January/February 2015 - Number 1

Transcription

Alberta Doctors'
DIGEST
January-February 2015 | Volume 40 | Number 1
Youth Run Club
ambassadors send
a clear message
The ambassador program
is a new addition to the
Alberta Medical Association
Youth Run Club
Board of Directors 2014-15
Emerging Leaders in Health
Promotion Grant Program
The rewards of reading: A literacy campaign
Thinking differently
Can physicians and patients learn?
Patients First®
We help get students
up and running.
The "We" of YRC includes physician champions.
You're integral to the success of YRC.
Step (or jog or run... whatever you prefer!)
into a school near you and walk the talk of a
physically active, healthy role model.
Get moving with Alberta's children
and send them home with messages
of activity, good nutrition
and healthy lifestyle.
We have the schools, the kids, the ambassadors,
the partners, the AMA... We just need you!
It's easy! Many great physician champion resources -- videos, a presentation, tip sheets
and more -- are featured on the Alberta Medical Association website.
If you're interested in being a Youth Run Club physician champion, call Vanda Killeen,
AMA Public Affairs at 780.482.0675 or email vanda.killeen@albertadoctors.org.
www.albertadoctors.org/youth-run-club
www.everactive.org/alberta-medical-association-youth-run-club
In October 2013, the Alberta Medical Association and Ever Active Schools launched the AMA Youth Run Club, a free,
school-based running program to promote physical activity in children and youth. By June 2014, 233 schools and
more than 11,000 children and teachers were involved.
CONTENTS
DEPARTMENTS
Patients First® is a registered trademark
of the Alberta Medical Association.
Alberta Doctors’ Digest is published
six times annually by the Alberta
Medical Association for its members.
Editor:
Dennis W. Jirsch, MD, PhD
Co-Editor:
Alexander H.G. Paterson, MB ChB,
MD, FRCP, FACP
Editor-in-Chief:
Marvin Polis
4 From the Editor
10 Health Law Update
14 Mind Your Own Business
16 Insurance Insights
20 Dr. Gadget
22
31 33
36
PFSP Perspectives
Residents' Page
In a Different Vein
Classified Advertisements
FEATURES
President:
Richard G.R. Johnston, MD, MBA, FRCPC
6 Youth Run Club ambassadors send a clear message
where it’s needed
President-Elect:
Carl W. Nohr, MDCM, PhD, FRCSC, FACS
Immediate Past President:
Allan S. Garbutt, PhD, MD, CCFP
12 Alberta Medical Association Board of Directors 2014-15
13 Know someone outstanding? Speak up!
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
March-April issue deadline: February 13
The ambassador program is a new addition to the Alberta Medical
Association (AMA) Youth Run Club
AMA seeks 2015 nominations for our highest awards
17 Calling all applicants! It’s time to check out the 2015
TD Insurance Meloche Monnex/AMA Scholarship
The AMA, in conjunction with TD Insurance Meloche Monnex, is very
pleased to be providing $20,000 in scholarship funds for 2015
18 Emerging Leaders in Health Promotion Grant Program
The opinions expressed in Alberta Doctors’ Digest
are those of the authors and do not necessarily reflect
the opinions or positions of the Alberta Medical
Association or its Board of Directors. The association
reserves the right to edit all letters to the editor.
The Alberta Medical Association assumes no
responsibility or liability for damages arising
from any error or omission or from the use
of any information or advice contained in
Alberta Doctors’ Digest. Advertisements included
in Alberta Doctors’ Digest are not necessarily
endorsed by the Alberta Medical Association.
© 2015 by the Alberta Medical Association
Design by Backstreet Communications
AMA MISSION STATEMENT
25 What's new on the web?
Websites are never finished. They only improve … or decompose!
26 Thinking differently: Can physicians and patients learn?
The Alberta Medical Association has a System-Wide Efficiencies and
Savings Consultation Agreement with Alberta government
28 Diagnosing schizophrenia
What can we learn from a historical perspective?
30 Want to participate in clinical research?
Here are some steps to success
The AMA stands as an advocate for its physician
members, providing leadership and support for
their role in the provision of quality health care.
COVER PHOTO: Paula Findlay and Tim Berrett are the AMA Youth Run Club's new
ambassadors. ( provided by Marvin Polis)
JANUARY - FEBRUARY 2015
3
4
FROM THE EDITOR
Coming of age
Dennis W. Jirsch, MD, PhD | EDITOR
T
he Queen now
needs a full seven
secretaries in
order to help her send
congratulatory notes to
centenarians. At the same
time, the global anti-aging
industry, currently worth
$195 billion, will jump to $275 billion by 2020.1 The
fastest growing segment of society, we’re reminded,
are folk past 85 or 90 years of age.
Stanford Professor James F. Fries talked about
“compression of morbidity” in the 1980s,2 suggesting
that we would all one day live longer, healthier lives, with
fewer disabilities. The “Boomer” version of this counts
on a life stretching into one’s 90s – one that might see
18 holes of golf one morning, perhaps some scuba diving
in the afternoon, a gourmet dinner, followed by brandy
and spirited, postprandial sex. Later in the evening, there
might be a pause in this parade of pleasantries – perhaps
a tickle in the throat … then … nothing. Life’s candle
would flicker out.
We’ve bought into this alchemy big-time. Our media
don’t tire of showing us elegant, graying couples cycling
round manicured grounds of posh retirement residences.
Romance persists and thrives, a testament to technology,
and there’s no need to lack tumescence in these
romantic places should the whim arise. Another nod
to technical achievement, there’s no need for troubling
dampness – male or female – and, if the commercials
are to be believed, lively dancing, accomplished ski turns
and a general healthy ruddiness will attend. The financial
industry is in step, and a bevy of banks and trusts promise
no fiscal missteps on the road to 30 or 40 years of
swell retirement.
The path’s so sunny, in fact, to prompt suggestions from
government, urging retirement post-65. After all, the best
is yet to come.
Not everyone can do this, though. One has to know
which anti-oxidant berries to nosh on, which exotic
supplements are best. Hey, they’re digging up new
AMA - ALBERTA DOCTORS’ DIGEST
roots in Guinea and along the Amazon all the time,
and the carapaces of certain bugs and turtles hold
particular promise. Attitude is key. One’s longevity
potential can flourish with crystals, shamans, the
clanging of bells found in secret valleys, or holding painful
body poses for minutes at a time, all done with fingers
held just so. Neuroscience helps too. Pursue challenging
computer games or three and four-dimensional puzzles.
Even learning new, alien languages can modernize an
aging encephalon.
So, is 80 the new 50? Why not? Indeed, why not?
(Reluctantly). The Truth, m’dear. That’s why not.
Certainly, average life expectancy has increased as more
survive birth trauma and childhood illnesses. Better
food, water, sanitation and vaccinations have helped us
get this far, but that’s pretty well the extent of it. Our
technological successes put a helpful spin on things here
and there, but the recipe for successful aging – as far
as we know it – is merely common sense: quit smoking,
exercise in moderation, maintain a healthy weight.
We can’t continue to base our
image of old age on those persons blessed
with hardiness, position or affluence, and
who remain sharp as tacks. We must see our
declension for what it is.
Beyond the rosy nonsense of our delusions, the facts are
grim.3 Age 65 and up, a third of us have trouble walking;
another third struggle with fine motor skills. About 10%
will have a diagnosable mental health disorder. Things
get worse. Most oldsters who live beyond their mid-80s
can expect protracted frailty and disability before they
die. Alzheimer’s or other dementia traps a third of us
past 85, and there’s a 50/50 chance we’ll end up in a
nursing home. >
> Our exits come it seems, not in an instant but over a
lengthy, excruciating period of time. Recall 300 years
ago that Thomas Hobbes said life is “nasty, brutish and
short.” Author Ira Rosofsky has updated Hobbes in his
new book on eldercare, Nasty, Brutish and Long.4
I’m not about to “diss” longevity research. Recall the
Epic of Gilgamesh and the Mesopotamian King who
searched for immortality after the death of his best
friend, or the three Chinese emperors in the Tang dynasty
who died consuming a potion of lead and mercury. Five
hundred years ago, conquistador Ponce de Leon sought
the fountain of youth and instead discovered Florida,
somewhere near present-day St. Augustine.
Our exits come it seems, not in
an instant but over a lengthy, excruciating
period of time.
Hormones have long seemed to be an answer. Early
neurologist Dr. Brown-Sequard5 was a strong advocate
of the injection of ground-up testicles of guinea pigs
and dogs. In the early 20th century physiologist Eugen
Steinach6 invented a unilateral vasectomy. Cutting
one vas deferens, it was thought, would stop sperm
production and bump up hormone production, with
unimaginable salutary effect.
Thousands had the operation7 including Sigmund
Freud and W.B. Yeats, who wrote extraordinary poetry
thereafter and took up with a 27-year-old actress.
The Dublin papers took note and referred to Yeats
as “the gland old man.” Many surgeons became
extraordinarily wealthy and the operation was so
wildly popular that its inventor’s name became a
verb: “Have you been Steinached yet?”
More recently, baseball legend Ted Williams has tried
another tack and has been frozen in liquid nitrogen,8
though head and corpus are, unfortunately, not in
continuity. “Freeze, wait, reanimate” has become the
mantra for cryopreservationists, who have nothing
if not faith in the future.
Most recently, age research has focused on red wine,
starvation diets and genetic manipulation: pretty much
the same rigmarole.
Dr. Ezekiel Emanuel, an oncologist, ethicist and National
Institutes of Health member, has broken ranks to
announce, in an Atlantic essay9, that once he hits 75
he’ll decline nearly all medical treatment – flu shots,
colonoscopies, pacemakers, etc. It’s less about cost
and more about quality of life, according to Emanuel,
who despairs the loss of vigor, autonomy, productivity,
“smarts” and ambition that oft accompany senescence.
Age 75 is arbitrary to Emanuel, who argues that a
diminished life is not worth prolonging.
Pretty brave stuff from an oncologist and ethicist, I think.
He’s reserved the right to change his mind, but I’m worried
that Emanuel, age 57 now, has 18 years to reconsider. In
oldsters’ terms he’s a pup or a cub – a newbie.
The neat thing about Emanuel’s essay is that “we all
get it,” and have to admire his extraordinary honesty.
As well, we can’t continue to base our image of old age
on those persons blessed with hardiness, position or
affluence, and who remain sharp as tacks. We must see
our declension for what it is.
Early versions of homosapiens, hunter-gatherers, likely
prized oldsters for their memories, helpful perhaps in
times of flood or famine, but eventually they were left
by the wayside. Things may have been better in later
agricultural communities with their emphasis on family
structure and responsibility, and there were likely greater
opportunities for useful employment. The elderly, once
again, may have had utility as repositories of memory.
By way of contrast, in our digital world, work and family
relationships are global and such memory as exists is not
anchored, but in the cloud. The aged are left to rely on the
beneficence of strangers and institutions as never before.
Still, who knows what old age is really like? Author
Malcolm Cowley has thought much about “the balance
sheet of perils and pleasures that come with old age.”10
As he says, “To enter the country of age is a new
experience, different from what you supposed it to be.
Nobody, man or woman, knows the country until he has
lived in it and has taken out his citizenship papers.”
We’re left somewhere between,
“Old age is a shipwreck,” and “Come grow
old with me! The best is yet to be.”
In particular, Cowley finds the greatest temptation is
simply giving up, something that may be all too easy
when the elderly feel functionless and no longer listened
to. A sense of purpose is as necessary in late life as
it is earlier.
We’re left somewhere between, “Old age is a shipwreck,”
and “Come grow old with me! The best is yet to be.”
What is it then? Some combo of chance, pluck or resilience?
We’ll see.
Perhaps.
References available upon request.
5
6
COVER FEATURE
Youth Run Club ambassadors
send a clear message where it’s needed
As an AMA/Ever Active Schools YRC ambassador and
Olympic triathlete, Paula “can’t remember not being
involved in sports.”
Paula played soccer, danced (ballet, jazz and tap) for
15 years, started swimming competitively when she was
11-years-old, took up track and field at the age of 14 and
began her triathlete career when she was 16. She grew up
in Edmonton, skiing and skating through the long winters
with her very active family.
“My parents were involved in sports and as kids we were
always encouraged to play sports and games, and just be
active. Our family has always been on the go and still is!”
says Paula.
We weren't all "born running," but AMA Youth Run Club ambassadors Paula Findlay
and Tim Berrett are living proof that we can all benefit from physical activity.
( provided by Marvin Polis)
T
he ambassador program is a new addition to the
Alberta Medical Association (AMA) Youth Run
Club (YRC). As the term “ambassador” implies
– “an authorized representative or messenger” – the
AMA and its YRC partner, Ever Active Schools, sought
ambassadors for the YRC who, as provincial or national
athletes or other role models, would stand as shining,
inspirational examples of the benefits of physical activity.
For the first year of this program, we were very fortunate
to bring on two outstanding athletes and role models:
well-known Canadian Women’s Olympic triathlete,
Paula Findlay and five-time Olympic race walking
competitor, Tim Berrett.
Once an athlete, always an athlete:
Olympic women’s triathlete, Paula Findlay
If you were to ask 25-year-old Paula Findlay’s mom,
she’d probably say Paula was born running, or at the
very least, born moving.
Prior to representing Canada
in the women’s triathlon at the London 2012
Olympics, Paula won five world triathlon
series events in 2010-11.
The YRC’s ambassador program seeks to enlist the
support and advocacy of local athletic role models
and mentors, who, with their actions and beliefs,
champion youth activity. Last fall, the YRC was very
fortunate to acquire Paula as a program ambassador.
With her childhood and youth focus on sports and
physical activities, Paula is a natural, credible advocate
of youth activity. Her impressive and well-earned
accomplishments in the competitive world of women’s
triathlon are a huge inspiration to all, particularly to
children and youth. Prior to representing Canada in the
women’s triathlon at the London 2012 Olympics, Paula
won five world triathlon series events in 2010-11.
“It had never really been a goal of mine, to go to the
Olympics,” says Paula. “But when I started competing >
> in triathlons in 2006, that’s when I started to think it
might be a possibility. This is my career, now,” Paula
continues. “Training every day, looking after my body
and health, performing at a world-class level, having
sponsors, being a role model … I love being a mentor to
children with similar goals and dreams.”
7
Having just arrived back in Edmonton after almost
a year in Australia, training to qualify for the 2016
Olympics, Paula acknowledges the challenges we face
staying active outdoors through our (usually) tough
Alberta winters.
“It’s REALLY hard to stay active outside when it’s cold!
But it can be done, by dressing warmly, in layers … and
you can always go indoors for your activity.”
But for Paula, probably the most important factor in
encouraging youth to be active is found at home. “I think
being in a family and a household that encourages an
active lifestyle is vital. My active family is really at the
core of my abilities and interests,” says Paula.
Paula Findlay shares the stage with some of the students at École Bellevue School in
Beaumont AB. ( provided by Ever Active Schools)
Paula was fresh off the plane when the YRC put her
to work as an ambassador with a presentation on
December 16, 2014 to 300 students at École Bellevue
School in Beaumont. The YRC will keep Paula running,
but she likes it that way!
Walking the walk … Olympic men’s race walker,
Tim Berrett
As an AMA/Ever Active Schools YRC ambassador,
49-year-old Olympic race walker Tim Berrett knows how
to walk THE walk – the Olympic race walk that is – and
he knows how difficult and painful it can be.
“The first time I did a walking race, I was about 13,”
explains Tim, who was born and raised in Tunbridge
Wells, England. “I ran cross-country with my school,
which also had a tradition of race walking. There was
a race coming up that went right past my parent’s front
door so I decided to try it. It was painful! My shins hurt
for several weeks after,” he says.
It’s REALLY hard to stay active
outside when it’s cold! But it can be done,
by dressing warmly, in layers … and you can
always go indoors for your activity.
Tim finished third in that race and had been bitten
by race walking bug. The Olympic bug followed
shortly thereafter. He continued developing as a race
walker throughout his school and university years,
supplementing his fitness and training with cross-country
AMA Youth Run Club ambassador Tim Berrett leads several groups of runners at
Westglen Elementary School in Edmonton. ( provided by Marvin Polis)
and track running. Tim went on to compete in five
successive Olympic Games between 1992 with his last
competition at the 2008 Beijing Olympics.
Soccer, rugby, cricket, running and race walking: Tim was
always active as a child and youth. This habit and pattern
of activity and associated good nutrition and health has
continued all through adulthood. Tim has been a worthy
competitor throughout his life – and is now a board
member of Athletics Alberta and Athletics Canada,
an athletics program leader at Edmonton’s Westglen
Elementary School and YRC ambassador. In all this, Tim
sees the benefits of physical activity for children and the
value of programs such as the YRC which “give the kids a
reason to be active, outside the school curriculum.”
“It’s important for kids to have the opportunity to
be active, whether in or outside of school and in an
affordable way,” Tim explains.
In addition to the YRC, Tim has been closely involved
with AthletiKids, a track and field-based, non-competitive
program for K-6 students at Westglen Elementary School
for close to nine years. As part of his AthletiKids program
at Westglen, Tim has developed the YRC into a fall
cross-country running program. >
8
Prior to representing Canada in the women's triathlon at the London 2012
Olympics, Paula Findlay won five world triathlon series events in 2010-11.
( provided by International Triathlon Union)
> “We also do some other activity initiatives that tie in
with the YRC, such as the Westglen Challenge, every
spring. We started these runs three years ago,” says Tim.
“We challenge the (approximately 290) kids to run/walk
2,000 kilometres collectively, during the last week of
May. They can bring their parents and families, as they
do their morning (before school) runs and laps around
the school field.”
Tim Berrett competed in five successive Olympic Games between 1992 with his last
competition at the 2008 Beijing Olympics. He also earned medals at two Commonwealth
Games. ( provided by James Aldridge)
Based on the success of the Westglen AthletiKids/
YRC program, Tim is ready to expand the program
to other schools.
These programs get kids active,
engaged and feeling good about themselves.
It’s important for kids to have the
opportunity to be active, whether in or outside
of school and in an affordable way.
“There is so much value to physical activity for adults
and kids,” Tim states. The teachers of kids who take part
in the AthletiKids/YRC programs at Westglen notice that
the children who participate in the activities are more
attentive in the morning and all through the day.
For the past several years, in addition to his work with
Athletics Canada and other sports management boards,
Tim supports the current coach of Canada’s emerging
group of world-class race walkers and through mentoring,
works to improve athletic performance. He’s also keenly
involved in the development of a race walking program
in Canada.
“These programs get kids active, engaged and feeling
good about themselves. With events such as the
Westglen Challenge, we involve parents and families and
it creates a real sense of community and a good feeling
of safety and support,” says Tim.
Please see the video at www.albertadoctors.org/advocating/
many-hands/ama-youth-run-club to learn more about the
AMA YRC ambassador program.
9
Paula Findlay's charisma lights up the
room as she talks about physical fitness
at École Bellevue School in Beaumont AB.
( provided by Ever Active Schools)
One of the ways Tim Berrett keeps active is by running and walking with
his dog. ( provided by Marvin Polis)
Paula Findlay (L) and Hayley Degaust, AMA Youth Run
Club coordinator (R), get the YRC ambassador program
off to a strong start at École Bellevue School in Beaumont
AB. ( provided by Ever Active Schools)
We want your feet!
Like to run? Have an interest in healthier kids
and healthier communities?
We’re rolling out all kinds of resources to help you get kids
running where you live. If you’d like to participate in a school
have other suggestions to get kids’ feet moving, we can help.
You don’t need to be a parent of a school-aged kid to
participate. Your willingness and interest are all you need.
hayley@everactive.org
Ready to get involved? Drop us a line: runclub@
albertadoctors.org
10
HEALTH LAW UPDATE
The three P’s:
Protection of privacy is paramount
Jonathan P. Rossall, QC, LLM | PARTNER,
O
ver the last six
months, there has
been a spate of
reports dealing with the
accidental or unauthorized
disclosure of patients’
health information. In
August of 2014, we
heard from the Office of the Information and Privacy
Commissioner relating to the theft of a medi-centre
consultant’s unencrypted laptop. That laptop contained
identifiable information relating to over 100,000 patients.
Last October, a laptop computer containing personal
health information was stolen from an office of a doctor
working in the department of internal medicine within
the Winnipeg Regional Health Authority. Personal health
information relating to personal consultations from
322 patients was contained on the computer. Anecdotal
stories of health information being misdirected or left
available on open computers abound.
The Health Information Act has been in existence for
14 years. Although there have been amendments to the
act and developments in the evolution of hardware and
software, one theme has remained constant: custodians
(including physicians) owe a duty to their patients to
protect the patients’ diagnostic, treatment, care and
registration information. That duty is found in section
60(1) of the Health Information Act, and essentially
places an obligation on a custodian to take reasonable
steps to maintain administrative, technical and physical
safeguards that will protect the confidentiality of the
health information, to protect against any reasonably
anticipated threats or hazards to the security or integrity
of the health information, or the unauthorized use,
disclosure or modification of the health information.
In the November-December 2014 edition of Alberta
Doctors’ Digest, the Health Law Update article quoted
Justice T.W. Wakeling of the Alberta Court of Queen’s
Bench, who said: “(o)penness is not the goal of the
Health Information Act. The preservation of the privacy
of an individual’s health information is one of the
purposes of the Act.”
MCLENNAN ROSS LLP
And so this brings me to a discussion of the Information
Sharing Framework (ISF) currently in place in Alberta
Health and Covenant Health facilities in Alberta.
The ISF is a model of information sharing whereby
physicians, Alberta Health Services (AHS), Covenant
Health and affiliates of each, share patient health
information relating to health services provided in
ambulatory clinics for the benefit of patient care.
This framework was developed jointly by the Alberta
Medical Association (AMA) and AHS, in conjunction
and consultation with numerous stakeholders including
the College of Physicians & Surgeons of Alberta (CPSA),
Office of the Information and Privacy Commissioner,
Canadian Medical Protective Association (CMPA),
Alberta Health and the faculties of medicine.
It is critical for physicians to understand
that the final responsibility for the protection
of their patient’s information lies with them,
as custodians.
The ISF is composed of a number of key agreements: an
information sharing agreement dealing with the terms
and conditions of sharing; an information management
agreement which outlines how AHS, as information
manager, physically stores and protects the information
and discloses it in accordance with that agreement; and
an information exchange protocol which lays out detailed
and comprehensive rules regarding the gathering,
storage, use and disclosure of health information.
There is a governance structure in place to oversee
the day-to-day operations of the ISF.
One of the primary purposes of these agreements is to
address the duty found in section 60(1) of the Health
Information Act – the duty to take reasonable steps to >
> maintain the confidentiality of health information and to
protect against reasonably anticipated threats. By signing
on to the ISF and agreeing to the terms of the conditions,
physicians are demonstrating their understanding of this
duty, and their intent to comply with the HIA and the
means by which that compliance is to be achieved.
The problem is, a large number of physicians in
Calgary and Edmonton are currently using the shared
information systems and contributing information
without having signed off on the ISF. This presents a
number of difficulties.
Physicians who are utilizing the
electronic medical records system in Alberta
Health Services ambulatory clinics without
having signed off on the Information Sharing
Framework documents are in breach of
the Health Information Act and their own
standards of practice.
First, the CPSA Standards of Practice require a physician
sharing patient or health information with others,
especially non-physicians, to have an information sharing
agreement in place. Second, the Health Information Act
requires custodians (i.e., physicians) who are disclosing
health information to an information manager (in
this case, AHS) to have an information management
agreement in place.
Both of these agreements form part of the ISF. Physicians
who are utilizing the electronic medical records system in
AHS ambulatory clinics without having signed off on the
ISF documents are in breach of the Health Information Act
and their own Standards of Practice. Work is currently
underway to educate physicians on the benefits of the
ISF and the need to be accountable and responsible in
terms of dealing with patient information.
The AMA, as a party to the ISF, is doing its best to ensure
that physicians’ questions are answered and physicians
are comfortable in entering into these agreements.
However, it is critical for physicians to understand that
the final responsibility for the protection of their patient’s
information lies with them, as custodians.
David B. MacNicol, Chartered Accountant*
*David B. MacNicol Professional Corporation
Professional Care for your Professional Corporation
Financial reporting, taxation and business advisory services
20 years public practice experience
Experienced with medical professional corporations
Corporate year-end �inancial reporting
(Financial statement compilation and review engagements)
Corporate taxation
Personal taxation
403 479 8049 | dbmacnicol@shaw.ca | www.dbmcpaca.ca
11
12
FEATURE
Board of Directors 2014-15
(
provided by Curtis Comeau Photography)
Seated, left to right: Dr. Robin Cox; Dr. Carl Nohr; Dr. Richard Johnston; Dr. Allan Garbutt; Dr. James Pope.
Standing, left to right: Paras Satija, MSA observer; Dr. Kathryn Andrusky; Dr. Jasneet Parmar; Dr. Neil Cooper;
Dr. Paul Boucher; Michael Gormley, Executive Director; Dr. Ernst Schuster; Dr. Sarah Bates; Dr. Paul Parks;
Dr. Christine Molnar.
Absent: Dr. Anshula Ambasta, PARA observer.
FEATURE
13
Know someone outstanding? Speak up!
AMA seeks 2015 nominations for our highest awards
T
he Alberta Medical Association (AMA) is calling for Achievement Award
nominations for individuals who have contributed to the improvement of
the quality of health care in Alberta.
The Medal for Distinguished Service is given to a physician(s) who has made
an outstanding personal contribution to medicine and to the people of Alberta,
and in the process has contributed to the art and science of medicine while
raising the standards of medical practice.
In 2014, three physicians were recognized
with Medals for Distinguished Service.
The Medal of Honor is awarded to a non-physician(s) who has raised the
standards of health care and contributed to the advancement of medical
research, medical education, health care organization, health education
and/or health promotion to the public.
• Dr. Donald E.N. Addington, Calgary
Nominations must be submitted by April 30. The awards will be presented
at the AMA’s fall 2015 annual general meeting in Edmonton.
In 2014, one individual was recognized with
the Medal of Honor.
To request a nomination form for these awards, please contact
Janice Meredith, Administrator, Public Affairs, AMA:
janice.meredith@albertadoctors.org, 780.482.2626, ext. 291, toll-free at
1.800.272.9680, ext. 291 or visit the AMA website at www.albertadoctors.org.
• Samuel Weiss, PhD, Calgary
• Dr. Steele C. Brewerton, Cardston
• Dr. Thomas E. Feasby, Calgary
To read more about the 2014 honorees visit
the AMA website at www.albertadoctors.org.
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14
MIND YOUR OWN BUSINESS
Need to manage change?
Focus on what makes people tick
Practice Management Program Staff
C
hange in health
care is constant
and physicians
are often called upon to
lead change. New technology, integration of allied health
professionals, panel management, new information
privacy requirements and new clinical protocols are
just a few of the many changes that physicians might
face in their practice.
The term “change management” is frequently used, but
not always well understood. Change management is often
focused on the mechanics of change implementation;
activities such as planning, communication or training.
However, without an understanding of the underlying
psychology and human factors involved, the success of
those change activities can be quite varied.
One model that is easy to remember and helpful
to understand the people-side of change has been
developed by Prosci Research. Their model is based
on the experience of hundreds of organizations across
multiple industries and is a respected model used
by many Fortune 100 companies. In each of these
organizations, they evaluated the factors that were
present when a project or significant change was
successful and when it failed. From this research they
developed a model called ADKAR® that defines the
stages of successful change and provides insights
on how to lead people through the stages.
are aware of why the change is necessary and what the
risks are of not changing. If people are going to apply
effort to do things differently, they need compelling
reasons for change.
Communication at this stage is less about the details of
the change or how to change than on building awareness
of the need to change. And unlike a toddler, it’s not
sufficient to fall back on “Because I said so.” The change
might be driven by a need to improve patient outcomes,
to create more timely access, to comply with legislation,
to create long-term financial sustainability or to reduce
risk of legal action – to name a few.
A number of factors will impact the audience’s
receptiveness at this awareness stage. These include:
• Their own personal satisfaction or dissatisfaction with
the status quo.
• The credibility of the messenger, including their past
history and level of earned trust.
• Misinformation or rumors that may have preceded the
communication.
• Validity of a direct causal link between the reasons given
for change and the change itself.
Desire for the change to occur
Awareness of the change
Once people are aware of the need for change, they
still need to find the personal motivation or desire to
move to the next stage of change. You cannot assume
because an individual is aware of the need for change
that desire will automatically follow. This is largely
because we are not solely logical beings and emotions,
personalities, psychological barriers and biases are part
of being human.
Lack of awareness was found to be the number one
reason for failure. If you’ve spent any time with a toddler
you will be familiar with their favorite question …
“Why?” Well, as adults we don’t really outgrow that.
The foundation of successful change is to ensure people
The key challenge at this stage for those leading change
is that there is limited ability to create desire in another
person. On the other hand, pushing ahead at this stage
will almost certainly increase overt or covert resistance
to the change. >
A – Awareness
D – Desire
K – Knowledge
A – Ability
R – Reinforcement
> There are numerous and complex factors impacting
whether or how quickly an individual moves through
this stage. The nature of the change, including the
magnitude of the change, the certainty of the outcome,
direct impact on the individual and perceived equity,
all impact whether awareness is converted to a personal
desire to change.
Environmental and personal factors will also impact
desire, including:
• The organizational culture and track record of
unsuccessful past changes.
• The number or magnitude of changes in a short
timeframe leading to change fatigue.
• The individual’s life situation including family
relationships, age, health and stressors impacting
their personal capacity for change.
• The individual’s personality and intrinsic motivation –
what makes them tick?
Addressing the varied reasons that may hold people up
at this stage requires understanding and tailoring your
message to multiple audiences. The focus here is to
identify “what’s in it for me?” and to help them overcome
the barriers they may have.
This stage may take patience and time to work through.
It can be tempting to take a directive approach and
push on with the change. However, this comes at the
risk of damaged relationships and a far more costly,
time-consuming process. It can result in either change
that does not meet the desired outcomes or is not
sustained in the long-term.
Knowledge of how to implement the change
This stage is all about training and education. When
people are in this stage they need detailed information
on how to use the new process or tools and clarity
about new roles and responsibilities. The time required
to move through this stage is dependent on whether
the concept is familiar or brand new, each individual’s
capacity to learn and access to available resources to
acquire the knowledge.
A common error in change management is to start with
training and education regardless of where individuals
are in the change process. There is an assumption that if
we throw more knowledge at people they will eventually
accept and adapt to the change. However, training is
of limited value if your audience is still grappling with
awareness and desire and is not ready to absorb the
new information.
Ability to act on acquired knowledge
At this stage, it is about translating facts and knowledge
acquired in the previous stage into action. A person may
have the desire to be a concert pianist and have the
knowledge to read music, understand chords and scales
and received excellent training – but still may not have
the ability (finger dexterity, musicality, dedicated practice
time, etc.) to be a concert pianist.
Whether a person has the ability to implement change
successfully can be influenced by physical abilities,
intellectual capacity, available time and resources, or
even psychological barriers.
At this stage, the focus for change leaders is to enable
people to acquire the ability through mentors, dedicated
time, access to expertise or other supports. In some
cases, there will be a need to bring in new resources
with the requisite abilities.
Reinforcement of the change
There is a natural tendency to slip back into the old way
of doing things if steps are not taken to actively reinforce
and sustain the change. Some of the tactics to sustain
change include providing recognition of successes
and effort, follow-up training, ongoing monitoring and
evaluation and making adjustments to reap the benefits
originally envisioned. For teams that employ PDSA
methodology (plan, do, study and act), the study
and act are effectively reinforcing change.
Key to application of the ADKAR® model is the
recognition that the order is important. Desire can
only be developed once there is awareness. Desire
must come before knowledge of what to do and
ability must follow knowledge so that it can be
translated from information to application. Lastly, of
course, reinforcement is only relevant once you have
successfully implemented change.
Keeping these five stages of the ADKAR® model in
mind can be helpful in communicating more effectively,
understanding where and how to focus change
management activities and, ultimately, implementing
sustained change that yields the desired results.
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.
15
16
INSURANCE INSIGHTS
Update on improvements –
TD Insurance Meloche Monnex
Don Warden | SENIOR
MANAGER, TD INSURANCE MELOCHE MONNEX – EDMONTON
D
uring the
Alberta Medical
Association
(AMA) Board of Directors'
mid-term contract review
of the TD Insurance
Meloche Monnex home
and automobile insurance
program in the spring of 2014, we committed to a
number of new processes and procedures that would
enhance the level of customer service to AMA members
and ensure that we were continuing to provide the high
level of care and attention to AMA members that they
have come to expect.
In an organization like TD with over 85,000 employees
(and TD Insurance with over 4,000), it takes time to
ensure that we have it right before we proceed with our
clients – in this case AMA members. We thank the AMA
and its members for their patience while we worked
to make these changes. Following is an update to our
promised changes:
• We are pleased to announce that as of December 1, 2014,
we have a new dedicated telephone line specifically for
AMA members. The phone number is 1.844.859.6566
and will be answered: “Welcome to the TD Insurance
Meloche Monnex Home and Auto Insurance Program
for the Alberta Medical Association.” We encourage
members to call this number for all claims, an inquiry
about your home or auto insurance, a billing inquiry or
any concern whatsoever. Additionally, all calls on this
line will be automatically advanced to the front of the
queue which should reduce call-wait times.
• A concern that arose during the mid-term contract
review was the overall coverage provided to AMA
members in the various packages we offer. The concern
was that a number of AMA members had insufficient
insurance, specifically those that had our basic, bronze,
silver or gold level home insurance coverage. The review
suggested that AMA members should generally be
covered under our platinum or platinum plus line of
insurance to be completely covered. To address this,
we put together a team to call all AMA members
that do not have platinum or platinum-plus coverage
(approximately 2,000), and this project was completed
last December.
• The Claims Advice Line is scheduled for implementation
in the first quarter of this year. This is a telephone line
that AMA members can use to call-in and get advice
on a claim without having any negative effect on their
claims history. This sounds simple, but actually runs
counter to how insurance companies operate, as
actuaries know that clients that call-in (whether a claim
is made or not) have a propensity to make additional
claims. The actuarial department has used this in the
past to calculate premium.
We would like to remind AMA members of our
MyInsurance website at https://myinsurancesoc.td.com.
This is a website available for our clients that requires an
initial registration (policy number required) after which
you can log in at any time to access information on both
your home and automobile insurance. You can print a
temporary pink card, get a quote, view your policy or
billing details, change your address, modify your auto
coverage, modify or remove a driver or vehicle or ask
general questions. Later this year we will be adding a
claims component so you can communicate with your
adjuster and track the claims process.
We will be adding additional features and services in
the coming months. Please watch for updates in future
editions of Alberta Doctors’ Digest and MD Scope.
If you are currently not insured with us, we invite you
to contact us for a quote using the AMA dedicated
telephone line at 1.844.859.6566 or you can obtain an
online quote at melochemonnex.com/ama.
FEATURE
17
Calling all applicants!
It’s time to check out the 2015 TD Insurance Meloche Monnex/AMA Scholarship
T
he Alberta Medical Association (AMA), in conjunction with TD
Insurance Meloche Monnex, is very pleased and excited to announce
that TD Insurance Meloche Monnex is providing $20,000 in
scholarship funds for 2015. By committee selection, four deserving applicants
will each be awarded $5,000 to put toward their additional training in clinical
areas of recognized need in Alberta.
This amount has been increased from $5,000 per year to the new $20,000 level
in recognition of the value that scholarship recipients bring.
Scholarship applicants must be:
• Seeking additional training in a clinical area of recognized need in Alberta.
• An AMA member.
• Enrolled and accepted in a clinical program of at least three months
duration in a recognized educational facility.
Scholarship recipients of the last
three years:
• 2014 Dr. Michael P. Chu, Edmonton
(clinical research fellowship in
mantle cell lymphoma, Stanford
Cancer Center, California)
• 2013 Dr. Jennifer K. Grossman,
Calgary (fellowship in primary
immune deficiencies, National
Institutes of Health)
• 2012 Dr. Gabriel Fabreau, Calgary
(fellowship in general medicine,
Harvard Medical School)
If that fits your situation, apply for the TD Insurance Meloche Monnex/
AMA Scholarship by March 31.
The proposed program must be supplementary to completion of a Royal
College of Physicians and Surgeons of Canada or College of Family Physicians
of Canada certification program, or the physician may be in an established
practice and wishing supplemental training.
To request a scholarship application form, please contact Janice Meredith,
Administrator, Public Affairs, AMA: janice.meredith@albertadoctors.org,
780.482.2626, ext. 291, toll-free at 1.800.272.9680, ext. 291, or visit the
AMA website at www.albertadoctors.org.
18
FEATURE
Emerging Leaders in Health Promotion Grant Program
T
he circle of life – at least, the circle of a healthy,
economically stable and educated life – was
the foundation of Darby Ewashina and Krystyna
Ediger’s Emerging Leaders in Health Promotion Grant
project: “The Rewards of Reading: A Literacy Campaign.”
Beginning in the fall of 2013, the two second-year,
University of Calgary medical students and active
members of the Student Run Clinic (SRC) – which
operates out of the Inn From the Cold homeless shelter
in downtown Calgary – introduced their literacy and
educational project to children/youth (0-11 years) of
SRC patients, who are also residents of the shelter.
With the reading and literacy project’s aim to have a
positive effect upon the future health of children at the
shelter, Darby and Krystyna strived to connect the dots
between health, level of education, socio-economic
status, prosperity and life-long learning.
“We know that health status improves with level of
education and we recognized a problem in that many
of the children at the shelter were often experiencing
a disruption in their schooling,” explains Darby.
We know that health status
improves with level of education and we
recognized a problem in that many of the
children at the shelter were often experiencing
a disruption in their schooling.
“We know too that education is closely tied to
socio-economic status and that effective education for
children and life-long learning for adults is key to health
and prosperity,” she continues. “It’s about getting off
on the right foot, getting equipped with the right tools
and then it’s easier to maintain that positive momentum
through life, via better employment, better income
and ultimately, better health.”
The premise of the project was to engage with the child
and youth SRC patients, while they were attending their
clinic appointments. With the reading and clinic spaces
housed in one, large room, the project leaders were able
to model good reading behavior to the children and their
parents/guardians. Efforts were also made to send the
children home with books in order to encourage reading
with their families, on their own time.
L to R: Second-year (fall 2013) University of Calgary medical students Krystyna Ediger and
Darby Ewashina unwrap their new textbooks … nope! They display a few of the books
provided for their Rewards of Reading health promotion program by FirstBook Canada’s
National Book Grant program. ( provided by Darby Ewashina)
Equipped with books and educational materials
acquired through FirstBook Canada’s National Book
Grant Program, Darby and Krystyna set up a child care
volunteer program with eight University of Calgary
Health Sciences students. During their monthly,
four-hour shift, the volunteer students would engage the
children and youth through reading circles and arts and
crafts, with an emphasis on literacy enhancement. >
> Under the guidance of project mentor Dr. Janette A.
Hurley, head physician of the SRC and a family medicine
practitioner in Calgary for 24 years, Darby and Krystyna
trained and worked with the volunteers to establish
the reading and craft activities while working with the
SRC’s 20 clinicians and four executive members to
set-up the program. Through these activities, Darby
and Krystyna met the requirement of the Emerging
Leaders in Health Promotion Grant Program to “facilitate
growth of leadership and advocacy skills in a mentored
environment.”
19
“Through the set-up of this whole program, we acted as
educators both to our colleagues and to the children at
the shelter,” says Krystyna. “We had to lead by example
when it came to implementation of the reading circles
and other educational projects. As well, we had to
communicate effectively with all parties and were often
looked to for advice and reassurance while the program
was in its early stages.”
With the support and involvement of the SRC’s 20
student clinicians, executive members, three staff
physicians and the volunteer Health Sciences students,
Darby and Krystyna’s literacy campaign has effectively
connected the SRC staff, its patients and their families,
meeting the final requirement of the Emerging Leaders
in Health Promotion Grant Program to “promote
development of the physician’s role as advocate for
healthy populations.”
Darby reads to the complete amusement of Rewards of Reading participants Carter (L) and
Henry (C). ( provided by Darby Ewashina)
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20
DR. GADGET
Where’s my CPS?
Wesley D. Jackson, MD, CCFP, FCFP
Y
esterday, I noticed
a first-year medical
student, who was
working with me for
the day, looking up a
medication that we were
considering prescribing
in the 2012 version
of the Compendium of
Pharmaceuticals and
Specialties (CPS). This
book, produced by the
Canadian Pharmacists
Association (CPhA),
was updated yearly
and distributed free of
charge to all Canadian
physicians, allowing
for quick access to key
information on most
pharmaceutical products
available in Canada.
First published in 1960,
the CPS contained
manufacturer and CPhA
monographs, product
information and pictures,
patient information, therapeutic guides, generic and
brand name information, and other useful information.
The 2012 blue bound, soft-covered book measured
10 x 12 inches with over 3,000 pages and, as with
previous versions distributed for more than 50 years,
adorned shelves in most physician offices across the
country. The physical size allowed for less chance of loss
while providing other innovative uses such as posture
improvement and core muscle development through
various balancing exercises using the book’s bulk.
This year, the CPS did NOT arrive at my office. Instead, I
received an email from the Canadian Medical Association
(CMA) inviting me to download a new app free of charge
to me through my membership, called RxTx Mobile. This
app, available for iOS and Android devices, is CPhA’s
mobile application providing offline access to all
3,000 plus pages of the CPS (Rx) as well as drug
choices (Tx), Health Canada Advisories, some medical
calculators and other information the publishers felt
might be useful to readers. Of particular use to many
physicians is the relative cost feature, available for
over 2,200 drugs, which was designed to illustrate the
comparative costs of therapy for a given condition. The
app, updated every two weeks, with a combined value
of over $500, is available to all CMA members who are
residents and practicing physicians.1
Information that previously was
available only on my shelf at the office,
is now almost always with me in my pocket.
The design of RxTx Mobile on both my phone and my
tablet is simple and very efficient, allowing me very
quick access to monographs, and several therapeutic
choices with a good search function for both generic and
brand names. Drug choices are particularly helpful for
searches such as the most recent treatment for bipolar
disorder or the red eye. Through the Health Canada
Advisories button, I was interested to learn, among other
things, that multiple distributors were selling unlicensed
home-use HIV test kits via amazon.ca. The calculators
available through RxTx Mobile will not be particularly
useful to most physicians and I was unable to locate
pictures of medications to identify that “little blue pill.”
The app does contain drug interactions within the
monographs, but unfortunately does not include an
interaction checker – a tool that I find very useful.
There are other excellent alternative apps available to
physicians. The National Physician Survey published
in December 2014 suggested that one of the most
popular apps in Canada is Epocrates. This app, produced
in the United States of America (USA), includes a
very well designed interface, a drug-drug interaction
tool, medication pictures and several useful medical
calculators – among other things. Unfortunately, the >
> interaction check lacks some important details and
because it is USA-centric, the app does not include
Canadian brand names or drugs available only in Canada.
This year, the Compendium of
Pharmaceuticals and Specialties did NOT arrive
at my office. Instead, I received an email from
the Canadian Medical Association inviting me
to download a new app, free of charge to me
through my membership.
Lexicomp, my preferred app in this category, is available
to all Canadian physicians after logging on to the
CMA website.2 This excellent resource provides drug
monographs, an interactions database, laboratory
tests, natural products and poisoning and toxicology
information. Lexicomp also includes Canadian drug
names. Adverse reactions to medications are clear and
often ranked in order of frequency. The current CMA
subscription allows for web access only through your
mobile device, but a very well-designed app is available
for offline use at a cost. Many physicians may already
have access to the Lexicomp app through university or
primary care network affiliation.
These apps, and others not mentioned here, have
greatly improved access to important medication
information. Information that previously was available
only on my shelf at the office, is now almost always with
me in my pocket. No longer will I need to debate that
Cialis really is indicated for benign prostatic hypertrophy
at the office Christmas party or try to remember all of
the side effects of the latest acne therapy at a family
gathering. I must admit, however, that my posture and
core strength are suffering.
References
1. https://www.cma.ca/En/Pages/cps-mobile-app.aspx.
2. https://www.cma.ca/en/Pages/drug-information.aspx.
PHYSICIAN(S) REQUIRED FT/PT
Also locums required
ALL-WELL
PRIMARY CARE CENTRES
MILLWOODS EDMONTON
Phone: Clinic Manager (780) 953-6733
Dr. Paul Arnold (780) 970-2070
21
22
PFSP PERSPECTIVES
Caring for yourself and your colleagues in the
years ahead. How will you make it happen?
Vincent M. Hanlon, MD | ASSESSMENT
A
nother year has
just ended. How
did you do in 2014
getting through your
pile of unread books (or
unopened book files on
your e-reader)? For me,
two volumes in particular
from my extensive collection of purchased and unread
books encouraged me to think differently about my work
as an assessment physician and educator with Physician
and Family Support Program (PFSP).
One was The End of Absence – Reclaiming What We’ve
Lost in a World of Constant Connection (2014) by
Canadian journalist, Michael Harris.1 He explores in an
even-handed fashion what it means to live a healthy
digital life – who we are and how we behave in our virtual
communities. He considers the loss of solitude and time
by ourselves, in both our on and off-line lives. Harris
suggests, “Ask yourself what might come from all those
silences you’ve been filling up.” What is gained and what
is lost when we shift away from face-to-face encounters,
and invest more of our time and ourselves in web-based
connections?
The other was the final book published by cultural critic,
Jane Jacobs. In Dark Age Ahead2 she speculates about
the future of community. That future may not be pretty.
“For communities to exist, people must encounter one
another in person,” says Jacobs. The imperative to build
community one personal encounter at a time seems
anachronistic in the digital world described by Harris.
For her part, Jacobs outlines the contemporary decline
of many supportive, stabilizing and life-enhancing
elements of community.
How willing and able are we to be physicians
for physicians?
Physicians are individual members of a professional
collective. We are the creators and the products of this
PHYSICIAN, PFSP
professional culture. Medical culture is made up of
multiple small and large communities, which we name
group practices, academic departments, primary care
networks, specialty teams and clinics. We live and work
within this rich and imperfect culture, and we contribute,
sometimes knowingly or sometimes unwittingly, to its
salutary growth or toxic dysfunction.
The healthy functioning of a community can be
demonstrated in the ways members look after each
other. As physicians, how interested and available
are we to care for colleagues? I remember physician
health researcher and advocate, Dr. Jane B. Lemaire,
speaking eloquently to a group of physicians a few
years ago about the the nature of support. She
differentiated the opportunities we have to support
and be supported by colleagues emotionally,
informationally and instrumentally.
To foster a healthy medical community, one thing we
need to appreciate is the dynamic nature of our identities
– most days we are physicians providing care, but there
are some days when we morph into patients with our
own health problems. An appreciation and acceptance of
these complementary identities can facilitate healthier
doctor-patient relationships – and specifically, healthy
physician-for-physician patient relationships.
National Physician Survey (2014)
demographic data
With Jane Jacob’s insights on culture and community
in mind, I reviewed some of the demographic data
contained in the 2014 National Physician Survey.3 The
average age of physicians in Canada is close to 50.
Half of male physicians and 30% of female physicians
are over 55 (nearly 32,000 in total). Look ahead
15 or 20 years. Although the average age of physician
retirement approaches 70 (Pong, 2011),4 we can
anticipate large numbers of this 55 plus physician group
reducing to part-time, reconfiguring or limiting their
practices in other ways, before eventually retiring. >
> What do all those numbers mean?
23
This demographic portrait of Canadian physicians
suggests two things to me:
1. Numerous physicians have already witnessed the
retirement or relocation of their family doctor. The
frequency of such occurrences is likely to increase.
2.At the same time, many of these older physicians
will be confronting serious illnesses, some for the
first time in their lives.
Just like many of their fellow Canadians, physicians may
wonder who will be there to look after them. Who will
be there to organize our care in the way that we have
organized the care of many patients, physicians and
non-physicians alike? And how should we view these
physicians-for-physicians initiatives? Some consider
them a form of preferential treatment; others argue they
are a legitimate benefit that arises from mutual concern
for members of our physician community.
We can anticipate large numbers of the 55 plus physician group reducing to part-time,
reconfiguring or limiting their practices in other ways, before eventually retiring.
( provided by Dr. Vincent M. Hanlon)
The healthy functioning of a
community can be demonstrated in the ways
members look after each other.
One of PFSP’s key messages is our belief in the value
of physicians caring for colleagues. PFSP maintains a
dynamic network of family doctors and psychiatrists
who support physicians, residents and medical students
with physical and mental health problems. If you have
an interest in providing care to members of our medical
community and would like to join this network, please
contact PFSP at pfsp@albertadoctors.org.
PFSP education sessions
PFSP sponsored two education sessions this past
autumn, one in Edmonton, the other in Calgary, as
part of our P4P initiative: Physicians-for-Physicians.
PFSP assessment physicians, Dr. Lil J. Miedzinski and
Dr. Elizabeth M. Monaghan, led these information and
orientation sessions. The feedback received was mostly
positive. First of all, the physicians valued and enjoyed
the opportunity to have a facilitated conversation with
peers about the rewards and challenges of looking after
a colleague. Participants welcomed the opportunity to
discuss setting boundaries, and reviewing generic case
studies, especially those with complex care issues.
If you don't have a family doctor, don't delay searching for one and arranging a first
appointment. ( provided by Dr. Vincent M. Hanlon)
Family physician, Dr. Margaret Anne T. Churcher,
attended the Calgary session and shared with the group
her approach in the office to welcoming a physician as a
new patient, including clarification of doctor/patient roles
and responsibilities.
This year PFSP is sponsoring two other topics related
to physicians caring for peers. This past January,
Dr. William A. McCay, an Edmonton psychiatrist,
spoke to a group of anesthesiologists about caring
for colleagues with mental health problems. This
session is the result of collaboration between PFSP and
Dr. Teresa E.C. Eliasson, a member of the department
of anesthesiology and pain medicine at the University
of Alberta. Dr. Eliasson coordinates the office of staff
wellbeing within her department.
In February, Dr. Jeremy R. Beach occupational health
specialist, will speak about the aging physician in the
workplace at our PFSP team meeting, and again for
family doctors attending the Alberta College of
Family Physician’s 60th Annual Scientific Assembly,
February 26-28 in Banff. >
24
> It’s not too late to make a resolution or two
If we value our own health and the good health of
our colleagues, how shall we best promote and
maintain that?
1. If you don’t have a family doctor, don’t delay searching
for one and arranging a first appointment.
2.If your family doctor is planning to retire soon,
discuss with them about finding a replacement to
take over your care. (And don’t forget to thank your
doctor for their good care before you see him or her
for the last time.)
References
1. Harris M. The End of Absence – Reclaiming What We’ve
Lost in a World of Constant Connection. He explores in an
even-handed fashion. Toronto: HarperCollins, 2014.
2. Jacobs J. Dark Age Ahead. New York: Vintage, 2004.
3. http://nationalphysiciansurvey.ca/.
4. Pong RW, PhD. Putting Away the Stethoscope for Good?
Toward a New Perspective on Physician Retirement. Ottawa
ON: Canadian Institute for Health Information, 2011.
3.In your search, don’t overlook younger colleagues
who have a good chance of still being in practice in
your later years.
4.Consider joining PFSP’s network of family doctors and
psychiatrists who look after colleagues. Contact us
at pfsp@albertadoctors.org.
Jane Jacobs gets the last word: “For communities to exist,
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FEATURE
25
What's new on the web?
W
ebsites are never finished. They only improve …
or decompose! With that in mind, the Alberta
Medical Association (AMA) is tirelessly
working to create new features while refining existing
aspects of our website for our members. Here are some
highlights from the past few months:
• Intra-sectional Relative Value (INRV) lookup tool: The
INRV lookup tool helps physicians understand how their
pay rates are set and valued by each specialty area. The
tool allows users to quickly and easily look up fee codes
by activity description or code to receive information on
fee-code owners, current rates and relative value rates.
You can find it in the member services > compensation
section, or by following this link: www.albertadoctors.
org/services/physicians/compensation-billing/
allocation/inrv-lookup.
• Online Membership Guide: In previous years, we have
printed and mailed out paper copies of our membership
guide. To ensure it is always up-to-date and readily
available, we have put the entire guide online. You can
get to it from the member services page, or by visiting
www.albertadoctors.org/membership-guide.
• 2014-15 Business Plan: What does the AMA want
to achieve this year? How will we go about it? Find
this year’s business plan online under the Leaders >
Governance section.
• Improved login help: Logging in to a website can
be a pain. What’s my username again? Which password
did I use? To improve members’ experiences, we have
identified a number of common problems and improved
our login processes and help section to make logging
in less of a headache.
That’s just the start. We plan on continuing to
improve and hope to see you along for the journey
at www.albertadoctors.org.
Have something you like/dislike about our
website, a feature request or something you’d like
us to focus on? You can always let us know at
webmaster@albertadoctors.org – we want to hear
from you.
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26
FEATURE
Thinking differently:
Can physicians and patients learn?
Dr. Aravind Ganesh | NEUROLOGY
RESIDENT PHYSICIAN
T
he Alberta Medical
Association (AMA)
has a System-Wide
Efficiencies and Savings
Consultation Agreement
with Alberta government.
One of the most significant
activities under this
agreement is an Alberta-based implementation of
Choosing Wisely Canada.
Choosing Wisely is an initiative that began in the United
States of America (USA) and has been imported and
adapted to the Canadian health care system. Through
education and awareness, we seek to encourage
informed conversations between physicians and patients
about tests and services for which evidence of benefit is
weak and that may actually cause harm. When we get
talking, we can change behavior. Patients will receive
better care, their satisfaction will increase and the
system’s resources will also be used most appropriately.
Can physicians and patients learn to work differently
together? We think so.
Alberta Doctors’ Digest (ADD) will bring your more
information about Choosing Wisely in Alberta in the
year ahead. You will receive communication in other
ways, too.
With this issue of ADD, we are pleased to bring you an
article “The Problem of Reflexive Testing and Procedures” by
Calgary-based neurology resident physician Dr. Aravind
Ganesh. Your comments and questions are welcome!
Email choosingwisely@albertadoctors.org.
Restoring sense to medicine – How can doctors
and patients “Choose Wisely”?
Choosing Wisely Canada (CWC) is a campaign to help
physicians and patients engage in conversations about
unnecessary tests, treatments and procedures, and thereby
make smart and effective choices to ensure high-quality care.
The problem of reflexive testing and procedures
“Don’t just do something, stand there!”
No, I didn’t get that wrong. One of my instructors in
medical school (who really was a master at turns of
phrase) would use this inverted comment to gently
chastise us for putting our patients through unnecessary
tests or interventions: Before blindly ordering a lab or
imaging test or reflexively performing a procedure, stop
and think for a moment – consider the patient’s full
situation and the implications of what you are about
to order. Does it actually make sense in the context of
what the patient’s diagnosis is likely to be? Will the test
actually help you confirm the diagnosis or decide on a
treatment? Will the treatment or intervention actually
help improve the patient’s outcome? Don’t just do
something. Stand there.
While that may sound really straightforward, in the
modern reality of clinical practice, with its frenetic pace
and insatiable demands, physicians often find themselves
ordering tests and interventions based on impulse rather
than evidence. When faced with an intimidating patient
load and the associated pile of paperwork, it’s certainly
easier to fall back on a routine “habit” of doing a certain
set of things when you see a certain type of patient,
even if there is zero evidence to support that type of
approach (I’m guilty of this myself). For example, it’s
common to find physicians who will order a CT scan of
the head pretty much every time they see a patient with
a headache or a MRI scan of the back whenever they see
someone with back pain.
Some of you might be wondering – so what if my doctor
orders some things habitually? Sure it may not be
intellectually elegant, but no harm done, right? And in
our litigious environment where a physician is more likely
to be sued for not doing something, doesn’t this practice
make sense? After all, when did you hear about a doctor
being sued for ordering a brain scan? Few doctors would
be surprised, on the other hand, if a patient came in
demanding a brain scan for their headaches or a lumbar
scan for their back pain. >
> This raises an important myth in modern medicine that
dupes physicians, patients and health care systems – that
more testing/interventions equals better care. But this
couldn’t be further from the truth. The reality is that we
physicians are responsible for wasting over $200 billion
annually in North America alone on unnecessary testing
and interventions, but our patients end up receiving only
about 55% of the recommended care as set out by the
most basic best-practice guidelines.
This trend for unnecessary testing also influences how
physicians interact with their patients – for instance,
the bedside assessment, which was the most important
part of the patient appointment in the past (and a type
of communion between patients and physicians), has
been taking more of a backseat in recent years. This is
a concerning trend because tests can only take us so
far in the diagnostic process – if we aren’t guided by a
clear framework of what the patient’s condition could
be, based on speaking to them and examining them.
Furthermore, tests and interventions carry their own
risks. Consider the concern about long-term cancer
risks with the accumulated radiation from unnecessary
CT scans, for example, or the risk of heart attacks,
other blood clots or pneumonia associated with surgical
procedures. Unless the benefits of performing these tests
or interventions outweigh the risks, it does not make
sense for physicians to order them or for patients to
demand them.
The Choosing Wisely Canada campaign
I recently met up with Michael A. Gormley, Executive
Director of the Alberta Medical Association (AMA)
and Dr. William S. Hnydyk, Assistant Executive Director
of Professional Affairs, in Edmonton to chat about the
Choosing Wisely Canada initiative, which has arisen in
response to these concerns about waste and impaired
diagnostic reasoning.
The Choosing Wisely campaign began in the USA
in 2012, when various specialty societies joined the
American Board of Internal Medicine Foundation and
Consumer Reports with the aim of helping physicians
and patients make smarter choices about tests,
treatments and procedures in order to ensure higher
quality of care. As part of this campaign, each society
developed a list of five tests or procedures that are
commonly used inappropriately in that specialty. Now,
this same campaign has come to Canada, headed by Dr.
Wendy Levinson, chair of the Department of Medicine at
the University of Toronto. The campaign is supported by
various medical societies across Canada, including the
AMA who are championing the initiative in Alberta.
In reviewing the top five lists made by different specialist
societies in North America, it’s interesting to note that the
majority of them directly relate to diagnostic imaging.
One frequently mentioned point is the problem I
mentioned earlier about imaging patients with headaches
who do not have any clear risk factors for structural
problems or patients with back pain who do not have any
‘red flags’ for dangerous causes. These were at the top
of the list of concerns for both the American College of
Radiology and the Canadian Association of Radiologists.
By disseminating this type of information to both patients
and doctors, the CWC campaign hopes to facilitate more
sensible conversations between Canadians and their
physicians about tests and procedures.
Don’t just do something, stand there. Thanks to the
Choosing Wisely initiative, it looks like more physicians
will be paying attention to that message.
Dr. Aravind Ganesh is a neurology resident-physician and
co-founder of the Calgary-based mHealth venture SnapDx.
He is also a clinical researcher, public health advocate and
a Rhodes scholar, currently working with the University of
Oxford’s Centre for Prevention of Stroke and Dementia.
What’s Up Doc? is a biweekly column covering the most
interesting doctors and health researchers in Calgary and in
our wider global community. If you are working on something
that is changing health care, we’d like to hear about it. Send
us a tweet at @snap_dx or email aravind@snapdx.co.
Need confidential advice
dealing with patient advocacy or
intimidation in the workplace? Call
the Zone Medical Staff Association
(ZMSA) operated
Practitioner advocacy
assistance Line (PaaL)
1.866.225.7112

The PAAL is a 24-hour confidential
service you can call to share the issue
and obtain advice from your ZMSA. All
calls are answered by Confidence Line,
an independent provider of confidential
reporting lines.
The PAAL service has been transferred
out of Alberta Health Services and is
now operated at arm’s length by ZMSAs.
For more information visit
albertadoctors.org/paal
27
28
FEATURE
Diagnosing schizophrenia:
What can we learn from a historical perspective?
Sarah Erem | STUDENT,
UNIVERSITY OF CALGARY
(PRECEPTOR: PROFESSOR DR. FRANK W. STAHNISCH, FACULTY OF MEDICINE, UNIVERSITY OF CALGARY)
Each fall the Alberta Medical Association Representative
Forum/annual general meeting features the Dr. Margaret
Hutton Lecture Series. Medical students present on various
interesting aspects of medical history. To share their excellent
research and conclusions, we are carrying the highlights of
the lectures in Alberta Doctors’ Digest.
This issue features guest author, Ms Sarah Erem of the
University of Calgary.
A
cross the range of psychiatric disorders,
schizophrenia can be considered both strange
and challenging, because of a variety of powerful
physiological symptoms and the social stigma attached
to it. This mental disorder is poorly portrayed and
misunderstood, from the past to the present.
This mental disorder is poorly
portrayed and misunderstood, from the past
to the present.
Thomas Szasz (1920-2012), famous psychiatrist,
University of Cincinnati, called schizophrenia “the sacred
symbol of psychiatry” of the 21st century.1 It is a complex
condition that is characterized by heterogeneity in
symptomatology. The differences in symptoms, family
and personal background, make it extremely difficult to
trace the historical origins of the mysterious disorder. It
is often suggested that “schizophrenia-like” illnesses had
existed in similar ways in the past since “madness” and
“lunacy” have been documented in medicine and written
annals from the beginning of high civilizations onwards.
The ancient Egyptian2 and Greek texts, the Bible as well
as non-Western sources are filled with many examples of
irrational and bizarre behaviors.3
However, the medical descriptions of “madness” before
the 1800s suggest that conditions occurred throughout
a person’s life rather than primarily in young people.4
Additionally, auditory hallucinations that occur in 75% of
current patients are extremely rare in cases of “insanity”
prior to the 1700s.5 Finally, the first recognizable medical
record of schizophrenia did not appear in Europe until the
early 1800s.6
Dr. Emil Kraepelin and his dichotomy
Dr. Emil Kraepelin (1856-1926) was a leading German
medical doctor who had a variety of research interests
in psychiatry, pharmacology, genetics and neurology.
His work had a major impact on modern psychiatry and
its understanding of mental illness based on natural
scientific concepts and experimental observation.7 After
obtaining his medical degree in 1881 from the University
of Leipzig, he pursued his interests in experimental
psychology in the laboratory of Wilhelm Wundt
(1832-1920). In 1882, he then worked in the research
lab of Wilhelm Heinrich Erb (1840-1921) in Heidelberg,
Germany who helped him to shape his neurological
understanding of pathology and define his own scientific
method for experimentation, which he later applied
in his first Psychiatric Classification8 (“Compendium
der Psychiatrie”) to differentiation of the concept of
endogenous psychosis.9 This, in his opinion, was caused
by internal biological conditions, such as organic brain
damage, metabolic dysfunctions or hereditary factors,
and was regarded as incurable by contemporary
psychiatrists and alienists.10 Kraepelin therefore offered
to differentiate between “manic depression insanity”
(currently: major manic depression – following DSM-V)11
and “dementia praecox” (“schizophrenia”– following
DSM-V),12 which he considered to be forms of an
inherited neurodegenerative disorder. In contrast, he
described manic depression as an episodic disorder,
which does not lead to permanently impaired brain
function.13
His ample clinical observations at the psychiatric clinic
of the University Hospital in Munich led Kraepelin to the >
> hypothesis that specific combinations of symptoms in
relation to the course of psychiatric illnesses allow one
to identify a particular mental disorder.14 One of the most
problematic issues about Kraepelin is his generalization
of psychiatric finding specifically to political and ethnical
contexts. In addition to that, he has not been known as
the most empathetic of doctors, which was not really
unusual. The patients in 19th century were rather seen as
“study material” for the medical researchers, who valued
their clinical observations and lacked in communication
with their subjects.15
In the later period of his career, as a convinced
champion of social Darwinism, he actively promoted
a policy and research agenda in racial hygiene and
eugenics, consequently, his influence in the medical
field declined largely due to his political view. After
this, the diagnosis of psychiatric disorders fell into the
hands of psychoanalysts established earlier by the
Vienna neurologist and psychiatrist Dr. Sigmund Freud
(1856-1939)16 and eventually made its way into the
classifications of DSM I and II.17
29
"The patient sees figures, spirits, the corpses of their relatives; something is falsely
represented to him, all sorts of devil's work, the patient hears abusive language and
threats." ( provided by Manic-depressive insanity and paranoia, 1921, p. 22)
Eugen Bleuler and birth of “schizophrenia”
In 1908, Eugen Bleuler (1857-1939) at the lecture of
German Psychiatric Association (“Deutsche Gesellschaft
für Psychiatrie”) in Berlin took “the liberty of employing
the word schizophrenia for revising the Kreaepelin’s
concept.” In his opinion, breaking up or splitting of
psychic functioning was an excellent symptom of the
whole group.18
Compared to Kreapelin, Bleuler saw a great value in
listening to the patients. While accommodating himself
in their environment, he realized that the condition
wasn’t a single disease (he referred to a “whole group”)
and didn’t always progress to full dementia, nor did it
always occur in young people.19 Consequently in his
book Dementia Praecox or the Group of Schizophrenias
1911, he divided symptoms into two broad categories:
fundamental and accessory. Bleuler believed that
fundamental were occurring in schizophrenia only
and therefore were pathognomonic. The accessory
symptoms, on the other hand, could occur in a variety
of different disorders. The second way of description
was primary (directly due to an assumed organic
deficit) or secondary (developing as a result of the
primary disturbance – this included delusions and
hallucinations).20
DSM III and revival of Kraepelin’s classification
In the 1970s, the medical community began to recognize
discrepancies in diagnostics between the USA, which
still relied on broad psychoanalytical diagnostics, and
the European classification using Kraepelinian “firmly
medical.”21 Consequently, the new findings resulted in the
revival of the Kraepelin dichotomy as strictly medical in a
new DSM III edition in 1980.22 It also did not emphasize
cognitive decline and included family studies and
"The group of patients reproduces the expression of mania mood in varied coloring
from quiet, cheerfulness and proud self-consciousness to unrestrained cheerfulness."
( provided by Manic-depressive insanity and paranoia, 1921, p. 22)
prevalence rates. With these minor modifications, Kraepelin’s
nosology remained fundamentally unchanged and is still used
in the current version of DSM V.23
Despite the speculations and criticism, Kraepelin’s dichotomy
has survived for so long for three major reasons: lack of
laboratory tests based on the neuropathology of the illnesses,
lack of robust scientific data and the complexity of forming
a new classification system.24 The reason Kraepelin’s ideas
have remained influential even in this century is because
it is a simple concept which allows psychiatrists to feel
confident, despite a complex clinical picture, to arrive at a
clear diagnosis, which Kraepelin himself doubted on several
occasions: “No experienced diagnostician will deny that there
is an alarmingly large number of cases in which, despite the
most careful observation, it seems impossible to arrive at a
reliable diagnosis.”25
References available upon request.
30
FEATURE
Want to participate in clinical research?
Here are some steps to success
A
Alberta (i.e., the Health Research
Ethics Board of Alberta, or the
Health Research Ethics Board at the
University of Alberta, or the Conjoint
Health Research Ethics Board at the
University of Calgary), and must
comply with the requirements of
the board.
Consent to participate in a study
should preferably be obtained in
writing. Specific issues related
to participation in the research
study should be discussed with
the research subject or substitute
decision-maker and documented in
the medical record.
Confidentiality
Legal and ethical framework
The CPSA also has a Standard
of Practice on Relationships with
Industry, aimed at ensuring
physicians avoid potential conflicts
of interest and that they maintain
their professional autonomy. The
standard stipulates, for example,
that physicians are to disclose any
relationships with industry, they
should participate only in ethical and
scientifically valid industry-sponsored
research, and they should not
accept gifts from industry. To further
reduce the possibility of conflicts of
interest, physicians should review
the research protocol carefully to
ensure it does not compromise their
professional autonomy.
lberta is home to world-class
medical research and the
physicians who participate in
research studies should be aware of
their legal, ethical, and professional
responsibilities and obligations. Many
of these obligations are described
in a recent article by the Canadian
Medical Protective Association
(CMPA), which is available on the
association’s website. The regulatory
framework in Alberta and the
guidance provided by the College
of Physicians & Surgeons of Alberta
(CPSA) serve to protect the interests
of both researchers and research
subjects and may be cited in legal
actions and regulatory authority
(college) complaints related to a
research study.
The Canadian Medical Association’s
(CMA’s) Code of Ethics provides
the ethical framework under which
Alberta physicians practice, and it
states, “Consider first the well-being
of the patient.” This ethical principle
applies equally when the patient is
involved in a research study.
Other sources of legal obligation
include the regulations under the
federal Food and Drugs Act, which
outlines requirements applicable
to all clinical trials involving human
subjects in Canada. In addition,
the CPSA’s Administration of
Practice states that physicians
must have their research proposals
reviewed and approved by one
of the applicable research ethics
boards operating in the province of
Consent
Research subjects must consent to
participating in or receiving treatment
considered experimental or part of
a research study. Courts have held
that the standard of disclosure for
consent to participate in research
is generally higher than for other
medical treatment.
While the information to be disclosed
varies based on each study, the CMA
Code of Ethics generally requires that,
at a minimum, the potential subject
be informed “about the purpose of
the study, its source of funding,
the nature and relative probability of
harms and benefits, and the nature of
the physician’s participation including
any compensation.”
Physician researchers generally owe
a duty of confidentiality to research
subjects. Alberta’s Health Information
Act and regulations establish the
rules that must be followed for
the collection, use, disclosure and
protection of health information
in the province. Before identifiable
personal health information may be
disclosed, the research proposal must
have been assessed by a research
ethics board, the researcher must
agree to comply with conditions
stipulated in the Health Information
Act, and the researcher must
enter into an agreement with
the information custodian. More
information about researcher
obligations concerning confidentiality
can be found in the Health Information
Act, Guidelines and Practices Manual.
Clinical trial agreements
Many of the issues identified here
may be addressed in a clinical trial
agreement between the study
sponsor and participating physicians.
Physicians asked to sign a clinical trial
agreement should carefully review
its terms to ensure it does not
conflict with their legal and
professional obligations.
CMPA members are always welcome
to contact the CMPA with any
medico-legal questions pertaining to
their participation in research.
RESIDENTS’ PAGE
31
Remove those 3-D glasses; our health is 4-D
Dr. Rithesh Ram | FAMILY
MEDICINE RESIDENT PHYSICIAN
I
have been fortunate in
my educational career
for numerous reasons,
including being provided
with opportunities to
attend meetings, forums, symposiums and conferences.
Beyond the personal development and growth that is
an inevitable bonus of being in attendance, once in a
while I’ve been invited to something that truly allows a
glimpse into the inner sanctum of our health care system.
I attended one such gathering not too long ago in Banff.
health, individual, system and time. Each is made up of its
own complexities. For example, health encompasses all
aspects that maintain or affect health, and the system
includes all aspects that maintain, destroy or improve our
system of health. The individual is the one with
expectations that time often cannot meet.
At this particular symposium, Chatham House Rules were
in effect; therefore, I am free to disseminate information,
but without any identities attached. I had never been
involved in a symposium under this particular rule, so it
was a new experience I looked forward to. The topics
included leadership in health care, innovation and patient
engagement with potential challenges and improvements
a part of each session.
The goal of keeping Albertans healthy
cannot stop at the doors of our medical centers;
the nature of people’s experiences in the
community plays an integral role in their health
and in the well-being of our community.
Now a reasonable question to ask: What does this have to
do with resident physician involvement and/or engagement
in the community?
From the choice of speakers, to the range of attendees, to
the conglomeration of sessions, it became apparent that
leadership – with regards to the health of our population –
is four-dimensional. Consider what the four elements are:
Dr. Rithesh Ram and family believe that keeping Albertans healthy cannot stop at the
doors of our medical centers. ( provided by Dr. Rithesh Ram)
At many points within this 4-D analogy, all of the elements
could seemingly come together; yet they rarely do. The
individual wants faster access that the system does not
allow or deem appropriate. The system wants to
implement measures that improve preventative health,
but the individual is challenged to comply. Health and time
will often be in disagreement, with time usually coming
out the victor.
Given the inability of these elements to naturally come
together, leadership is required to build what would be
a statistically significant rapport. Not perfect, but with
a margin of error acceptable in almost all aspects of
health research. >
32
> That is where PARAdime, in its sixth year, enters
the battle.
The PARAdime campaign is a resident physician-driven
initiative to collect backpacks filled with everyday
necessities for various shelters throughout the province.
As one of my colleagues stated in the past, it is “a
reminder that the goal of keeping Albertans healthy
cannot stop at the doors of our medical centers; the
nature of people’s experiences in the community plays
an integral role in their health and in the well-being of
our community.”
Indeed.
The PARAdime campaign is a resident
physician-driven initiative to collect backpacks
filled with everyday necessities for various
shelters throughout the province.
And as medical professionals, we have a responsibility to
promote health on an individual and communal level
within and beyond the system itself.
Initiatives like PARAdime emphasize the connection
between health, individual and system. It is timely, as it
occurs during the winter season when concerns regarding
the health of Albertans are heightened. It also serves as a
reminder of how as physicians we can advocate for patient
health outside of typical medical venues.
PARAdime reminds me that successful advocacy stems
from knowledge of not only how the individual
experiences the system, but how the system frames
individual experience. Without being engaged beyond our
silos of residency, medical schools, operating rooms or
clinics; without being informed beyond traditional media,
social media, high impact journals or coffee line gossip;
without being reflective beyond our best/worst patient
encounters, or our best attempt at mindfulness, we will
never have any hope of carrying the 4-D health of our
population forward into the next century. Hence attending
meetings, conferences and symposiums are essential to
building professional awareness of the policies that could
help or hinder our ability to advocate for patient health
and wellness.
As physicians, we are automatically connected to three
elements: health, individual and system. The challenge
is to invest the time to improve the relationships that
already exist.
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IN A DIFFERENT VEIN
33
Fighting the slings and arrows
of outrageous fortune
Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR
A
ah … we’ve all
enjoyed the cheap
thrill of hearing
juicy gossip, eh? But it’s
not such fun when you’re
on the receiving end.
Back in snowy September
2014, a Hollywood-North
newspaper, let’s call it the Hogtown Star, published a
shock/horror headline article on the misbehavior of
clinical investigators in Canada (myself among them) – at
least in the eyes of the US Food and Drug Administration
(FDA) and the Hogtown Star.
“Drug Testing Rules Broken by Canadian Researchers,”
screamed the headline – with the breathless first
sentence: “Top Canadian doctors running clinical trials
have risked patient safety, failed to report serious
side-effects suffered by their human test subjects and
botched the scientific research of the drugs.”
Well, that covers pretty much everything and we may as
well go home and hang up the snowshoes. The evidence?
FDA site reviews.
As politicians say when they’re going to obfuscate,
“Let me be clear….” Newspapers have every right to
investigate whatever they want. I will defend this right to
the last lunchtime cocktail. But surely they should also
offer a platform for explanations.
The article (by a young investigative reporter) was based
on FDA site reviews over the last 26 years on clinical
trials of medications being considered for approval in
the United States of America (USA) and performed in
Canada in the last 31 years. These reviews and associated
correspondence are now in the public domain for anyone
with the interest and perseverance to read some really
boring stuff. The FDA site reviews (as they are meant to)
found many errors, inconsistencies and practices that, in
a many instances, were not up to current standards.
As a piece of investigative reporting, it was fair enough to
bring these less-than-stellar reviews to public attention,
although it should have been noted that FDA reviews of
American clinical research are just as scathing. But where
the Hogtown Star let Canadians down – and where many
of these investigative pieces foment discord – was the
newspaper avoiding looking at all sides of the story and
their disinterest in giving a platform to us bunglers and
botchers to explain ourselves. You’d almost think they
were publishing a duff story just to sell their newspaper.
Most depressing of all was the rush of tweets
applauding the article: “Thank God for the FDA,”
or “Another example of the lack of ethics, morality
and professionalism of doctors in this country.…”
They all rushed to judgment. Not one mentioned the
possibility that there might be reasonable explanations or
extenuating circumstances, and that the FDA is not the
great savior of the people and that Health Canada might
not be an incompetent body of lazy prats.
The article was a missed opportunity, and at worst,
mischievous. It did nothing to promote the needs of
patients or research. It may have scared some patients
from entering clinical trials. And weirdly, it enhanced the
reputation of the FDA.
Newspapers have every right to
investigate whatever they want. I will defend
this right to the last lunchtime cocktail. But
surely they should also offer a platform for
explanations.
I admire many aspects of the USA but these do not
include Hershey's chocolate, Twinkies, the Central
Intelligence Agency, Jerry Springer or the FDA – which is
a huge bureaucracy employing over 14,600 full-timers.
(Health Canada has 2,400 full-timers for the same work
volume.) The FDA’s job has evolved into demanding
unnecessary tests (especially too frequent X-rays), >
34
> conducting intrusive investigations with demands for
irrelevant clinical data and finger-wagging lectures from
people that have never run a clinical study themselves.
Clinical trials are difficult to do, from idea inception
through to agreement from colleagues, funding, ethical
issues, privacy considerations, starting-up, accruing with
patient informed consent, monitoring, data collecting,
analysis and write-up. It’s much easier not to do them.
I’ve found pretty much everything in life was encountered
at school by age 12. An FDA review is like the “bad report
card problem” from teachers that don’t really like you
much. We’ve all had that and one’s first reaction is to try
to figure out ways of avoiding the parental review. This
never works. Lord Northcliffe, the 19th century editor
of the Daily Mail (or perhaps it was W.R. Hearst) said:
“News is something somebody wants suppressed. All
the rest is advertising.”
So suppression (or hiding behind legal advice to say
nothing) is not going to work unless you’re guilty. The
next and best approach is to sigh, hand the report card
to the parent and try to explain the circumstances.
A major job of the FDA is to discover fraud (of which
there is a fair amount in the USA; much less so in
Canada). They are trained detectives and do their jobs
thoroughly. Among the many hundreds of thousands
of observations, they find errors (in the American way,
excessively called “violations”). People who understand
medical practice, they are not.
Where the Hogtown Star let
Canadians down – and where many of these
investigative pieces foment discord – was
the newspaper avoiding looking at all sides
of the story and their disinterest in giving
a platform to us bunglers and botchers to
explain ourselves. You’d almost think they
were publishing a duff story just to sell
their newspaper.
Consent was verbal until around 1986. It was a messy
trial to do – the surgeons seeming to know the answer
without doing the trial (oophorectomy was OBVIOUSLY
better than tamoxifen) so accrual was slow.
This trial resulted in tamoxifen being approved for
use in pre-menopausal women with recurrent breast
cancer. This has extended many lives with usually a
good life quality.
Enter, Mr. Carp (not his real name, but similar), the
FDA reviewer, on a wet Monday morning in 1988 in
Edmonton. Mr. Carp came in with fedora and trench coat,
lapels drawn up like Dick Tracy and flashed his badge. I
put out my hand to shake his and he drew away like I had
ebola. I then asked if he wanted to go for lunch during the
week. He refused with a look as if I’d offered a bribe.
“I’ll see you at the end of the week, dah-cter,” he said.
Friday arrived. I was summoned. He sat with a pile of
charts on the opposite side of the table.
“D’ja want the bad noos or the good noos, dah-cter…”
“Er, I’ll take the good news.”
“The good noos is that as far as I can tell, every patient
on this trial actually existed.”
“That’s the good news?” I said.
I then spent the next two hours explaining why
Mrs. Jones did not have her chest X-ray when she was
meant to because she visited her sister in California;
why the dose of tamoxifen was doubled or halved
seemingly on a whim (our protocol didn’t go into details
like that); why in the chart I had dictated that the patient
was stable and yet the radiologist had reported that the
sclerotic bone disease was progressing (the assessment
of bone disease in breast and prostate cancer remains
hard with frequent disagreements between radiologist
and clinician). And so on. One or two discrepancies
were serious, most were minor. Remember, clinical trial
assistants were non-existent in those days. Protocols
were simple and brief.
Mr. Carp then berated me for a lack of written consent
forms for half the patients.
“But we only introduced written consents in 1986,” I said.
In our case, the trial that the Hollywood-North rag was
interested in was one we did with a Toronto colleague
starting in 1983. It was a trial in metastatic breast
cancer, randomizing patients between oophorectomy
and tamoxifen with cross-over on disease progression.
In 1983 (before Nelson Mandela was put in jail, and
likely before my Hogtown Star interrogator was born)
clinical research was a bit of a novelty. Trial protocols
were perhaps five pages long, in contrast to the 150-plus
pages nowadays anticipating every conceivable scenario.
“I wanna see written consents, dah-cter.”
It was the “past practice should be like the present”
fallacy, the silly notion that because practice has evolved,
you were responsible for the past and, using a crystal
ball, should have behaved like it was the present. It’s the
same fallacy the Hogtown Star article fell into – judging
trials, not in the context of the times but by current
standards. It’s as daft as the handwringing that goes
on when talking today, in a time of peace, security and
friendship, about Japanese internment camps in Canada >
> and the USA during the war like it’s our fault. Both sides
had them (the camps in Japan were much worse than
ours). In the context of war, thinking changes, dude.
Thousands of observations with multiple interactions
occur in a clinical trial. There are going to be mistakes
and errors. This never happens in journalism.
So the article appeared, reputations were shaken.
Letters from physicians and patients explaining the
circumstances were sent. None were published. They
were onto Rob Ford’s sarcoma.
This increasingly dismal world has become more black
and white. When something is controversial, there are
only two sides – a right side and a wrong side. Twitter
feeds amplify half-baked opinions.
One of the disappointments for me was the lack of
support from Alberta Health Services (AHS) “public
relations” staff. Not one contacted me to help.
Oh, there had been a flurry of emails from people rushing
to the scene, largely to ensure that there was not going
to be negative publicity. The “media relations” and legal
people in AHS said: “Don’t talk.” This was bad advice.
These folks are paid by administration and are there
to protect administrators and “the system.” “Media
relations” issued a statement saying that current clinical
trials were now run properly without flaws, completely
ignoring the fact that today’s practices are a result of
actions taken following the kinds of review that the
Hogtown Star was pouring scorn on.
They are not there to protect YOU, dude. Thinking
they are is like those reckless physicians who decline
Canadian Medical Protective Association (CMPA)
insurance, fondly imagining the hospital insurance will
back them up. To be fair, the Sunnybrook Hospital media
people did not give this kind of advice. They actually
helped a colleague in distress and emphasized the
benefit of facing accusers head on when you have
a good case.
As a veteran of the 1993 breast cancer pseudo-scandal
when the Chicago Tribune headlines screamed “Breast
Cancer Fraud” on a quiet Sunday, I knew the best
approach was to stand up and make it clear what actually
happened. The way the Chicago Tribune article was
written made it look like the actual results of National
Surgical Adjuvant Breast and Bowel Project (NSABP)
trials, a leading breast cancer trials group in the USA
(including the critical breast conservation study B-06),
were fraudulent. In this notorious case, what happened
was that a surgeon in Montreal had circumvented
the patient inclusion criteria of some clinical trials by
including patients who didn’t fit the criteria (such as
starting their chemotherapy a day or so later than in the
protocol). He was into being the top accruer. There was
no fudging of any end-results and his actions would have
no conceivable biological effect on the results. When
this scandal broke, the truth was lost in the accusations
flying around.
I called a meeting of all the patients on these early
studies and explained what happened. “Is that all?”
was the general response. These patients were wiser
than the bureaucracy of the National Cancer Institute
headed by Dr. Sam Broder (where is he now?) who
used the pseudo-scandal to fire Bernard Fisher,
Director of the NSABP, a surgeon who did more for
breast cancer patients than anyone. Since I have had
more FDA reviews than most in Canada, and although
I would have liked to have kept my head down, I knew
I was going to be targeted.
He was a polite young man with a Scottish surname
(though I failed to negotiate much sympathy) and I spent
over an hour on the phone with him, hoping to educate
him on the history of clinical trials in western medicine.
I’ve done a lot of clinical trials, some good, some not
so good. The first trial I participated in was at the Royal
Marsden Hospital, London, England in 1973 – a trial in
myeloma patients. Professor Tim McElwain thought
that high dose IV melphalan with prednisone might be
a useful treatment. (He was correct.) The protocol was
a hand-written page pinned on the notice board of the
doctors’ coffee lounge.
I’ve had several reviews by the FDA over the years –
always fraught occasions – fraught because these people
are top-class detectives. Their job is to detect scientific
fraud – and they’re good at it. What they’re not good at is
seeing the big picture as to whether the trial was timely,
well thought through and the observations were correct.
They tend to focus on details: when blood counts were
done, whether the timing of X-rays was as dictated
in the protocol.
My youthful interrogator at the end of my grilling
asked me what lessons I’d learned from all this. I gave
a trite answer, but on reconsideration, here are the
lessons learned:
1. When the past comes back to bite you, bite back. Don’t
hide from the press if you have a good case.
2.Do not rely on “media relations” people to help. A good
department might help a bit but they are there to serve
administration, not you.
3.Being a principal investigator in a clinical trial is a big
responsibility. Most of the time things go smoothly but
when things go wrong, you are the one holding the baby
and responsible for the errors of the whole team.
4.Tell investigative reporters that their career will go
further if they look at all sides of a story. A good
reporter will consider this and welcome a platform
for explaining extenuating circumstances.
35
36
CLASSIFIED ADVERTISEMENTS
PHYSICIAN WANTED
CALGARY AB
TotalCardiology™ is seeking a
community-based clinical cardiologist
to join their growing office practice
and Rapid Access Cardiology Clinic
(RACC).
We are the largest community-based
private practice in Canada located
in Calgary and currently have 23
cardiologists in our practice. Our
cardiologists together with their
multidisciplinary team of more
than 150 people, provide the
highest-quality of cardiovascular
care to the patients we serve.
The hallmark of TotalCardiology™
is our patient-centered values
and approach to cardiovascular
care. Using the principles of the
advanced access service model,
TotalCardiology™ provides chest
pain evaluation and cardiology
assessments at our RACC. In addition
to the RACC, our cardiologists also
see patients for consultation in our
clinical care office.
Supporting our robust consultation
practice, TotalCardiology™ also offers
outpatient cardio-diagnostic testing
in our new state-of-the-art office as
well as cardiac rehabilitation and risk
reduction services in a world-class
public sport and fitness facility.
All candidates should be certified in
cardiology by the Royal College of
Physicians and Surgeons of Canada.
Interested individuals should submit
an application letter and curriculum
vitae to: Leslie Austford,
Chief Operating Officer
laustford@totalcardiology.ca
Visit our website for additional
information about TotalCardiology™
at www.totalcardiology.ca.
CALGARY AND EDMONTON AB
EDMONTON AB
Imagine Health Centres in Calgary
and Edmonton have an immediate
opening for a psychiatrist certified
with the College of Physicians &
Surgeons of Alberta (CPSA).
Alberta Health Services is inviting
applications for full-time family
physician positions within the family
care clinic at East Edmonton Health
Centre. These positions are open
to physicians who wish to establish
a new full-time practice within an
interdisciplinary setting, supporting
a vulnerable, culturally diverse and
complex population. Remuneration
for these positions will be on a
guaranteed/sessional rate.
Imagine Health Centres are dynamic,
multidisciplinary clinics with a large
array of services including family
physicians, specialists and many
other allied health professionals such
as pharmacists, physiotherapists,
psychologists and more. Imagine
Health Centres is dedicated to
promoting the health of patients
utilizing the most up-to-date
preventative and screening strategies.
The successful candidate will work
closely with our multidisciplinary
team to optimize management of our
patients with mental health issues.
Collaborate with our large network of
family physicians and their referrals to
maximize outcomes for your patients.
Opportunities for group therapy and
corporate health are available. There
are also opportunities to help develop
leading programs for mental health
at all levels of primary care within
our multiple sites located throughout
Calgary and Edmonton.
An attractive compensation package
will be offered to the successful
candidate.
All candidates must be immediately
eligible for licensure or already
licensed with the CPSA and provide
proof of malpractice insurance from
the Canadian Medical Protective
Association. Compensation is
fee-for-service.
All inquiries will be kept strictly
confidential and only qualified
candidates will be contacted.
Submit your CV to: Joanne Oliver
joanne.oliver@imaginehealthcentres.ca
The clinic offers patients access to
an interdisciplinary primary care
team including family physicians,
nurse practitioners, registered nurses,
licensed practical nurses, mental
health/social workers, dietitians
and cultural support workers. The
team works closely with community
agencies and external partners to
provide comprehensive primary care
services. Clinic operations are fully
computerized with an electronic
medical record (EMR). Other
co-located programs include public
health services, addictions and mental
health, adult and children’s home care
and region 6 social services.
This is a combined clinical practice
and teaching environment and
successful candidates will be
encouraged to hold clinical
appointments in the Department of
Family Medicine at the University
of Alberta, Faculty of Medicine &
Dentistry. Successful candidates will
also be expected to become members
of the North Edmonton Primary
Care Network.
Interested applicants must hold
an MD or equivalent, be eligible
for a license to practice medicine
in Alberta and have completed a
Residency in Family Medicine. >
> All qualified candidates are
encouraged to apply; however,
Canadians and permanent
residents will be given priority.
Alberta Health Services hire on the
basis of merit. We are committed to
the principle of equity in employment.
We welcome diversity and encourage
applications from all qualified men
and women, including persons with
disabilities, members of visible
minorities and Aboriginal persons.
The competition will remain open
until the position is filled.
To apply please forward a copy
of your curriculum vitae and
a letter of interest to:
Karen DeViller, Site Director
East Edmonton Health Centre
karen.deviller@albertahealthservices.ca
EDMONTON AB
HealthPointe Medical Centre is
a dynamic multidisciplinary pain,
spine and sport medicine clinic
in Edmonton. We have a part- or
full-time opportunity for a family
physician or specialist that has a
strong interest and experience in
the medication management of
chronic pain patients.
The medication management
physician will be responsible for
seeing consultations within the clinic
and should be well versed in pain
assessment; it would be an asset
to have his/her methadone and
suboxone license, but not required.
The successful candidate will work
closely within our multidisciplinary
team to optimize management
of our patients with chronic pain.
Physicians working at HealthPointe
enjoy an efficient workflow, paperless
electronic medical records and
friendly support staff; physicians
are able to easily maintain a work/
home life balance with flexible
days available.
If you are interested in learning more
about our clinic, please contact us.
confidential.
Contact: Roberta Fyffe or
Dr. Sean Gonzales
T 780.453.5255
staff@healthpointe.com
EDMONTON AB
EDMONTON AB
Busy west Edmonton clinic, close
to West Edmonton Mall seeks a
family physician interested in part- or
full-time work. Flexible hours, good
split and working environment.
Two positions are immediately
available at the West End Medical
Clinic/M. Gaas Professional
corporation, located at unit M7, 9509
156 Street, Edmonton AB T5P 4J5.
Full-time family physician/general
practitioner positions are available.
The physician who will join us at this
busy clinic will provide family practice
care to a large population of patients
in the west end and provide care to
all patients of different age groups,
pediatric, geriatric, antenatal and
prenatal care.
Contact: bemececontact@gmail.com
Attention: Manager
EDMONTON AB
Urban Medical Clinic in vibrant
southeast Edmonton is a new
state-of-the-art medical clinic that
is rapidly expanding. The clinic uses
TELUS PS Suite electronic medical
records. Our team currently includes
two family physicians and we are part
of Edmonton Southside Primary Care
Network with a full-time nurse and
dietician. We have 8,000 patients
registered. The clinic is growing and
we are recruiting part- and full-time
physicians. Competitive overhead
for long term commitments. We
have eight examination rooms, one
procedure room and one specially
designed wheelchair room.
Contact: Dr. Oshean Naidoo
onaidoo@telus.net or
Dr. Dhanakodi Rengan
drengan@telus.net
T 780.757.9545
EDMONTON AB
Beverly Medical Clinic is a new
state-of-the-art medical clinic that is
rapidly expanding. Our team currently
includes three family physicians, two
internists and a pediatrician.
The clinic is growing and needs more
dedicated family physicians as one of
the physicians is planning on slowing
down. Competitive overhead for long
term commitments; 75/25% split.
We have 10 examination rooms, one
treatment room and one specially
designed pediatric room.
Contact: Dr. A. Elfourtia or
Dr. Z. Ramadan
Beverly Medical Clinic
4243 118 Ave
Edmonton AB T5W 1A5
T 780.756.7700
C 780.224.7972
The physician income will be based
of fee-for-service payment and the
overhead fees are negotiable. The
physician must be licensed and
eligible to apply for licensure with
the College of Physicians &
Surgeons of Alberta (CPSA). Their
qualifications and experience must
comply with the CPSA licensure
requirements and guidelines. If you
are interested please contact us.
Contact: Dr. Gaas
T 780.756.3300
C 780.893.5181
F 780.756.3301
westendmedicalclinic@gmail.com
EDMONTON AB
The Beverly Towne Medical Clinic is a
new state-of-art medical clinic that is
rapidly expanding. Our team currently
includes three family physicians,
pediatrician and gynecologist.
The clinic is growing and needs
more dedicated specialists and
family physicians as one of the
physicians is planning on slowing
down. The family physician position
is permanent, full time and fee-forservice. The physician and clinic will
share fee-for-service billings, 70%
(physician) and 30% (clinic) for
overhead expenses.
For eligibility criteria please visit this
link: http://www.cpsa.ab.ca/Services/
Registration_Department/Alberta_
Medical_License.aspx
Contact: Dr. A. Elfourtia or
Dr. Z. Ramadan
Beverly Towne Medical Clinic
11730 34 St
Edmonton AB
T 780.756.7700 or
T 780.224.7972
beverlymedicalclinic@gmail.com >
37
38
> EDMONTON AND FORT
MCMURRAY AB
MD Group, Lessard Medical Clinic,
West Oliver Medical Centre and
Manning Clinic each have 10
examination rooms and Alafia
Clinic with four examination rooms
are looking for six full-time family
physicians. A neurologist, psychiatrist,
internist and pediatrician are required
at all four clinics.
Two positions are available at the
West Oliver Medical Centre in a
great downtown area, 101-10538
124 Street and one position at the
Lessard Medical Clinic in the west
end, 6633 177 Street, Edmonton.
Two positions at Manning Clinic in
northwest Edmonton, 220 Manning
Crossing and one position at Alafia
Clinic, 613-8600 Franklin Avenue in
Fort McMurray.
The physician must be licensed or
eligible to apply for licensure by the
College of Physicians & Surgeons
of Alberta (CPSA). For the eligible
physicians, their qualifications and
experience must comply with the
CPSA licensure requirements and
guidelines.
The physician income will be based
on fee-for-service with an average
annual income of $300,000 to
$450,000 with competitive overhead
for long term commitments; 70/30%
split. Essential medical support and
specialists are employed within
the company and are managed by
an excellent team of professional
physicians and supportive staff. We
use Healthquest electronic medical
records (paper free) and member of
a primary care network.
Full-time chronic disease management
nurse to care for chronic disease
patients at Lessard, billing support and
attached pharmacy are available at the
Lessard and West Oliver locations.
Work with a nice and dedicated
staff, nurse available for doctor’s
assistance and referrals. Also provide
on-site dietician and mental health/
psychology services. Clinic hours are
Monday to Friday 8:30 a.m. to
8:30 p.m., Saturday and Sunday
10:30 a.m. to 5 p.m.
Contact: Management Office
T 780.757.7999 or
T 780.756.3090
F 780.757.7991
lessardclinic@gmail.com
RED DEER AB
Well-established family practice
clinic with four physicians has
an opportunity to add a part- or
full-time physician. Diverse patient
population, electronic medical
records and primary care network
support. Hospital privileges necessary,
obstetrics optional. Excellent support
regarding on-call schedule.
Contact: Dr. L. Ligate
F 403.346.4207
lora.l@shaw.ca
SHERWOOD PARK AB
The Nottingham Medical Clinic in
Sherwood Park is expanding and
we are looking to add part- and
full-time family physicians. Currently
the clinic has four physicians and is
appointment-based. We use Med
Access electronic medical records
and offer flexible hours, laboratory,
X-ray and on-site pharmacy.
Clinic is associated with the Sherwood
Park Primary Care Network providing
additional benefits.
Contact:
T 780.416.3220
sdenson@shaw.ca
PHYSICIAN AND/OR
LOCUM WANTED
CALGARY AND EDMONTON AB
You require balance … you demand
the best. Join the fastest growing
medical group in Alberta to practice
medicine the way it was meant to be.
Imagine Health Centres (IHC) is
currently looking for family physicians
and specialists to join our dynamic
team in either Calgary or Edmonton.
Physicians will enjoy extremely
efficient workflows allowing for very
attractive remuneration, no hospital
on-call, paperless electronic medical
records, friendly staff and industryleading fee splits.
Imagine Health Centres 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, psychologists, nutritionists
and pharmacists.
Imagine Health Centres prides itself
in providing the very best support for
family physicians and their families in
and out of the clinic. Health benefit
plans and full financial/tax/accounting
advisory services are available to
all IHC physicians. There is also an
optional and limited time opportunity
to participate in ownership of our
innovative clinics.
Compensation is fee-for-service.
Current positions available are locum,
part- or full-time.
We currently have three Edmonton
clinics with a fourth coming soon to
Windermere (southwest Edmonton)
early this year. The current clinics are
near South Edmonton Common,
Old Strathcona and West Edmonton.
We currently have one clinic in
southeast Calgary and a second clinic
opening downtown early this year.
confidential and only qualified
candidates will be contacted.
Submit your CV to: Joanne Oliver
joanne.oliver@imaginehealthcentres.ca
SPACE AVAILABLE
MAPLE RIDGE BC
Prime downtown street level large
medical office space for lease in
Maple Ridge; prime main street
exposure with street and lot parking.
Contact: Adrian Keenan
Re/Max Lifestyles Realty
T 604.312.6488
akeenan@telus.net >
>
PRACTICE WANTED
CALGARY AB
I am a family doctor looking to take
over any medical clinic from which
the owner is relocating or retiring.
I would also consider buying a medical
building.
If you are a family physician or
specialist looking for part- or full-time
work please contact me.
Contact: Dr. D. Das
T 403.585.6840
drddebasish@gmail.com
COURSES
CME CRUISES WITH
SEA COURSES CRUISES
• Accredited for family physicians
and specialists
• Unbiased and pharma-free
• Canada’s first choice in CMEatSEA®
since 1995
• Companion cruises FREE
EASTERN CARIBBEAN
March 14-22
Focus: Primary Care Update
Ship: Independence of the Seas
BRITISH ISLES
July 15-27
Focus: Endocrinology, gastroenterology
and infectious diseases
Ship: Celebrity Silhouette
ALASKA GLACIERS
August 2-9
Focus: Cardiology and respirology
Ship: Celebrity Infinity
MEDITERRANEAN
September 19-October 2
Focus: Challenges in medicine
Ship: Celebrity Equinox
ST. LAWRENCE
September 19-27
Focus: Third annual McGill CME cruise
Ship: Crystal Symphony
FIJI TO TAHITI
November 10-21
Focus: Endocrinology and diabetes
Ship: Paul Gauguin
CARIBBEAN
November 15-22
Focus: Trends in aesthetic medicine
Ship: Nieuw Amsterdam
TAHITI AND TUAMOTUS
March 18-28
Focus: Geriatrics, physician health
Ship: Paul Gauguin
PANAMA CANAL
November 20-30
Focus: CME with Ontario
Medical Association
Ship: Zuiderdam
HAWAIIAN ISLANDS
April 20-May 1
Focus: Primary and palliative care
Ship: Celebrity Solstice
SOUTH AFRICA
November 24-December 9
Focus: Adventures in medicine
Ship: Regent Seven Seas Mariner
DALMATIAN COAST
May 28-June 9
Focus: Cardiology and dermatology
Ship: Celebrity Constellation
CARIBBEAN NEW YEAR’S
December 27–January 3, 2016
Focus: Dermatology and
women’s health
Ship: Freedom of the Seas
EXOTIC ASIA
June 15-24
Focus: Women’s health and
endocrinology
Ship: Quantum of the Seas
AUSTRALIA AND NEW ZEALAND
January 5-19, 2016
Focus: Caring for an aging patient
Ship: Celebrity Solstice
SOUTHEAST ASIA HIGHLIGHTS
January 31–February 14, 2016
Focus: Internal medicine and
primary care
Ship: Celebrity Millennium
For current promotions and pricing,
contact: Sea Courses Cruises
TF 1.888.647.7327
cruises@seacourses.com
www.seacourses.com
SERVICES
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
DISPLAY OR
CLASSIFIED ADS
TO PLACE OR RENEW, CONTACT:
Daphne C. Andrychuk
Communications Assistant,
Public Affairs
T 780.482.2626, ext. 275
TF 1.800.272.9680, ext. 275
F 780.482.5445
daphne.andrychuk@
albertadoctors.org
39
“I INVEST WITH
MD BECAUSE
I FEEL THEIR
ULTIMATE GOAL
IS TO IMPROVE
OUR LIVES.”
− Dr. Judy Chow, Family Physician
MOST CANADIAN PHYSICIANS CHOOSE
MD AS THEIR PRIMARY INVESTMENT FIRM.1
MD is the only financial services firm created to meet the specific
needs of physicians. We offer personalized, objective advice on
everything from investments and incorporation, to insurance,
banking, borrowing and estate and trust.
WHY WILL YOU INVEST WITH MD?
CONTACT AN MD ADVISOR TODAY TO DISCUSS
YOUR INVESTMENT NEEDS.
1 877 877-3706 | md.cma.ca/invest
1
Fifty-three per cent of Canadian Medical Association members chose MD as their primary financial services firm,
with the closest competitor at 12%. Source: MD Financial Management Loyalty Survey, June 2014.
MD Financial Management provides financial products and services, the MD Family of Funds and investment
counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca.
Incorporation guidance limited to asset allocation and integrating corporate entities into financial plans and wealth
strategies. Professional legal, tax and accounting advice regarding incorporation should be obtained in respect
to an individual’s specific circumstances. Banking products and services are offered by National Bank of Canada
through a relationship with MD Management Limited. Credit and lending products are subject to credit approval
by National Bank of Canada.

January/February 2015 - Number 1

Transcription

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