what to do. q REFERENCES

6. WHAT IS “BIOIDENTICAL HORMONE THERAPY”?

Bio-identical hormones refer to hormones that are “identical” to endogenous human hormones such as estriol. estradiol, estrone, or progesterone , usually derived from naturally occurring sources (eg. plant). These are compounded into formulations that are neither standardized nor regulated by the FDA. There is currently conflicting and insufficient evidence to recommend bio-identical hormone therapy over “regular” hormone therapy. There is no “risk-free” hormone treatment and all forms of HRT must be assumed to carry some risk.

1. SOGC menopause and Osteoporosis Update 2009, JOGC Vol. 13, No. 1, January 2009, Supp. 1 2. Counselling postmenopausal women about Bioidentical Hormones: Ten Discussion Points for Practicing Physicians – J Am Board Fam Med 2011; 24: 202-210 3. American Association of Clinical Endocrinologists Medical Guidelines For Clinical Practice For the Diagnosis and Treatment of Menopause, Endocrine Practice Vol. 17, (Suppl 6), November/December 2011 4. Obstetrics and Gynecology Clinics, Vol. 38, issue 3, September 2011,Copyright 2011 W.B. Saunders Company

—By Dr. Kathy Johns

Crowfoot Village Family Practice

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Making the Decision to Stop Driving H

ave you ever wondered if it’s time for you or a loved one to stop driving? If it has even entered your mind, you should consider it seriously. Remember that driving is a complex task that involves observation, decision-making and physical coordination that must happen together in a very short time frame. Impairment in even one area can make someone an unfit driver.

Some of the behaviours that indicate it might be time to give up driving include getting lost while driving in familiar places, thinking you are being safer by driving less than the speed limit, driving only a few blocks to the grocery store or church, driving only during daylight hours, or limiting driving to non-busy hours.

There are many reasons that people give up driving, but most revolve around the driver’s health. Some of these include: • loss or decrease of vision (for example, cataracts, macular degeneration), • loss or decrease of hearing • decreased mobility (eg arthritis that limits neck mobility, decreased range of motion) • slower reaction times • new onset medical conditions that may impact consciousness (e.g. heart problems, seizures)

• poorly controlled metabolic diseases (e.g. diabetes) • illness that affects mental capacity or awareness (e.g. depression, dementia) • problems with coordination (e.g. Parkinson’s disease, alcoholism) Your doctor may ask you to take a cognitive screening exam in the office or ask you to do a formal driving test. Sometimes your doctor may also tell you that you are not safe to drive and will send correspondence to the Driver Fitness and Monitoring Branch of the Alberta Ministry of Transportation advising that you are not fit to drive. Driving suspensions can be temporary or permanent. In some provinces, physicians must report unfit drivers by law. In Alberta, physicians have an ethical responsibility to report unfit drivers.

Stopping driving isn’t an easy decision for most people, as the reduced mobility can have a big impact on quality of life. However, it is also important to consider the potential impact of unsafe driving on both yourself and others in the community. See your doctor to discuss your concerns - it might save a life. q ­—By Dr. Michelle Klassen

Frequently Asked Questions about Medical Teaching at CVFP Q: My doctor is also a teacher?

A: Yes. Most of the doctors at CVFP are regularly involved in teaching residents and clinical clerks.

Q: What do you mean by “residents”?

A: Residents are doctors that have finished their undergraduate medical degree and are now training in their chosen specialty of medicine. At CVFP, we work with residents that are training to be the family physicians of tomorrow. It usually takes two years for a resident to complete the family medicine program.

Q: What is a “clinical clerk”?

A: A clinical clerk is a medical student in his/her senior year, who has yet to fully complete medical school. All clinical clerks do a mandatory rotation in family medicine, even if that is not their aspired career path.

Q: Is medical teaching at CVFP a “new thing”?

A: No. CVFP doctors have been 16 Crowfoot Village Family Practice

teaching medical learners for many years. However, CVFP became an official core training site for family medicine residents from the University of Calgary in 2007, and for clerks in 2009.

We are now supervising up to 5 new residents and 6 new clerks each year.

Q: What are some of the benefits of teaching residents and clerks?

A: There are many benefits: - I t helps address the doctor shortage by promoting family medicine to the

next generation of doctors.

- Collegiality: Doctors who teach often enjoy practice more than those who do not teach.

- Residents and clerks are often helpful members of the team - whether it’s doing patient assessments, medical literature searches or chart reviews two heads are often better than one.

- It makes your doctor a better doctor.

Learners often bring questions and perspectives that help us improve our own practice.

- Succession: Some of our graduated residents fill in for your doctor when he/she is away, and some others have set up long term practices at CVFP. Q: C an I refuse to see a resident or clerk?

A: Yes, you can, by informing the nurse that checks you in. However, we really appreciate when our patients allow learners to be involved in their care. q —By Dr. Reid McLean Wiest

The Importance of Vaccination Y

our physician may recommend vaccinations for either yourself or your child. With all the information out there in the media, do you find yourself questioning the wisdom of such a recommendation? You are not alone if you said “yes”.

Vaccines were first developed in 1796 when Dr. Edward Jenner noticed that milkmaids did not develop smallpox.

He took some of the pus from a cowpox pustule (common in milkmaids), gave it to a non-infected 8 year old boy and noticed that this child was protected from smallpox. The process was called variolation. Later, Louis Pasteur renamed the process of inducing active immunity vaccination in honor of Dr. Jenner, as cowpox is a vaccinia virus.

In modern society we don’t see the infections that our grandparents sawthe devastation of polio, the pain of mumps, the scarring of chickenpox nor do we see the deaths involved. Why? Vaccination. Do you ever wonder if these viruses and bacteria that we vaccinate for are wiped out? The simple answer is no. With the exception of smallpox (for which we no longer vaccinate), all of the common viruses and bacteria that vaccines protect against can all still be found in animals other than humans. This population of other animals is called an “animal reservoir” and because it exists, we need to keep vaccinating our human population.

There is a concept in vaccination, critical to success in protecting the population, called herd immunity. If most of a population is vaccinated, the few that aren’t vaccinated are protected because it is more difficult for the disease causing organisms to be passed from person-to-person. Studies have been done to establish the level of immunity a population needs to have to establish herd immunity. If the level of herd immunity falls below the

necessary percentage of vaccinated individuals, then outbreaks of disease start to occur as person-to-person transmission of the organism can occur. Figure 1 illustrates the concept of herd immunity.

Vaccination rates in Alberta, and across Canada, have been dropping steadily since an erroneous paper came out in 1998 that linked autism and

the MMR vaccine1. This paper was fully retracted2 and the author charged with dishonesty and child endangerment. In August 2012, our provincial vaccination rate for pertussis, more commonly called whooping cough, was 73%3. The percentage of the population that needs to be vaccinated for herd immunity is 92-94%4. In recent months, there have been outbreaks of pertussis in Alberta and, unfortunately, death has been reported from these outbreaks. The herd immunity threshold for measles is 83-94%. Alberta’s vaccination rate for measles is 85%. If our vaccination rate drops any lower, we will likely start seeing outbreaks of measles in the province.

If you are worried about vaccinations, please talk to your physician about your concerns. There are several good sources of information on the Internet regarding vaccines and safety.

Your team at CVFP encourages you to make an informed decision regarding vaccination and will work with you to make that decision. q Websites for vaccination information: www.phac-aspc.gc.ca/im/index-eng. pup www.vaccineinformation.org www.cdc.gov/vaccines/pubs/vis/ References

1. The Lancet, Volume 351, Issue 9103, Pages 637 641, 28 February 1998.

2. BMJ 2010; 340, p 696, 2 February 2010.

3. h t t p : // w w w. a l b e r t a h e a l t h s e r v i c e s . c a / P u b l i c a t i o n s /a h s - p u b - p r-2 0 1 2 - 0 3 performance-report.pdf. Retrieved October 23, 2012.

4. History and Epidemiology of Global Smallpox Eradication From the training course titled “Smallpox: Disease, Prevention, and Intervention”. The CDC and the World Health Organization. Retrieved October 23, 2012.

Courtesy: National Institute of Allergy and Infectious Diseases

—By Dr. Michelle Klassen Crowfoot Village Family Practice

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Chasing the fountain of youth?

The science of Testosterone Replacement Therapy

T

he television ad guarantees increased strength, virility and YOUTH! A 60 year-old poster boy celebrity with a full head of hair and a “six pack” abdomen gives enthusiastic testimony and proof of the claims. Is this the sought-after “fountain of youth” after all?

Unfortunately this increasingly frequent marketing threatens to throw the medical science of Testosterone Replacement Therapy (TRT) back a decade or more! So what is testosterone and what is the hype and controversy about male hormone replacement all about?

Testosterone (T) is a steroid hormone and is primarily secreted in the testicles of males and the ovaries of females.

It is the principal male sex hormone and an anabolic steroid.

In men, testosterone plays a key role in the development of male reproductive tissues such as the testis and prostate as well as promoting secondary sexual characteristics such as increased muscle, bone mass, and body hair. To put it simply, testosterone literally makes men into men.

There are certain medical conditions where testosterone production is impaired or deficient either because of faulty signals from the brain or from failure of the testicle itself. Men can be born with these conditions or they can be the result of injury / trauma. In these uncommon cases, TRT is essential.

Testosterone levels decline gradually with age in human beings. The clinical significance of this decrease is debated.

There is disagreement about when to treat aging men with testosterone replacement therapy. Most medical experts believe that TRT in aging men is indicated when both clinical symptoms and signs suggestive of hormone deficiency and decreased testosterone levels are present. Hypogonadism is the medical term used to describe this condition.

Symptoms of hypogonadism include sexual dysfunction 18 Crowfoot Village Family Practice

(erectile dysfunction or E.D., reduced libido or sexual desire, difficulty attaining orgasm, and reduced ejaculate), reduced energy and stamina, depressed mood, increased irritability, difficulty concentrating, anemia, osteoporosis, and hot flushes. As testosterone decreases some men experience symptoms similar to those of menopause in women.

Identification of inadequate testosterone in an aging male by symptoms alone can be difficult. There is some confusion amongst physicians as to which laboratory test(s) to order and which are most reliable and clinically significant. A serum testosterone level (blood test) drawn in the morning is usually the simplest screening test recommended. If this test shows a low normal or borderline result, more sophisticated testing can be done.

For men who have clinical symptoms associated with their low testosterone levels, treatment is essential for the prevention of sexual, cognitive, and bodily changes.

Replacement therapy can take the form of injectable depots (shots), transdermal (skin) gels, and oral therapy (pills). There are advantages and disadvantages to each form of therapy and a lot depends on personal preference and insurance plan coverage. It is recommended that physicians screen for prostate cancer with a digital rectal exam and PSA (prostate specific antigen) level before starting therapy, and monitor hematocrit (“thickness” of Red Blood Cells) and PSA levels closely during therapy.

So if you are suffering from reduced libido, unusual fatigue, or E.D. consider talking to your health care team about testosterone testing. While not the fountain of youth, TRT, if appropriate, can truly change the lives of men. q —By Dr. Ted Jablonski

Proactive Care at CVFP

O

ften when patients are seen by their health care provider it is in reaction to a symptom or series of symptoms they may be experiencing. We refer to this simply as “reactive.” At CVFP, we know that your health is of the utmost importance. Our goal is to ensure you are as healthy as possible and to support this we have implemented a new and innovative strategy we call the CVFP proactive care program.

This program was initiated in fall of 2011 with the introduction of a new position to our care team called a POET (Proactive Office Encounter Technician). The POETs work with a dedicated physician and nurse to ensure your office visit is productive, prepared and thorough. They contact patients ten days prior to their booked appointments, such as an annual physical. The POET ensures the patient chart is up to date and will make arrangements for any anticipated required lab and diagnostic testing which can be completed prior to the appointment. This can also include milestones for your periodic health exam for things like mammograms, colonoscopy and bone density scanning.

During the patient visit, the POET assists with the initial assessment recording medications and a review of all

collected lab and diagnostic imaging results thus negating the need for potential future appointments. The POETs work with patients to schedule any further investigation arrangements and specialist referrals, and ensure appropriate follow-up is arranged.

The POET, physician and nurse huddle each day to monitor the daily schedule and ensure patients are appropriately booked. Using current clinical care guidelines, we can ensure patients are getting the highest standard of care possible.

Over the past year, the proactive care program has resulted in an increase in available appointments for the doctors as their patients did not need as many visits as they did before. This means it will be easier for you to book an appointment with your family doctor, and you may need to be seen less frequently because your office visit will be more efficient.

As of early 2013 we have rolled out the proactive care program to all teams in our clinic. New staff have been hired and POETs are in various stages of training. Next time you book your appointment for your annual physical you will very likely receive a call from your POET! q ­ —By Shauna Wilkinson Executive Director Crowfoot Village Family Practice

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North Location South Location Crowfoot West Business Centre, 295 Midpark Way S.E., 600 Crowfoot Crescent NW, Suite 300 Suite 350

Disclaimer: This information is not intended for medical diagnosis, treatment or to take the place of professional medical advice.

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