Medical Post - September 2018 by ensembleiq

Our provincial ranking 12

7 physician-friendly small towns 23

Burnout on the rise 39

How to incentivize staff 49

BEST PLACES TO PRACTISE Canna for chrobis pain PA nic GE 3 1

SEPTEMBER 2018 THE MEDICAL POST SEPTEMBER 2018 1

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Contents UPFRONT

Dreamville, Canada

Books: Medical pains

PMHx: B.C. doctors’ 40% fee hike in 1981

Profiles of a few physicianfriendly small towns

Editorial

The CMA is making big changes but without MD Financial can it convince members of its value?

7 Feedback

Your thoughts on last issue’s column on assisted suicide and the role of physician assistants

8 Rounds

What the CMA might do with its $2.6-billion windfall

FEATURES

39 Doctors are burning out more now

20 Q&A: How do doctors find their home? Unpacking health human resource trends

54 What to do when you make a mistake

We spoke to a few doctors about the healthiest ways to move forward

Doctors in a dangerous time

Dr. Eric Cadesky reflects on a moment during his medical training when he knew he should have spoken up but didn’t

The lure of the travelling circus

Editor Colin Leslie examines two false assumptions about how doctors decide where to settle

A U.K. immigrant shook up how medical associations negotiated

The best provinces to practise in

Where to set up practice

Dr. Frank Warsh’s memoir paints a funny and relatable picture of life as a Canadian doctor

Dr. John Crosby considers how medicine has changed and which of these things have contributed to burnout

Cover, Justin Poulsen

BACK PAGES

12 Ranking professional satisfaction to regulator favourability

VOLUME 54 NO. 4

Dr. Ted Jablonski talks about applying for a far-off job, and the thrill of wondering what it would be like to move

49 Solve my problem: Incentivizing staff Advice for you

50 Advanced theatrical life support 101 Dr. Stephen Starr covers the tried-and-true formula for resuscitating an action star

VISUAL ARTIST Justin Poulsen is producing all the Medical Post covers this year using props that he creates and then photographs. We’ve been asking him questions related to the theme of each issue. He now lives and works in Toronto but arriving in Ontario’s capital was driven by a professional demand. “Up until 2013 I lived and worked in Calgary. Calgary’s economy is very much dependent on the oil and gas industry. Around 2011/12 I saw signs of impending market failure and decided that I had to move in order to properly diversify income streams. Proximity to potential client headquarters and their respective advertising agencies played a large part in my choice to move to Toronto.” Toronto also has more industrial supplies, which he uses for props and can get quickly without paying and waiting for shipping.

Next Issue: October FINANCE is the theme for our October issue and it seems like a great time for it as doctors of all generations are expressing a desire to become more independent and not rely on anyone else for money management. So we’ll unpack and research the best answers to some of doctors' most common financial questions. We'll also have the inside story of the sale of MD Management to Scotiabank.

THE MEDICAL POST SEPTEMBER 2018 3

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Indication: HUMALOG (insulin lispro injection) is indicated for the treatment of patients with diabetes mellitus who require insulin for the maintenance of normal glucose homeostasis. HUMALOG insulins are also indicated for the initial stabilization of diabetes mellitus. HUMALOG is a short acting insulin analogue and is for use in conjunction with a longer acting insulin, such as HUMULIN N (insulin isophane (rDNA origin) NPH), except when used in a subcutaneous insulin infusion pump. Consult the product monograph at www.lilly.ca/en/pdf/product-monograph/humalog-ca-pm-approved.pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The product monograph is also available through our medical department. Call us at 1-888-545-5972. * Comparative clinical significance has not been established. † Clinical significance has not been established. References: 1. Humalog® Product Monograph, Eli Lilly Canada Inc., November 28, 2017. 2. Eli Lilly Medical/Regulatory attestation letter. February 27, 2018. Humalog® and KwikPen® are registered trademarks owned by or licensed to Eli Lilly and Company, its subsidiaries or affiliates. © 2018, Eli Lilly and Company. All rights reserved.

PP-HI-CA-0078

EDITORIAL

Three days in Winnipeg

The CMA is re-examining its role and that has some doctors excited – and some doubtful The Canadian Medical Association has

been going through some existential self-examination. It has its new 2020 strategic plan and the association’s board had hoped to pass a whole slew of governance changes in one omnibus motion by delegates at its annual meeting in Winnipeg last month. Tensions were high amongst delegates and I watched in astonishment from the side of the room as they broke the omnibus motion into components, accepting some changes and rejecting others. Governance machinations probably aren’t all that important to your average working doctor, yet many are still wondering: Does the “new” CMA provide value for members? So what is the CMA’s new direction? For one, it is a different course than that of the provincial/territorial medical

THE MEDICAL POST PRESIDENT, ENSEMBLEIQ CANADA Jennifer Litterick jlitterick@ensembleiq.com GROUP BRAND DIRECTOR, HEALTHCARE Donna Kerry dkerry@ensembleiq.com VICE PRESIDENT/ GENERAL MANAGER EVENTS Michael Cronin mcronin@ensembleiq.com AUDIENCE DEVELOPMENT MANAGER Lina Trunina ltrunina@ensembleiq.com

EDITOR-IN-CHIEF Colin Leslie cleslie@ensembleiq.com ASSOCIATE EDITOR Tristan Bronca tbronca@ensembleiq.com WEB OPERATIONS MANAGER Valerie White vwhite@ensembleiq.com DIRECTOR OF PRODUCTION & DESIGN, CANADA Derek Estey destey@ensembleiq.com PRODUCTION MANAGER Lisette Pronovost lpronovost@ensembleiq.com

PHYSICIAN ADVISORY BOARD DR. GILLIAN ARSENAULT DR. TARYL FELHABER community medicine GP in oncology DR. BENJAMIN BARANKIN DR. JANET FRIESEN dermatology family medicine DR. MARIO ELIA DR. SARAH GILES family medicine family medicine DR. FERRUKH FARUQUI DR. LARA HAZELTON family medicine psychiatry

associations (known as PTMAs). In every province—with the exception of Quebec—the PTMAs are responsible for negotiating physician compensation with the governments so, naturally, this makes their priorities different than those of the CMA. The CMA also wants to engage patients more than it has in the past; to have “courageous and influential dialogue to advance health in Canada,” as it says in its strategic plan. Some doctors feel this new focus on patients means that physician advocacy will become secondary. But outgoing CMA president Dr. Laurent Marcoux disputes this. As he said in our recent interview: “A physician is only a physician when there is a relation with patients.” If one were to take the optimistic view, they would argue that there’s no

ART DIRECTOR Nancy Peterman npeterman@ensembleiq.com GRAPHIC DESIGNER Erin McPhee DIRECTOR OF MARKETING Alexandra Voulu avoulu@ensembleiq.com SALES BRAND DIRECTOR Martin Rissin mrissin@ensembleiq.com ACCOUNT MANAGER Norman Cook ncook@ensembleiq.com ACCOUNT MANAGER Scott Tweed stweed@ensembleiq.com

QUÉBEC GROUP PUBLISHER Caroline Bélisle cbelisle@ensembleiq.com ACCOUNT MANAGER Pauline Shanks pshanks@ensembleiq.com CLASSIFIEDS Nancy Dumont ndumont@ensembleiq.com CORPORATE OFFICERS EXECUTIVE CHAIRMAN Alan Glass CHIEF EXECUTIVE OFFICER David Shanker

CHIEF OPERATING OFFICER & CHIEF BRAND OFFICER Richard Rivera CHIEF BRAND OFFICER Korry Stagnito PRESIDENT OF ENTERPRISE SOLUTIONS Terese Herbig CHIEF DIGITAL OFFICER Joel Hughes CHIEF HUMAN RESOURCES OFFICER Jennifer Turner SENIOR VICE PRESIDENT, INNOVATION Tanner Van Dusen

COLIN LESLIE EDITOR-IN-CHIEF

reason to think physician and patient advocacy are mutually exclusive; that this 151-year-old national association may find ways to solicit patient input and use it to improve the workday of every Canadian doctor. But ultimately the CMA is a voluntary membership-based organization, and it will need to convince every member of its ongoing value. Starting in 2019, medical students, residents and retired physicians will see their CMA membership fees waived and the annual membership fee for practising members will be reduced to $195 from $495. The $2.6 billion the CMA recently received from the sale of MD Financial gives the CMA a fairly long runway to convince Canada’s doctors of the value of the association.

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Contents copyright © 2018 by Stagnito Partners Canada Inc., may not be reprinted without permission. The Medical Post receives unsolicited features and materials (including letters to the editor) from time to time. The Medical Post, its affiliates and assignees may use, reproduce, publish, re-publish, distribute, store and archive such submissions in whole or in part in any form or medium whatsoever, without compensation of any sort. The Medical Post, ISSN-0025-7435, PM Agreement No. PM42940023, established 1965, is published 6 times per year except for occasional combined, expanded or premium issues, which count as two subscription issues by EnsembleIQ, 20 Eglinton Avenue West, Suite 1800, Toronto, Ontario, M4R 1K8. Montreal Office: 1425 René Lévesque ouest, 2e étage, Montréal, Québec, H3G 1T7. Printed in Canada at Transcontinental

THE MEDICAL POST SEPTEMBER 2018 5

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Feedback Divided views on assisted suicide column, getting only ‘hard’ cases and the role of PAs

The cultural failing of assisted suicide (June) Dr. Ferrukh Faruqui’s column produced a wave of online comments in support and opposition to her position. “I appreciate the moral courage required to write candidly on controversial topics. Thank you,” wrote Dr. Michael Ackermann of Sherbrooke, N.S. “The writer of the article is entitled to her opinions, that is the mainstay of democracy,” wrote Dr. Diane Wallis of Nanaimo, B.C. “However, using the comparison of the Holocaust to describe MAiD and its dedicated providers is both insulting and ignorant. The Canadians that I have personally helped end their lives have been full of gratitude, both for the legality of the process and the moral

courage of practitioners such as myself who have taken the decision to do this challenging but rewarding work. I feel privileged to live in a society where the law reflects the will of those who choose to end their suffering in this way. I am not doing this work because I have been ordered to do it, but because I recognize it as some of the most caring, loving and compassionate work I have ever done as a physician of 35 years standing.” Embracing allies: non-MD providers can lower your workload (June) “If a system were set up where the ‘easy’ cases were skimmed off by healthcare workers outside my office (e.g., pharmacists) it would lead to physicians like me having to do more work for less remuneration and would not be sustainable for us. A huge cog in the wheel to have healthcare workers practise at the top of their scopes is avoiding unintended consequences like physician burnout,” wrote Dr. Jonathan Marcus of Toronto. “Proponents of integration and innovation, with lower-paid providers ‘displacing’ higher-paid ones, sound sensible. However, many of us in general practice

“Every day we see what comes in appearing as simple visits lead to valuable discussion or diagnosis.”

can’t picture our work being chopped up and neatly sorted into ‘complex diagnostic work’ and ‘simple delegable jobs.’ A huge part of our work isn’t just providing information, but building trust over many visits and connecting the dots,” wrote Dr. Adam Chen of Mississauga, Ont. “Every day we see what comes in appearing as simple visits lead to valuable discussion or diagnosis. If I had delegated to another practitioner, the ‘job’ is done but I don’t gain insight about the patient.”

Playing doctor (June) An assertion by a physician commenter on this article that “(Physician assistants) were invented in the army for reasons having to do with efficiency and risk management (i.e., physicians are too precious to risk on the battlefield)” was brought short by the president of the Canadian Association of Physician Assistants. “You are right that the PA profession had its origins in the military but not for the reasons you think. Post-Vietnam, the same physicians and surgeons who treated the wounded in Vietnam recognized the quality of care wounded soldiers had received on the battlefield and wanted the same for their patients back in the U.S. Subsequently, in 1968 Duke University started a PA program,” wrote Trevor Stone. PA Kevin Dickson of New Brunswick wrote about the reference in the article that PAs are not required to have insurance. “I have liability insurance and so do many of my peers. It is available to PAs quite reasonably because there have been no claims. I owe it to my physician supervisors in a busy ED to carry my own coverage.” MP

THE MEDICAL POST SEPTEMBER 2018 7

Rounds DISPATCH VITALS

Ranking factors in practice location

$2.6 billion: Possible CMA ‘moonshots’

BY COLIN LESLIE

There is a cadre of doctors who see the $2.6 billion In June the Medical Post conducted an online survey and got responses from 231 doctors and medical students. We asked respondents to rank the following for how important each is in determining where they want to practise (we’ve totalled the “important” and “very important” responses):

94% Good work-life balance 78% Quality hospitals 69% A high income 69% Feeling a part of the community 69% Cost of living 67% Good schools 66% Working relationship with provincial government 65% Being near extended family 65% Availability of choice hobbies 61% Quality outdoor recreation 61% Professional opportunities for spouse 38% Locum support 35% Diverse population

8 SEPTEMBER 2018 THE MEDICAL POST

the Canadian Medical Association received from the sale of MD Financial Management as a legacy that the association can use to affect change in a way it’s never been able to before. What moonshots— ambitious, ground-breaking projects undertaken, perhaps, without an exhaustive investigation of the risks and benefits—might the CMA take that could change the way doctors work? What if . . . the CMA vowed to bring in a single national licence within three years? With so much money, it could almost bribe the provinces to tell their provincial colleges to work together to figure out a way. If that didn’t work within two years, what if the CMA aggressively pushed the federal government to recognize that not having panCanadian licences is a matter of “national concern” under section 91 of the Constitution Act, 1867, and thus Ottawa can create policy that forces the colleges to create a national licence? What if . . . the CMA argued that flagrantly onerous paperwork was a threat to patient safety and said—moonshot!—within three years it would start suing hospitals, insurance companies and ministries with the most egregiously complicated forms? What if . . . the CMA could genuinely improve how patients interact with doctors? Just before its annual meeting, the CMA released a survey that found the youngest adult generation—the “Google generation”—consult their physician 11 times a year. Some physicians wonder how the health system will sustain that level of use from basically healthy young people. Well, Google search results are produced by algorithms so what if—moonshot!—the CMA engaged with tech companies to curate the top search results? To ensure the answers patients see first don’t indicate that minor or fleeting symptoms are something serious. When hearing hoofbeats, Dr. Google should also think horses not zebras. —COLIN LESLIE

ROUNDS

AUSCULTATIONS

“Wouldn’t it be good if we had a single national licence?”

“I think the Russians have hacked our voting devices.”

“Axe the fax. Set the damn date and let us get on with it.”

—Dr. Gigi Osler, new Canadian Medical Association president.

—Dr. Dennis Kendel of Saskatchewan tweeted. He was joking after there were a few glitches with the electronic voting at the CMA annual general meeting but it caught the flavour of a challenging meeting that saw delegates vote to reduce the size of the CMA board but reject a proposal to dissolve General Council.

—Zayna Khayat, a Toronto-based futurist, arguing that sometimes change only comes when you set a date in the near future and then force through the change.

Sources: Canadian Medical Association’s Health Summit and AGM

DISPATCH

Technology, the great leveler? Perhaps the most vigorously applauded quote to

come out of the recent CMA Health Summit came from Indigenous physician Dr. Alika Lafontaine. After a morning listening to a hologram of Dr. Peter Diamandis, a tech entrepreneur who counts Elon Musk as one of his friends, and others who were bullish that new technology was well on its way to solving the health and societal ills that plagued us throughout history, Dr. Lafontaine had a pithy and sobering retort. “Technology doesn’t create equity; equity creates equity,” he said. Equity here is shorthand for health equity; the idea that all patients would have access to care that is not only timely and appropriate, but in accordance with their need. Of course, too often the patients who are in greatest need face the greatest barriers to care and have the poorest health. But in his keynote Dr. Diamandis suggested this

was changing. Global computing power is growing and the price of technology is dropping, both at exponential rates. These advances are correlated with increasing lifespans and literacy rates, and decreased infant mortality. Dr. Diamandis himself said he expected his children to live to 160. We know the democratization of technology has a strong impact on the social determinants of health. Giving indigent patients a cell phone increases their lifespan and improves the quality of healthcare they’re able to access. Which makes it easy to adopt “a rising tide lifts all boats” attitude. But technology is not a panacea, and there are plenty of people anchored to the bottom. As more wealth is created, for example, income inequality grows worse, and technology is expected to exacerbate the problem rather than solve it (many leading Silicon Valley entrepreneurs are now advocating for universal basic income). Smartphones may be almost universally used, but healthcare costs remain high, and will become higher as new life-extending drugs and treatments are introduced, hence the need for strong public investment. Still, it’s not wrong to suggest technology improves health equity. Dr. Lafontaine’s point was that it’s wrong to suggest it happens without deliberate effort. —TRISTAN BRONCA

THE MEDICAL POST SEPTEMBER 2018 9

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A new oral anti-obesity agent for chronic weight management What are some facts about obesity in Canada? • Obesity is considered a chronic disease by the Canadian Medical Association.1

• Obesity affected 1 in 4 Canadian adults in 2011-2012.2

What is the mechanism of action of CONTRAVE?*

Demonstrated effect of CONTRAVE on cardiovascular and metabolic parameters

Non-clinical studies suggest that CONTRAVE has effects on two separate areas of the brain involved in the regulation of food intake.3

The effect of CONTRAVE on cardiovascular morbidity and mortality has not been established.3§

1. Hypothalamus (appetite regulatory centre) 2. Mesolimbic dopamine circuit (reward system) The exact neurochemical effects of CONTRAVE leading to weight loss are not fully understood.

Change in cardiovascular and metabolic parameters from baseline to week 56 in patients who are overweight or obese without diabetes

• The number of Canadians affected by obesity increased by 17.5% from 2003 to 2011/2012.2

Hypothalamus (appetite regulatory centre)

Mesolimbic Dopamine Circuit (reward centre)

What is CONTRAVE? CONTRAVE is an anti-obesity agent used in weight management that contains naltrexone and bupropion.

Indication CONTRAVE is indicated as an adjunct to a reducedcalorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: • ≥30 kg/m2 (obese) or

Adapted from Product Monograph3 * Clinical signiﬁcance is unknown.

How effective was CONTRAVE in clinical trials? CONTRAVE patients were shown to lose 4x more weight vs. placebo. Mean change in body weight was -5.4% in the CONTRAVE 32 mg/360 mg group vs. -1.3% in the placebo group (ITT population).3§ Mean change in weight over 56 weeks in the completer population

• ≥27 kg/m2 (overweight in the presence of at least one weightrelated comorbidity (e.g., controlled hypertension, type 2 diabetes mellitus, or dyslipidemia). Make CONTRAVE part of their weight-management journey

Adapted from Product Monograph3 ‡ p<0.001 vs. placebo ITT-LOCF=intent to treat at last observation carried forward

50.1% of patients in the placebo group and 49.2% of patients in the CONTRAVE group discontinued treatment.

Adapted from Product Monograph3 Full analysis set: Based on LOCF with the last on-drug observation carried forward. * Least square means, from all randomised subjects who had a baseline measurement and had at least one post baseline body weight measurement while on study drug. Based on LOCF with the last on drug observation carried forward. † Values are baseline median, median % change, and the Hodges-Lehmann estimate of the median treatment difference.

§ COR 1 study design: Phase 3, 56-week multicenter, double-blind, placebo-controlled study of patients with obesity (BMI ≥30 kg/m2) or overweight (BMI ≥27 kg/m2) and at least one comorbidity (hypertension or dyslipidemia). Patients were randomized to naltrexone (16–50 mg/day) and/or bupropion (300–400 mg/day) or placebo. Results presented are for the recommended daily dose of two 8 mg/90 mg tablets taken twice daily for a total dose of 32 mg/360 mg. Treatment was initiated with a 3-week dose escalation period followed by approximately 1 year of continue therapy. Treatment included a program consisting of instruction to follow a reduced calorie diet resulting in an approximate 500 kcal/day decrease in caloric intake, behavioral counseling, and increased physical activity. Co-primary endpoints were percent change from baseline body weight and proportion of subjects achieving ≥5% total decreased body weight. Mean baseline weight: CONTRAVE group 99.8 kg (N=538); placebo group 99.5 kg (N=536). Mean baseline values CONTRAVE/placebo: waist circumference (cm) 108.8/110.0; triglycerides (mmol/L) 1.3/1.3; HDL-C (mmol/L) 1.3/1.3; LDL-C (mmol/L) 3.1/3.1; systolic blood pressure (mmHg) 118.9/119.0; diastolic blood pressure (mmHg) 77.1/77.3; heart rate (bpm) 72.1/71.8.

Was CONTRAVE generally well tolerated? CONTRAVE has a demonstrated safety and tolerability profile.

How is CONTRAVE dosed? The recommended daily dose is two tablets BID.3 CONTRAVE dosing should be escalated according to the following schedule:

• 24% of CONTRAVE patients discontinued treatment due to an adverse event vs.12% for placebo.3

›

The most frequent adverse reactions leading to discontinuation with CONTRAVE were nausea (6%), headache (2%), dizziness (1%) and vomiting (1%).

• The most frequently reported adverse reactions for CONTRAVE (incidence ≥5% and twice the incidence in placebo) vs. placebo were nausea (32.5% vs. 6.7%), constipation (19.2% vs. 7.2%), vomiting (10.7% vs. 2.9%), dizziness (9.9% vs. 3.4%) and dry mouth (8.1% vs. 2.3%).3

›

Headache was also more commonly observed in CONTRAVE patients than in placebo (17.6% vs. 10.4%).

• The vast majority of subjects treated with CONTRAVE who experienced nausea reported the event within four weeks of starting treatment. Events were generally self-limited; the majority of events resolved within four weeks and almost all resolved by Week 24.3

›

The incidence of severe nausea was low, but was higher with CONTRAVE than placebo (severe nausea: naltrexone / bupropion 1.9%, placebo <0.1%).

Dosage adjustments are required in subjects with hepatic impairment (maximum dose 1 tablet in the morning in mild or moderate hepatic impairment) or renal impairment (maximum dose 2 tablets, one in the morning and one in the evening in moderate or severe renal impairment), and with concomitant use of CYP2B6 inhibitors (maximum dose 2 tablets, one in the morning and one in the evening). All patients with hepatic or renal impairment should be closely monitored for possible adverse effects (e.g., insomnia, dry mouth, seizures) that could indicate high drug or metabolite levels. CONTRAVE should not be taken with a high-fat meal. The tablets should not be cut, chewed, or crushed.

The maximum recommended dose is 32 mg/ 360 mg per day (two tablets twice daily). In order to minimize the risk of seizures, the maximum recommended daily dose should not be exceeded. Blood pressure and pulse should be measured prior to starting therapy with CONTRAVE and should be monitored at regular intervals consistent with usual clinical practice. CONTRAVE should not be given to patients with uncontrolled hypertension and should be used with caution in patients with controlled hypertension prior to treatment. Response to therapy should be evaluated after 12 weeks at the maintenance dosage. If a patient has not lost at least 5% of baseline body weight, discontinue CONTRAVE, as it is unlikely that the patient will achieve and sustain clinically meaningful weight loss with continued treatment.

1-855 CNTRAVE (268-7283) • One-on-one phone support from registered nurses • Access to ongoing phone support throughout the course of their CONTRAVE treatment journey • Patient tools and motivational support through digital and print interactions › To stimulate patient engagement in their CONTRAVE treatment journey › Nutritional and activity counselling • Financial assistance

For more information, visit www.contrave.ca

Clinical use: • The effect on cardiovascular morbidity and mortality has not been established. • The safety and effectiveness in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations,have not been established. • Geriatrics (≥65 years of age): Use with caution. • Pediatrics (<18 years of age): Not indicated. Contraindications: • Uncontrolled hypertension • Seizure disorder or a history of seizures • Use of other bupropion hydrochloride-containing products • Current or prior diagnosis of bulimia or anorexia nervosa • Chronic opioid or opiate agonist or partial agonists use, or acute opiate withdrawal • Patients undergoing an abrupt discontinuation of alcohol, benzodiazepines or other sedatives and antiepileptic drugs • Concomitant administration of monoamine oxidase inhibitors (MAOI) • Concomitant administration of the antipsychotic thioridazine • Pregnancy • Severe hepatic impairment • End-stage renal failure

Most serious warnings and precautions: • Potential association with behavioural and emotional changes, including self-harm: monitor for such changes and suicidal ideation • Seizures: to minimize the risk of seizures, the maximum recommended daily dose should not be exceeded

For more information: Please consult the Product Monograph at https:// health-products.canada.ca/dpd-bdpp/index-eng.jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-361-4261.

Other relevant warnings and precautions: • Interference with the action of opioid-containing drug products, vulnerability to opioid overdose, and precipitated opioid withdrawal • Increase in blood pressure and heart rate; not for use in patients with uncontrolled hypertension • Dependence/tolerance • Risk of hypoglycemia in patients with type 2 diabetes on antidiabetic therapy • Hepatotoxicity; discontinue in the event of symptoms and/or signs of acute hepatitis • Drugs metabolized by CYP2D6; do not use in combination with tamoxifen • Angle-closure glaucoma • Activation of mania and hallucinations • Allergic reactions • Not recommended in nursing mothers. • Closely monitor patients with hepatic and renal impairment; dose adjustments required in mild-to moderate hepatic impairment and moderate or severe renal impairment • Contains lactose

References

This Q&A is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908. No part of this Q&A may be reproduced, in whole or in part, without the written permission of the publisher. © 2018

1. CMA recognizes obesity as a disease. Canadian Medical Association. News & Announcements https://www.cma.ca/ en/pages/cma-recognizes-obesity-as-a-disease.aspx. Accessed March 9, 2018. 2. Navaneelan T, Janz T. Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias. Statistics Canada, Catalogue no. 82-624-X. Health at a Glance. May 2014. https://www.statcan.gc.ca/ pub/82-624-x/2014001/article/11922-eng.htm. Accessed March 9, 2018. 3. CONTRAVE Product Monograph. Valeant Canada LP, February 12, 2018. CONTRAVE and the CONTRAVE logo are (registered) trademarks of Orexigen Therapeutics, Inc. and are used under license by Valeant Pharmaceuticals International, Inc. or its afﬁliates. Valeant Canada LP, 2150 Boul. St-Elzear Ouest, Laval, Quebec H7L 4A8. valeantcanada.com

THE BEST

PROVINCES TO PRACTISE IN BY TRISTAN BRONCA AND COLIN LESLIE

MEDICAL POST RANKS:

WE GATHERED a lot of data to create

this chart but there are some subjective decisions we had to make. We made these decisions based primarily on our survey of what doctors found important in choosing where to practise (see VITALS, page 8) but also based on our years of experience covering the profession journalistically. The percentage weights are explained on the next page; we tagged professional satisfaction as the most important factor (25%), followed by compensation (20%), and lower percentages for the other four

12 SEPTEMBER 2018 THE MEDICAL POST

metrics. The letter grades for each of the six metrics come from the data we collected in each area. It is important to note these metrics look at the balance of only certain professional factors, so things such as “good weather” are not tracked but then, it is always 21°C inside a hospital. For cases where provinces have the same letter grade, the provinces are ranked according to the percentages we used to come up with the letter grades (for example, B.C.'s overall score was 68% versus Nova Scotia which scored 66%).

A- B B B- B- C+ C+ C+ C+ C

Alberta Saskatchewan P.E.I. Quebec New Brunswick B.C. Ontario Nova Scotia Newfoundland Manitoba

Getty Images

BEST PROVINCES TO PRACTISE IN

WEIGHTS PROVINCE’S QUALITY OF LIFE MEDICO-LEGAL FAVOURABILITY PROFESSIONAL SATISFACTION COMPENSATION WORK-LIFE BALANCE REGULATOR FAVOURABILITY

25%

Professional Satisfaction We combined the number of responses from doctors who said they were “satisfied”

20%

Compensation These are the latest average gross clinical payment numbers (2015/16) from the Canadian Institute for Health Information. While cost of living does vary between provinces, we didn’t account for that because Statistics Canada

17%

Regulator Favourability Here we looked at a few standard metrics between the colleges of physicians and surgeons. First, the total number of complaints as a percentage of the total registrants (i.e., practising doctors). We used this to establish a very approximate measure for how likely it was that Average Joe (or Jane) MD might face a complaint in a given province, and we gave a grade for that. We also calculated how many of those complaints were eventually dismissed, which, in most cases, meant complaints that were either

or “very satisfied” with their professional life by province from the 7,184 physicians who completed the Canadian Medical Association’s 2017 Physician Workforce Survey. We then applied standard academic letter grades to the percentages.

15%

does not track that at the province-wide level. Statistics Canada does compare the cost of a common set of goods between Canadian cities, which suggests the cost of tliving in Edmonton and Regina are about the national average; Toronto’s costs are 8% above the average; Vancouver 2% above and costs are below the average in Winnipeg (-5%), Montreal (-8%) and St. John’s (-2%).

13%

withdrawn, dismissed outright or dismissed with only minor comments, and gave a grade for that. These two grades were averaged to produce the overall “regulatory favourability” grade in each province in 2017 (the year these numbers are from). The length of time to resolve a complaint is noted but not factored into the grades because the data was near-impossible to standardize between provinces. In some cases it was provided as a benchmark, and in others where it was tracked, it was almost always in reference to different streams of complaints. It’s also important to note that complaint data fluctuates significantly year to year and, again, these numbers are only from 2017.

Work-Life Balance We combined the responses from doctors who said they were “satisfied” or “very satisfied” with their “balance

Medico-Legal Favourability The Canadian Medical Protective Association doesn’t track lawsuits against doctors or payouts by individual province—only by four fee regions: B.C. and Alberta as one; Ontario; Quebec; and the Atlantic provinces, Saskatchewan and Manitoba are all in the same fee region (of course every province in each region received the same grade because all of their data is combined). Similar to the regulators, we looked at the total number of lawsuits relative to the number of CMPA members in each region to approximate how likely it was that any given member

10%

Quality of Life The Centre for the Study of Living Standards took the same metrics the United Nations human development index uses to rank the quality of life in various countries

between your personal and professional commitments” by province from the 7,184 physicians who completed the Canadian Medical Association’s 2017 Physician Workforce Survey. We then applied standard academic letter grades to the percentages.

would face a lawsuit, and gave a grade for that. Then, we looked at the number of cases that resulted in a favourable outcome for the doctor (a favourable judgment or a dismissal) and gave a grade for that. We also looked at the combined cost of unfavourable judgments and settlements and issued a grade based on the regional ranking (lower cost relative to the other regions = higher grade). These sub grades were averaged to produce the overall grade for “medico-legal favourability.” Again, there were limitations. Perhaps most significantly, the number of lawsuits and payouts varied significantly year over year, even within a five-year period (this data is from 2017). We noted some of those variations in the chart notes.

(where nations such as Norway usually come out on top) and, using 2014 numbers, they ranked Canadian provinces on those metrics. These are markers such as life expectancy and education level and, using those, Alberta came out on top. We converted those results roughly to letter grades for each province.

THE MEDICAL POST SEPTEMBER 2018 13

BEST PROVINCES TO PRACTISE IN

CRITERIA

WEIGHTS

B.C.

ALBERTA

SASK.

MANITOBA

25%

A-

B+

76%

80%

85%

77%

C+

A+

B+

$284,918

$380,384

$353,856

$343,944

C+

B-

C+

13,353/1,012*

10,400/826

2,480/216

2,824/199

8% B-

9% B-

7% B

Number of complaints dismissed

523**

513*

108*

83*

Percentage of complaints dismissed (Graded on bell curve)

52% C

62% B-

50% C

41% D

255 days

223 days**

120 days

Not provided

*921 concluded. **Includes complaints that generated none or very minor criticism, or were withdrawn.

*Includes 288 dismissed outright and 225 dismissed after investigation. An additional 104 were resolved informally. **Stats date back to 2013, and this is only for complaints that were investigated and dismissed (other timelines varied).

*50% of complaints were “deemed unfounded,” per college.

53%

58%

53%

57%

B+

PROFESSIONAL SATISFACTION

20%

COMPENSATION REGULATOR FAVOURABILITY

17%

Registrants/Total complaints Likelihood of facing complaint

Length of time to resolve

These results are all for 2017

15%

WORK-LIFE BALANCE MEDICO-LEGAL FAVOURABILITY

13%

*Includes cases that were withdrawn or for which comments were issued with no further action.

Number of CMPA members/ Total lawsuits

25,503/152

13,090/78

Likelihood of facing lawsuit (Graded on bell curve)

<0.6% A

Dismissal/Judgment for doctor

83/11

50/4

Percentage of favourable outcomes (Graded on bell curve)

62% B-

69% B+

$34,593,267

$19,872,599

$596,436 B

$828,025 C

Settlements Total compensation for patients Average payout per unfavourable settlement Four-year trends

Total comp. to patients has dropped since 2013 when it was $64,750,127.

Total comp. to patients has risen since 2013 from $13,404,011, though it dropped to just $3,876,052 in 2014. Since 2014 there have been zero judgments in favour of patients.

These results are all for 2017

QUALITY OF LIFE RANKING THE MEDICAL ASSOCIATIONS . . . AND WHY WE COULDN’T DO IT Originally, we had planned on including the supportiveness of the medical associations as one of the metrics in our ranking of the physician-friendliest 14 SEPTEMBER 2018 THE MEDICAL POST

10%

B+

provinces. If most physicians felt their medical association supported them, then naturally the professional environment there would be more attractive. While all medical associations across the country track physician satisfaction, nearly all of them refused to provide this data,

A+ making comparisons unfeasible. From the data we were able to obtain, we found that Alberta physicians were, by and large, the most satisfied, with over 77% of surveyed members agreeing that their association is an effective advocate for them. Others, particularly Nova Scotia, ranked

C+

lower. Just 42% of members agreed their association did a satisfactory job supporting them. But additional context is warranted here. Alberta physicians are the highest paid in the country, and have so far been blessed with a relatively friendly government administration. The Nova Scotia gov-

BEST PROVINCES TO PRACTISE IN

ONTARIO

QUEBEC

N.B.

N.S.

P.E.I.

NFLD./LAB.

B-

B+

C+

70%

78%

75%

73%

77%

68%

B-

C+

$348,056

$325,096

$290,457

$262,164

$366,934

$275,781

B-

B+

32,987/2,682

20,313/2,566

2,087/46

2,435/220

317/16

1,342/88

8% B-

12% C

2% A

9% B-

5% B+

7% B

1,625*

1,790*

35*

177*

10*

60*

61% B-

70% B+

76% A-

80% A

63% B-

68% B

202 days**

Few months

90 days (goal)

180 days (goal)

Not tracked

365 days (median)

*Total number that resulted in no action, including after investigation. **This is a median length for the conclusion of a new complaint.

*The college investigated 1,114 and of these 776 resulted in some action.

*43 complaints resulted in cautions or reprimands.

*Only 12 were finalized, one was referred to fitness to practise committee, one to board of inquiry.

47%

56%

49%

40%

C+

39,218/392

19,877/145

13,090/78

1% B

<0.8% A-

<0.6% A

253/11

46/22

50/4

67% B+

47% D

69% B+

119

$161,028,255

$30,288,202

$19,872,599

$1,258,033 D

$393,353 B+

$828,025 C

Total comp. to patients has risen from $96,902,063 in 2013, but dropped to $81,859,414 last year w/o significant change in the number of cases or outcomes.

Total comp. to patients has risen from $17,335,167 in 2013, though it had dropped in 2015 to $16,512,138.

A ernment, on the other hand, recently moved to reduce spending, making Nova Scotia physicians the lowest compensated in the Atlantic provinces. And, of course, such moves are occasionally beyond the control of even the fiercest physician contract negotiators.—TRISTAN BRONCA

*11 complaints resulted in counsels, cautions or censures.

*Also includes some that were “dismissed with direction.”

Same malpractice region as Sask./Manitoba, so data in those columns includes these provinces as well.

C+

B-

THE GRADING SYSTEM

Where percentages were available we used the following grading system: A+ 90%–100%; A 85%–89%; A- 80%–84%; B+ 77%–79%; B 73%–76%; B- 70%–72%; C+ 65%–69%; C 55%–64%; D 50%–54%; F less than 50%. To calculate the weights we used the middle of each grade range as the percentage which produced the following raw percentages for the provinces: Alberta 80.14%, Saskatchewan 73.56%, P.E.I. 73%, Quebec 71.39%, New Brunswick 71.31%, B.C. 68.23%, Ontario 66.19%, Nova Scotia 65.68%, N.L. 65.25%, Manitoba 63.79%.

THE MEDICAL POST SEPTEMBER 2018 15

ANALYSIS

Where to set up practice? Knocking down two false assumptions about the best answer to this question and finding some good answers BY COLIN LESLIE

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BEST PROVINCES TO PRACTISE IN

THE BEST PLACE to set up your practice is where you can best build a good life. But that can be a tricky proposition. As I’ve been pondering this topic for the last couple of months, I have spent a lot of time thinking about two assumptions I had about how physicians decide where to set up practice in Canada that I ultimately decided were false. The first false assumption came out of me wondering if the medical education system in Canada drives a significant number of doctors out of their home province to do their residency. We know

there is a strong correlation between where doctors do their residency and where they settle, perhaps because it’s so easy in your 20s and 30s to move to a different part of the country away from your extended family. I know I did, but I also know that later in life you can miss physical proximity to that family. So, one of my assumptions was that the best place to practise in Canada is wherever your extended family is. I ran this idea by some doctors I know and Dr. Gillian Arsenault, 66, replied: “For some people, the best place to practicse may be where your extended family isn’t!” There may be some truth to that. After spending a couple of weeks in Victoria with my extended family this summer, I remembered you can love these people but they’re nuts (in the lovely way all families probably are). And moreover, though the med-ed system in Canada does shuffle many trainees to different provinces, the data doesn’t tell us whether a significant number ultimately end up settling in a different province than they grew up in.1

1 Canadian medical schools are provincially funded and most reserve seats for students from that province (generally you need to live two years in that province to be considered “from” that province). But Canadian Post-M.D. Education Registry (CAPER) data for the 2017/18 school year show that 53.4% of residents from Englishlanguage universities were training in the same province in which they received their MD. (In contrast, 93.3% of post-MD trainees attending a French-language university also received their MD in Quebec.) Most doctors stay in the same region where they did their residency. For instance, recent CAPER data show that two years after residents exited postgraduate training at Dalhousie in 2013, 74% were still living in Atlantic Canada. Compare that to the lessthan-half of the exit cohort who had done their undergraduate degree there. However, we don’t have data on where they completed their BSc or BA degrees before entering the MD program.

The second (probably) false assumption was that we can easily

THE MEDICAL POST SEPTEMBER 2018 17

BEST PROVINCES TO PRACTISE IN

“It was such an excellent shift in life in terms of living, community and job.”

measure what makes a satisfactory practice location. We spent significant time gathering the professional metrics that we used to create the chart on pages 12 to 15. But when I spoke to a number of doctors over the last two months about how they decided where to practise and what about that location gives them satisfaction, they often talked about things that aren’t easy to measure. Professional satisfaction, many doctors said, is not so much about where you practise as it is about with whom you practise and the environment within which you all practise. Dr. Arsenault, who was forced to retire from practice as a medical health officer by a disabling medical condition not yet diagnosed, said she thinks “the things that really count are relationships with colleagues and patients, the ability to be able to get appropriate care for your patients when they need it (without having to fight tooth-and-nail for it), and when what you do helps make things better, especially in tough times; whether by figuring out a difficult diagnosis or by finding a more effective or less burdensome treatment, or just by being there.”

18 SEPTEMBER 2018 THE MEDICAL POST

With that in mind, I want to tell a few stories from doctors I spoke with and what stood out about their choices.

1: The power of passion and returning to your roots

Dr. Rithesh Ram, now 39, grew up in Camrose, Alta., and imagined his professional career would take him “bigger and better” places. His path to family medicine was circuitous. He studied electrical engineering in Edmonton and then did a PhD in epidemiology intending to become a health researcher. “I distinctly remember in the first year the physicians came in and for 45 minutes ran through what our life was going to be like as a health researcher.” (Short answer: unstable, contracts for a year and lots of moving around.) Dr. Ram said about 20% of the class were MDs and the doctor who spoke to the class said to him: “Why don’t you grab that MD at the same time?” That proved to be a key decision. He finished the MD/PhD program in Calgary but even with his medical degree he was still driven by the dissatisfactions that had caused him to switch his earlier

career focus. “I was very disgruntled with the way medicine was being done on the individual and (system) level.” He even thought about—again—going back to school to train for something else. That all changed during his FP residency on a six-week rotation in Drumheller, Alta. He returned to Calgary after the first few days in Drumheller and started talking about the experience with his wife. “I think you’re smiling,” she said, looking at him. He was taken aback. “Don’t I smile?” “Not when talking about your work.” That was an eye-opener for him and as he thought of returning to an Alberta community about the same size as the one he’d grown up in, he wondered if maybe he’d missed something. So on July 1, 2015 he moved full-time to Drumheller and began his practice with a group. Starting July 1, 2017 he opened his own clinic and that, he said, is what really offered him the opportunity to shift how medicine was done. One example: “In Drumheller, for as long as anyone can remember, patients would call on the first Monday of the month to book an appointment with

BEST PROVINCES TO PRACTISE IN

their doctor for the next month. They would have called Aug. 6, 2018 to book an appointment with their doctor in September. So the fastest appointment available to you would be at least four weeks away unless you were fortunate enough to have a doctor who was not always full. Unfortunately for patients, if they were worried about their health, many would choose to simply book appointments, regardless of whether they might need them,” Dr. Ram said. “This obviously disrupted continuity of care, as patients would then have to go to the emergency department for simple prescription refills. It also created a system where no-shows were prevalent, and patients who actually needed to see their doctor could not get in to see them . . . As a very simple solution, we offer same day and walk-in appointments. This significantly improved our access and continuity of care while reducing our no-shows.” Dr. Ram said his clinic now has 3,000 patients and he’s the sole doctor but he works with an NP and LPN in a team environment. “We managed to really turn care on its head, 180 degrees.” As for Drumheller, with its famous dinosaur fossil collection and its rock formations known as Hoodoos, “it was such an excellent shift in life in terms of living, community and job,” he said. “The openness and warmth was just great.”

2: For FPs, the value of mid- to small-sized communities

“I am in the Goldilocks city, just right,” said Dr. John Crosby, 71, of Cambridge, Ont. “When you are in a university centre you line up behind the residents and interns and watched, but in Cambridge I was thrown into the deep end and was delivering babies, seeing patients on my own and assisting at surgery. Pure heaven.” Dr. Crosby said he loves his city since it’s neither too big nor too small and is close to Toronto, Kitchener, Hamilton and London. “We raised three boys and they could have cheap, close tennis, ski and guitar lessons. They went to terrific schools and had a great small-town upbringing,” he added.

“Even as a new doctor I was bright enough to know that a middle-sized city was a good choice,” said Dr. Crosby. “If you go to a small one you end up never getting off call and dying in harness. In a big city, you become a triage officer.” Of course if the community is small, you’re going to find that work-life balance can be hard to strike. “You have to accept the fact that you’re going to see patients everywhere and they may or may not ask you questions,” Dr. Ram said. But a lot of the challenges about smaller communities that used to exist have been reduced. Online ordering, for instance, means you don’t automatically have fewer options in your life outside of big cities. “The world is smaller,” said Dr. Ram. For Dr. Barb Watts, 63, of Orangeville, Ont. the move from practising in Scarborough (an east-end Toronto suburb) to a smaller community was great. “As a family doctor, I really enjoyed giving comprehensive care,” she said. “I got to do more.” Dr. Watts does admit that she started to enjoy practising less over the years due to paperwork and changing patient attitudes, so nine years ago she quit her family practice to do full time emerg. “I find that much more satisfying.” Now she’s one year into a three-year role as part-time chief of medicine. Dr. Mike Simon, 55, a family doctor in Saint John, N.B., outlined several benefits he enjoys from practising in a smaller city: Five-minute drive to the office, six to the nursing home, seven to the hospital; home for lunch; relatively small medical community so you can pick up a phone and ask for advice; colleagues will return your call. But he also said there are drawbacks. Because you’re so close, you’re there every day. Small community means small numbers of specialists, and can mean long waiting times. And it’s worse when someone leaves or gets sick. Colleagues are busy. Call is more frequent in smaller groups. And you need a connecting flight to go anywhere.

3: Quality of practice environment

“Mine was not an impulsive decision” said Dr. Tom DeMarco, 58, of his practice in Whistler, B.C. “I worked in 52

practices in 12 provinces and territories as a GP locum, from coast to coast to coast before settling here in Whistler to join my brother, also a GP.” Dr. DeMarco said his choice had nothing to do with the outdoor recreational opportunities for which this resort town is world-famous, but rather the practice clientele. “I meet people from all over the world on a daily basis, providing me ample opportunity to use my five languages. And patients here actually get better! I have a few diabetics and hypertensives among my 2,000 clients, but no COPD, no malingerers, and virtually no chronic fatigue. Most cases are acute infections, acute injuries or derm conditions.” He said he also enjoys getting out of the office to see patients in the hotels. “I do almost 100 house calls annually. Financially, with a lot of private billings, I do very well. I could have retired years ago, but enjoy my work-life balance, taking 13 weeks per year to travel the world on my bicycle.”

4: Social need

Doctors make their choices about where to practise for a wide range of reasons. At the core there’s a deeply personal element about the choice. But an important aspect for some is social need. Dr. Sarah Giles, 40, regularly locums in communities in the far north and says it is social need that drives that choice. “It’s a great feeling to provide medical care in chronically understaffed communities,” she said. “I put in a lot of unpaid hours doing chart reviews for every patient before I start the day because I know that people who receive episodic care from different providers often have problems that fall through the cracks and that cancer screening is often missed. I’ve always been the fan of the underdog—so remote fly-in communities, communities where you can’t drink the water, and places where patients complain they have faced systemic racism give me extra satisfaction when I work there. But it’s not all out of the goodness of my heart. These patients are incredibly resilient people in tight knit communities who keep an eye on their neighbours.” MP

THE MEDICAL POST SEPTEMBER 2018 19

Q&A

How do doctors find their home?

Physicians want more choice in where they practise, but in recent years they are finding their options have narrowed BY TRISTAN BRONCA

Dr. Franco Rizzuti

DECIDING WHERE to practise is often a

long and personal process. Still, there are some interesting insights to be gleaned from the data. For example, Canadian Post MD Education Registry data tells us that where a physician does their postgraduate training better predicts which region they'll eventually settle in (Atlantic, Quebec, Ontario, Prairies, etc.) than where they did their medical degree. So, decisions doctors make immediately after medical school seem to play a huge role in determining where they practise.

20 SEPTEMBER 2018 THE MEDICAL POST

Which brings us to Dr. Franco Rizzuti. He’s a second-year public health resident in Calgary and the former president of the Canadian Federation of Medical Students. Not only is he wrestling with these decisions himself, but he’s also looked closely at the trends, and has been involved with a large health human resource initiative. He spoke with the Medical Post about how doctors decide where to call home and how doctors’ choices—or lack thereof—impact physician supply.

Q: When doctors are making these decisions, which factors weigh most heavily? There’s variability but there are a few big buckets that come into play. One is personal factors: Are they married, do they have kids, what’s their partner doing? Job mobility, house, stuff like that. The second one that’s quite prominent is network and job availability. Who do they know, what’s the job market like? And that one tends to have quite a bit of weight in career decision-making. The secondary factors tend to be things like salary. When I talk to colleagues who are further along in their careers, they’re not talking about who has the best package or compensation. They tend to be focussed on “what practice do I want to do, what’s the demographic I want to work with.” Q: That makes things difficult for recruiters because you can offer people more money but you can only offer them a certain kind of practice if you’re in a certain place. That’s one of the things we talk about a lot with rural and remote recruitment.

Q&A

It’s different than even 20 years ago, when we had households where the physician was the sole breadwinner. You may not be able to recruit a physician to somewhere remote because their partner needs to be in a corporate centre. That’s one of the bigger challenges we’re starting to see. You also see it in certain parts of the city, where some doctors are more interested in treating affluent patients than marginalized ones. But the rural issue is a harder one to solve. Q: The sense I get is that doctors often feel they can’t leave their communities because of a feeling of obligation to patients. Would you agree that once most decide where they’re going to be, they stay? I would agree, by and large, both for family medicine and for specialties. One of the big reasons is that commitment to their patients. But the other big reason is the opportunity costs and investment energy. You have your office, you have your team there, your EMR, you know how the referral system works. Moving to another region—there’s a lot of having to rebuild and re-establish. The exception is those who get into leadership roles: Folks who go from institution to institution, for department head position or a role within medical education leadership. Q: And there’s a generational shift with more young doctors wanting to do locums…. That’s a much more prominent conversation now than it was even 10 years ago. I’d say it’s driven by some of the job pressures. It can be hard to find a job, and it can be expensive to buy into a clinic. But also some doctors want to get a feel for the practice they might do before settling down. Q: Do old school doctors look down their noses at that? There’s definitely an intergenerational tension. That wasn’t the model 30 years ago when you got out of residency and you started practising. Q: Is that changing the physician supply needs? Or is it a chickenand-egg scenario, where doctors

do this because the health human resource needs are different? Having served on the physician health human resource planning advisory committee a couple of years ago, I’ve got a good pulse on this. We can get the physician supply piece right in terms of bodies. We know how many doctors are working, we know how many medical students and residents we have. What’s really difficult is figuring out what a full time equivalent (FTE) is for a doctor and for a resident. Acute care facilities and hospitals are so reliant on trainees that it’s a little bit misleading to look at how many doctors they have per admission. But it’s also hard to compare among doctors. I know a physician who has a caseload of 4,000 patients who wants to retire and is looking for people to take over their practice. And doctors—not just newer doctors, but in-practice doctors—have said, “I don’t want 4,000 patients, I will take 1,000 patients max, because I just can’t provide the quality of care I want (at the higher numbers).” That’s making it difficult to assess how many doctors you need in an area. Plus you have to consider who comprises those 4,000 patients. Is it healthy 30-year-old males who see the doctor once every three years? Is it a bunch of 80 year olds with multiple chronic diseases who are in every month? We also know that this generation coming into practice is not going to have the same percentage of individuals who are 100% in one clinic and that’s all they do. We’re going to have a higher proportion who have a split or mixed career so maybe it’s a 0.2 (FTE) here, a 0.6 somewhere else, as well as work-life balance considerations. Q: How do you think you’ll decide where to go? Public health and preventive medicine is a bit of a different entity. For me, it’s not a question of going out and establishing a practice somewhere, it’s applying for jobs. My career planning started in medical school. I was actually planning on doing neurology for a while, but I was in a car accident and had an injury that shifted my career planning. I realized the intensity of 1-in-4 call and the disruption

to my sleep cycle was not going to be a great fit long term, and public health moved up my list. Now I’m beginning to consider where to go and what to do for graduate work, to develop an area of competence and I also have a partner who is in public health so we’re talking about how that plays into it. I’m also looking down the road. I don’t want a full-time 1.0 MOH (medical officer of health) job, I’m looking at probably a 0.8 MOH and then some time maybe teaching or doing some consulting or project work. Q: You’ve been pretty methodical about all this. I try to be but at the same time be nimble. Government is changing, funding is changing, models are changing, so I think as a resident you have to have that flexibility. Q: So what’s the best case scenario for you and your partner? The best case would be us both getting some MOH positions, but they don’t come up that often and to have two come up in the same geographic area is highly unlikely. She has more of a clinical interest, so I’d see probably a bit of split practice for her as well. But there could be variants of that. Maybe one of us takes an MOH job and then the other one does other public health-related work. We still have a few years. We’re going to take it step by step and see what makes sense. Q: To what degree do you—and physicians generally—feel like you have a choice in where you end up? It is a balance as to what are our obligations to the public who have invested in us, and what works for us. Establishing that balance will vary person to person but I think it should factor into everyone’s decision. I also think that because it’s becoming harder in some provinces to get a practice ID and find a job, we’re in a situation where one can’t be as selective as in previous years. We still have the ability to choose, but there are definitely more outside pressures. MP Edited for length and clarity

THE MEDICAL POST SEPTEMBER 2018 21

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Patients should continue for 5 days after completion of the antibiotic therapy

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* 2 capsules vs. placebo; †1 capsule vs. placebo; ‡1 capsule vs. 2 capsules § Randomized, double-blind, placebo-controlled dose-ranging study of 255 patients. Each probiotic capsule contained 50 billion c.f.u. of live organisms (L. acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®). Probiotic prophylaxis began within 36h of initial antibiotic administration, continued for 5 days after the last antibiotic dose, and patients were followed for an additional 21 days. ⁋ Clinical signiﬁcance has not been established. ¥Pharmacy Practice+Business and Profession Santé 2018 Survey on OTC Counselling and Recommendations, Probiotics category. Bio-K+ helps: reduce the risk of AAD; reduce the risk of CDAD in hospitalized patients; support intestinal/gastrointestinal health.6 Please consult the Bio-K+ Product Licence at https://health-products.canada.ca/lnhpd-bdpsnh/info.do?licence=80015104 for more information, or visit biokplus.com. Always direct your patients to read the label. Call us at 1-800-593-2465 to order your patient handouts today.

References 1. Blaabjerg S, et al. Antibiotics (Basel) 2017;6(4):21. doi:10.3390/antibiotics6040021. 2. Langdon A, et al. Genome medicine 2016;8:39. 3. Jemberg C, et al. Microbiol 2010;156:216-23. 4. Gallo A, et al. World J Gastroenterol 2016;22:(32):7186-202. 5. Gao XW, et al. Am J Gastroenterol 2010;5(7):1636-41. 6. Bio-K+ Product Licence.

This Counselling Corner is published by EnsembleIQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908. part MEDICAL of this Counselling Corner may be reproduced, in whole or in part, without the written permission of the publisher. © 2018 22 SEPTEMBER 2018 No THE POST

FEATURE

Dreamville, Canada Profiles of some of the physician-friendliest small towns in our great nation—and the incentives they’ll offer doctors to come

Getty Images

BY TRISTAN BRONCA

ACROSS THE VAST GEOGRAPHY of our country there are hundreds of small towns, counties, hamlets, and communities of all sorts who want you— yes, you—to come practise there. And municipalities themselves often organize modest resources to sweeten the deal. Some have hired full-time recruiters who personally usher visiting doctors around town and set up professional retreats (as happened in Goderich, Ont.), while others offer paid-for house and luxury

car rentals (such as Quesnel, B.C.). We reached out to some of these physician recruiters, as well as health authorities, medical associations and other local experts in every province in hopes of finding some of the most welcoming and unique opportunities for GPs in rural Canada. These are towns that need doctors, and that not only have appealing professional incentives, but much more to offer beyond their clinics and hospitals.

These jobs may seem out of reach for some, but we’re betting that you and your family may at least consider what it would be like to uproot your lives to settle down in these towns. Of course, it would be impossible to feature every community that deserves your attention—or even all the things about these communities that do. But we hope this sparks a new sense of curiosity about the opportunities that exist beyond your hometowns and metropolises.

THE MEDICAL POST SEPTEMBER 2018 23

FEATURE

Dr. Nicola Smith snapped this picture while kayaking one day after clinic in July.

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THE SALES PITCH: It’s a small fishing town on the north end of Cape Breton (which was voted by Travel and Leisure magazine readers as the most beautiful island on the continent, by the way) with a year-round population of less than 1,000 people. The Cabot Trail also runs past Neil’s Harbour and the region hosts arguably some of the best outdoor activities in the province (it’s not unheardof to see a beluga whale in the waters off the coast). But the real charm, according to Dr. Nicola Smith, a family doctor who has led the recruitment efforts there, is the Maritime hospitality. “Locals will drop by on a Friday night with a Sobeys bag full of crab, offer to take you out lobster fishing,” she said. “Patients have offered up homemade chowder to new doctors.” INCENTIVES: The county will put up any new doctor in a fully furnished ocean-view family home within walking distance of the hospital. At the local clinic there is also: One fully funded family practice nurse, a fully integrated EMR (direct billing and lab reports), and overhead well below the provincial average. Doctors who apply would also be eligible for several other incentives from the provincial health authority, including tuition relief for new graduates (up to $120,000), return of service for setting up a practice (up to $60,000), debt assistance (up to $45,000) and relocation allowances. The province also reimburses travel expenses for physicians who visit to explore job opportunities.

Dr. Nicola Smith

AVAILABLE ON-DEMAND

FEATURE

Top by Picnic Studios; Bottom by Béatrice Schuler

Lunenburg, N.S.

THE SALES PITCH: One of the betterknown towns on the list, Lunenburg is another fishing village much closer to Halifax. But a sleepy small town this is not. Tina Hennigar, the town’s population growth co-ordinator, said that in addition to local agrarians, artisans, vibrant festivals and markets one might associate with the seaside county, some residents also create worldrenowned video games and design parts found on the space shuttle. Nearly 100 of these residents recently attended a local meeting to discuss ways to attract and keep doctors. Sailors offered free boat rides and brew masters offered their beers. “We’re experiencing a lifestyle boom,” she said. “People here care about the air they breathe, the food they eat. They care about how long they’re in their cars, how well their seniors are looked after. And they care about the people who are caring for them.”

INCENTIVES: All of the provincial incentives available in Cape Breton are also on offer here. Doctors who fill the two family physician vacancies, one in Bridgewater and the other in Mahone Bay, would be compensated according to an alternative payment model.

(Above) Aerial shot of Mahone Bay, and (below) Dr. Cecilia Newton, a family doctor, with two-year-old Theo.

THE MEDICAL POST SEPTEMBER 2018 25

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• Syncope (fainting) can occur following, or even before, any vaccination as a psychogenic response to the needle injection • Should be given with caution to individuals with thrombocytopenia or any coagulation disorder • As with any vaccine, a protective immune response may not be elicited in all vaccines For more information: Please consult the Product Monograph at http://ca.gsk.com/media/591956/synflorix.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. References: 1. Synflorix® Product Monograph. GlaxoSmithKline Inc. September 21, 2017. 2. Data on file. GlaxoSmithKline Inc. 3. Data on file. GlaxoSmithKline Inc. † Comparative clinical significance unknown. § Universal mass vaccination, as of May 2018.

Pneumococcal polysaccharide conjugate vaccine (adsorbed)

FEATURE

Prescott-Russell, Ont.

Top photos, Barnyard Studio du Coin; Bottom (both of Quinte West) by Johnny CY Lam

THE SALES PITCH: Located on the border of Quebec and Ontario, the county of Prescott-Russell is only about an hour in each direction from Montreal, Ottawa, the U.S. border, and the Laurentian mountains. In addition to being home to several of the country’s best known agri-businesses including Beau’s Brewery and St. Albert’s Cheese, many of the towns in the region were also recently named by MoneySense magazine as the best places to live in Canada because of the quality-of-life to cost-of-living ratio.

Quinte West, Ont.

THE SALES PITCH: Located just south of Ontario’s 401 corridor, Quinte West is nestled in a region that is a hotspot for the farm-to-table movement in Ontario. Just north of Prince Edward County, there are no fewer than 50 wineries plus 20 craft breweries and cider houses within 45 minutes, as well as four provincial parks within the same distance. The area is perhaps best known for the Trenton military base but there are also a few unique quirks that are worth mentioning. Just one block

INCENTIVES: By the end of next year

the Hawkesbury and District General Hospital will have completed a $160-million redevelopment project. It’s offering physicians relocation assistance ($5,000), competitive remuneration, oncall premiums, and strong mentorship opportunities. But because of the patient and clinician population, Frenchlanguage fluency is a must.

away from the hospital is Mount Pelion, atop which is a lookout that Samuel de Champlain climbed in 1615. Then, just south of Trenton, there’s “the boulder,” a two-storey, 2.3-billion-year-old rock and the pride of geologists across Canada. It’s believed to be one of the oldest glacial erratics in North America.

(Top left) the Prescott-Russel Trail; (top right) a barn near Hammond; and (bottom) a farm near St. Pascal-de-Baylon.

Two views of the Trent Port Marina in Quinte West.

INCENTIVES: A $100,000 bursary for

opening a full-time practice with a five-year commitment, plus grants for continuing education, programs for spousal employment support, housing support and financial services support, and a new state-of-the-art clinic. Housing is also particularly affordable, with an average home price under $300,000. And, with over 1,200 km of waterfront in the region, plenty of them have a view.

THE MEDICAL POST SEPTEMBER 2018 27

FEATURE

(Top) Johnson Island and (below) a Kenora canal leading to Lake of the Woods.

THE SALES PITCH: When people think of the great natural getaways in The Heartland Province, Kenora may not immediately come to mind, perhaps because it seems to be more a part of Manitoba than Ontario (it’s just two hours away from Winnipeg). But it should. While the region is home to 30,000 people year-round, the summer population reaches 70,000. Lake of the Woods, a pristine body of water on which Kenora is situated, has over 14,000 islands, plus there’s a vibrant art and music scene in the town itself. “I’ve lived in some big cities, and you just don’t get the same opportunities in terms of outdoor life,” said Dr. Brad Kyle, a GP. “If you want to go out for whatever your recreational activity is—whether it’s kayaking, white-water canoeing, downhill skiing, snowmobiling, fishing, etc., you walk out your door and you’re doing it.”

28 SEPTEMBER 2018 THE MEDICAL POST

to explore job opportunities. The Sunset Country Family Health team offers new recruits a turnkey clinic environment, fully integrated EMRs, as well as a full complement of allied healthcare providers, including nurse practitioners, dieticians, a pharmacist and a chiropodist.

Top, Randy Kokesch; bottom Kim Pirie Milko

Kenora, Ont.

INCENTIVES: Doctors who sign on for a four-year commitment become eligible for HealthForceOntario’s Northern and Rural Recruitment and Retention Initiative, which pays $113,600. It also offers a community assessment visit program to cover the travel expenses for any physician who visits the area

FEATURE

INCENTIVES: The town offers an un

specified incentive package for physicians who are interested in moving into the existing family health team. Doctors would also be eligible for a Saskatchewan

Medical Association’s $25,000 grant. According to the job posting, there are two family doctor positions available, both fee-for-service, with earning potential of up to $400,000 a year.

Gravelbourg, Sask.

THE SALES PITCH: In the fourth verse of Johnny Cash’s rendition of “I’ve Been Everywhere” he references a little town out in the middle of the Canadian prairies. That town is Gravelbourg. With a population just over 1,000, the town was founded as a FrenchCanadian outpost by a Quebecois priest and soon began to draw settlers from across the provinces and the U.S. Today the town is home to several heritage buildings, including a massive Roman Catholic cathedral. The town’s strong religious roots allowed culture, industry, education, and other institutions to flourish. The locals call it “a touch of Europe on the prairies.”

The old court house, a heritage property, that now serves as the town office.

Aerial view of New Denver shot directly above the Slocan Community Health Centre.

Top, Isabelle Blanchard

New Denver, B.C.

THE SALES PITCH: There’s a rumour that the Dalai Lama once called the Slocan Valley one of the most sacred places on earth. A few towns with a combined population of around 1,000 people are situated along the shores of the eponymous lake at the foot of B.C.’s interior peaks. And the residents of New Denver, population 500, say the natural beauty has done something to the people there. “There are more artists, musicians, writers, gardeners, philosophers, and healers here than you might imagine. We have more community groups per capita than most cities,” writes Anne Champagne, a publisher who also sits on the health committee. “In how many

communities with fewer than 5,000 people can you expect to find three art galleries, regular concerts by touring musicians, a summer school for classical music, literature events, and a lecture series?” INCENTIVES: Doctors working in

the family health team at the Slocan Community Health Centre are the only practitioners for about 150 km in any

direction. Though the call schedule can be intense (the doctors require a subspecialty in emergency medicine to treat those working in the mines and natural resource industries nearby), schedules are flexible and vacation time negotiable. There’s a flat retention fee of $19,705, relocation funding of up to $15,000, a prorated recruitment incentive of $20,000, and $5,720 in funding for CME. MP

THE MEDICAL POST SEPTEMBER 2018 29

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Colloquium The Role for Medical Cannabis in Chronic Pain Management Medical cannabis has been a reality in Canada since 2001 when Health Canadaâ&#x20AC;&#x2122;s Marihuana Medical Access Regulations (MMAR) allowed patients with certain conditions whose conventional treatments had failed to possess limited amounts of dried marijuana. The law has evolved slowly over the ensuing years and today the use of medical cannabis is governed by the Access to Cannabis for Medical Purposes Regulations (ACMPR). The latest data suggest that by the end of March 2018, more than 296,700 clients had registered with Health Canada through ACMPR, up from fewer than 100 in 2001. Health practitioners, however, remain widely reluctant to prescribe medical cannabis for their patients, owing largely to a dearth of education and training opportunities, pervasive social and professional stigma surrounding cannabis, and limited research in many therapeutic areas. The net result is that many patients who may benefit from medical cannabis for a variety of indications are not being given the choice. This discussion will examine the complexity and utility of prescribing cannabinoids to manage pain in a primary care setting, how to interpret the evidence supporting their use, the importance of maintaining a medical channel for clinical use of cannabis and other key considerations.

CHAIR:

Alan Bell, MD, FCFP Department of Family and Community Medicine, University of Toronto, Humber River Hospital Toronto, ON

THE PANEL

Hance Clarke, MD, FRCPC, PhD Director, Pain Services Medical Director, Pain Research Unit Toronto General Hospital Toronto, ON

Matthew Hill, PhD Hotchkiss Brain Institute, University of Calgary Executive Director, Canadian Consortium for the Investigation of Cannabinoids Calgary, AB

Caroline MacCallum, BScPharm, MD, FRCPC Department of Medicine, University of British Columbia Medical Director, Greenleaf Medical Clinic, Vancouver, BC

Blake Pearson, MD Founder & Chief Medical Officer, Greenly Medical Consulting and Greenly Health, Sarnia, ON

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Shelita Dattani, BScPharm, PharmD Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association Pharmacist, West Carleton Pharmasave, Ottawa, ON

T HTEH RO E RO L EL F E OFRO R M EMDEICA D ICA L CA L CA N NNANBAI B SIS I NI N C HCRO H RO N IN CI C PAPA I NI N MAMA N AG N AG E ME E ME N TN T

The current opioid crisis suggests there are unmet needs in the management of chronic pain. What are those unmet needs? Dr. Hance Clarke, Toronto General Hospital: Our entire chronic pain approach has traditionally been centred upon treating numbers, not patients. Lowering pain scores has become the focal point, and there’s a pervasive belief among physicians that opioids are going to magically fix that number. It is critical to remember that not all pain is created equal — neuropathic pain is completely different from inflammatory pain, which is different from visceral pain and ischemic pain. Opioids are the best medications available for acute pain, but when it comes to chronic non-cancer pain they are not the ideal choice because of the risk for physical dependence, toxicity and bothersome side-effects over the long term. The real unmet need, then, is to move beyond pain scores to treat patients holistically and focus on what’s truly important, which is their functioning, how well they are coping with their condition, and their quality of life. What does the collective clinical experience tell us about medical cannabis as a tool to treat pain? Dr. Clarke: For chronic neuropathic pain, the Canadian Pain Society (CPS) guidelines (1) recommend gabapentinoids, tricyclic antidepressants and SNRIs as first-line therapies, with tramadol and controlled-release opioids as second line ahead of third-line cannabinoids. When we wrote those guidelines, we based our guidance solely on available evidence, and at the time there just wasn’t anything that supported putting cannabinoids ahead of opioids, even from a harm reduction perspective. As evidence unfolds over time and

better science is brought to the table over the next few years, that discussion will be revisited and there may be sufficient reason to move cannabinoids above opioids. Clinicians who are comfortable prescribing cannabis are certainly identifying windows where it is readily utilized, and I think appropriately so. Opioids, for example, can be difficult for patients to self-manage in conditions that feature waxing and waning symptoms or peaks and valleys of pain. These patients can use cannabis for as long as they need — it helps them to function and they can put it aside when they feel they no longer need it. That can be a challenge with opioids because it takes time to stabilize the opioid dose and then appropriately wean patients off them. In the palliative care setting I have been able to utilize cannabis for select patients who needed some pain relief for two to four hours and also wanted to remain lucid with their family. Overall, we need to identify — through better research and the development of academic centres of excellence — where medical cannabis fits clinically and whom it helps and where it doesn’t. We do have positive data about cannabis and pain; it can be another tool in the armamentarium. Is it the only drug we should be using? No. But all pain medications reduce central nervous system excitability and that is exactly what cannabis does and it does it well. What do primary care physicians need to understand about how the endocannabinoid system influences pain? Why is modulating it an attractive target for pain management? Matthew Hill, PhD, Hotchkiss Brain Institute: The endocannabinoid system provides a multi-pronged

approach to influencing pain pathways in the body. Endocannabinoids behave like endorphins: when a noxious stimulus occurs, there is a release of endocannabinoids that suppress the perception of pain. There is also evidence that a component of stress-induced analgesia, which is not regulated by several neuropeptides and neurotransmitters such as endogenous opioid, monoamine, y-aminobutyric acid and others, is endocannabinoid dependent.(2) Endocannabinoids can work at the spinal level to affect nerve transmissions related to pain (3) while other evidence suggests they can reduce peripheral pain, even at pain initiation.(4) Interestingly, they also seem to modulate the way the frontal limbic part of the brain manages the emotional component of pain. There’s clearly a very significant overlap between emotion and pain sensitivity —people who have chronic pain often have psychiatric comorbidities, while those who experience high emotionality tend to be more prone to developing chronic pain.(5) There is evidence to show that when you elevate endocannabinoid signalling, you can reduce the emotional component of pain, such as anxiety and depressive symptoms, in animal models. Conversely, if you inhibit endocannabinoid functioning, it can make these symptoms worse. Limited clinical data coupled with a growing number of anecdotal reports also suggest that medical cannabis may improve quality of sleep. This could be a useful function because sleep disturbance is a common thread across almost every single disease state in which cannabis treatment is used. One thing we’ve learned in the neuroscience and psychiatric communities is that poor sleep can create a vicious cycle for

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T HTEH RO E RO L EL F E OFRO R M EMDEICA D ICA L CA L CA NNNANBAI B SIS I NI N C HCRO H RO N IN CI C PAPA I NI N MAMA N AG N AG E ME E ME N TN T

TABLE 1. THC vs CBD THC (tetrahydrocannabinol)

CBD (cannabidiol)

Partial agonist of CB1 and CB2 receptors

Antagonist with low affinity for CB1 and CB2 receptors; affects activity of other enzymes and receptors

Euphoric

Non-euphoric, opposes action of THC (makes the “high” more tolerable)

Mixture of stimulant and depressant effects: • Elevated mood, relaxation, increased appetite • Paranoia, depression, anxiety • Hypertension, tachycardia • Analgesic, antiemetic, appetite stimulant and antispasticity properties

• Anxiolytic, neuroprotective • Anticonvulsant, analgesic, antiemetic, anti-inflammatory properties

psychiatric conditions which can, in turn, increase pain sensitivity. Endocannabinoid signalling, because it can regulate these processes, may offer a different modality that could influence outcomes in chronic pain beyond analgesia. Are there meaningful differences in the effects of cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) on pain? Dr. Hill: Everything that we study in the endocannabinoid system typically focuses on endocannabinoid signalling at CB1 receptors, which mediates the ability of endocannabinoids to reduce pain sensitivity and modulate the emotional component of pain. THC has a very clear target: it acts on those CB1 receptors. We still don’t really know how CBD works, however. It’s an interesting molecule that seems to influence a host of different systems. Certainly, cannabis formulations that evenly balance THC and CBD have been

found to have some benefit. There is some evidence to suggest that CBD may also mitigate some of the adverse central side-effects of THC, such as anxiety or the “high” that recreational users want (see Table 1). We need more research to better understand how all of the components of cannabis work and in the next few years I think we will see genuine evidence emerge to answer some of these questions in a more accurate manner. Some of the revenue from the sales of legalized recreational marijuana is earmarked to support research, which will go a long way in clinical circles to raise the level of comfort for adding medical cannabis to the treatment arsenal. What does the evidence tell us about the efficacy and safety of medical cannabis in chronic pain and other conditions? Dr. Caroline MacCallum, University of British Columbia: There is good

evidence for cannabis use, as reported in hundreds of peerreviewed studies. In 2017, the National Academies of Sciences, Engineering and Medicine published an extensive review of 10,000 cannabis publications titled The Health Effects of Cannabis and Cannabinoids. It concluded that there is “conclusive or substantial” evidence for the application of medical cannabis in chronic pain in adults, patient-reported multiple sclerosis spasticity symptoms and as an antiemetic in the treatment of chemotherapyinduced nausea and vomiting.(6) Health Canada also summarized current research in its 2014 publication Information for health care professionals: cannabis (marihuana marijuana) and the cannabinoids.(7) The Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS) is the largest analysis of the long-term safety of cannabis for the treatment of chronic pain. Patients in the cannabis group saw improvements in pain, symptom distress, mood and quality of life with no increased risk of serious adverse drug events or harms on cognitive, pulmonary, liver and renal function, or hematological profile.(8) Cannabis may have application in treating several other conditions, but more studies are needed. In terms of safety, there have been no recorded deaths due to overdose attributable to medical or recreational cannabis use; this is due to lack of CB1 receptors in the brainstem cardiorespiratory centres.(9) The lethal dose is approximately 1,500 pounds inhaled over 15 minutes. The therapeutic index for cannabis, or the ratio of effective dose to fatal dose, is >1:1,000, compared with opiates (1:5) and alcohol (1:10).(10) In terms of cannabis dependency,

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T HTEH RO E RO L EL F E OFRO R M EMDEICA D ICA L CA L CA N NNANBAI B SIS I NI N C HCRO H RO N IN CI C PAPA I NI N MAMA N AG N AG E ME E ME N TN T

the risk based on a recreational cannabis population is approximately 9%, in comparison with heroin (23%), alcohol (15%) and tobacco (32%).(11) The side-effects of THC are dose-dependent. The more common acute symptoms include dizziness, drowsiness/fatigue, anxiety and euphoria (see Table 2).(7, 12) Rarer side-effects are tachycardia, psychosis/paranoia, hypotension and cannabis hyperemesis. Interestingly, CBD has demonstrated benefit in psychosis when used as an adjuvant in psychosis clinical trials.(13) Many patients also report fewer THC-associated side-effects when used in combination with CBD.(14) Naive cannabis users without tolerance to THC may be more prone to experience side-effects. Medical cannabis users develop tolerance over time and frequently experience fewer and milder side-effects. CBD has minimal side-effects. In some psychosis and seizures trials using large doses of CBD (1000 to 2000 mg/day) fatigue (12% vs. 2% in placebo) and GI symptoms such as nausea and diarrhea (19% vs 6% in placebo) were noted.(15) These side-effects may be dose dependent; we need further research to determine the adverse events of CBD. The systematic review by the National Academies found an increase in respiratory symptoms, including bronchitis, cough and phlegm with smoking but not with vaporizing cannabis. Studies show that vaporization produces little if any carbon monoxide.(15) Health Canada has approved two vaporizers as medical devices for this reason. There is moderate evidence to show that there is no statistically significant association between cannabis and lung or head and neck cancers, and limited evidence of a statistical association between

TABLE 2. Adverse events associated with cannabis-based medicines Side-effect

Most common

Drowsiness/Fatigue

✓

Dizziness

✓

Dry mouth

✓

Cough, phlegm, bronchitis (smoking only)

✓

Anxiety

✓

Nausea

✓

Cognitive effects

✓

Common

Euphoria

✓

Blurred vision

✓

Headache

✓

Rare

Orthostatic hypotension

✓

Toxic psychosis/paranoia

✓

Depression

✓

Ataxia/dyscoordination

✓

Tachycardia (after titration)

✓

Cannabis hyperemesis

✓

Diarrhea

✓

Adapted from MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med 2018;49:12-19.

cannabis use and ischemic stroke/ subarachnoid hemorrhage and acute myocardial infarction.(6) What do we know about the relative differences in dosing, frequency, delivery routes, etc.? Dr. MacCallum: Cannabis comes in several administration and dosage forms (see Table 3).(12) Oral oil (or oil-filled capsules for ingestion) is long-acting, with an onset of one to two hours and effects lasting six to eight hours on average, which makes it applicable to chronic or persisting symptoms. Vaporization of dried plant can be considered a short-acting dosage form for acute or intermittent symptoms with an onset of five to 10 minutes and effects lasting one to

four hours on average. Oils for ingestion are easier to reliably dose in comparison to inhaled dried product. There are other dosage forms including sublingual tinctures, topical (which likely feature fewer systemic side effects versus oral or inhaled forms, but the evidence here is limited) and suppositories, which may be ideal for GI symptoms and in palliative or geriatric care.(12) Both CBD and THC cross the blood brain barrier and affect the brain. However, CBD is non-intoxicating and does not cause euphoria while THC can cause intoxication, depending on the dose. Cannabis and opioids are synergistic. Preclinical studies have demonstrated that mean effective dose of morphine with THC was

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T HTEH RO E RO L EL F E OFRO R M EMDEICA D ICA L CA L CA NNNANBAI B SIS I NI N C HCRO H RO N IN CI C PAPA I NI N MAMA N AG N AG E ME E ME N TN T

TABLE 3. Administration factors in cannabis delivery Vaporization/Smoking

Oral

Oral mucosal

Topical

Onset (minutes)

5 to 10

60 to 180

15 to 45

Variable

Duration (hours)

1 to 4

6 to 8

Variable

Rapid onset for acute or episodic symptoms

Less odour, discreet and convenient â&#x20AC;&#x201D; an advantage for chronic disease/ symptoms

Pharmaceutical form (nabiximols) available with documented efficacy and safety

Less systematic effect; good for localized symptoms

Titration challenge due to delayed onset

Expensive, spotty availability

Only local effects

Pro

Dexterity required; some vaporizers are expensive, not all are portable Con

Smoking is associated with inhalation of known harmful products of combustion. Long-term effects of vaporization are unknown.

Adapted from MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med 2018;49:12-19.

3.6 times lower than morphine alone and mean effective dose of codeine with THC was 9.5 times lower.(17) Medical cannabis users have reduced their consumption of opioids, benzodiazepines, antidepressants, alcohol, tobacco and illicit drugs.(18) Furthermore, there are data showing that medical cannabis legalization in the United States has significantly reduced opioid prescriptions(19) and overdose mortality rates.(20) What knowledge gaps remain about medical cannabis? Dr. MacCallum: One of the more pressing knowledge gaps is how to evaluate cannabis effects in the workplace and driving impairment. This is especially important for medical cannabis patients who develop tolerance when using reasonable daily doses of THC and who may experience minimal, if any, impairment compared with naive, intermittent or heavy recreational users. There

are no serum assays that can accurately measure impairment due to THC. Similarly, we need to understand the relationship between serum/buccal THC concentration and impairment, and whether CBD minimizes THC impairment. Development of THC-specific functional impairment testing vs. body fluid quantification is essential. We need more clinical trials to examine the pharmacokinetics and dynamics of delivery routes and formulations, as well as the utility of cannabis for other medical conditions, especially mental health. More evidence is also needed on individual cannabis plant varieties, which contain unique combinations of CBD, THC and other cannabinoids and terpenes, to determine which is best for specific conditions in order to personalize cannabis therapy. Finally, we need growing and testing standards to ensure quality control of cannabis

products. Cannabis plants should be standardized as much as possible. This will create a consistent product with reproducible effects from batch to batch. Standardized laboratory testing is much in need. Currently there can be great variation between labs due to methods used. Cannabis should be free of contaminants such as pesticides, bacteria, fungus, heavy metals and solvents such as butane. Where does medical cannabis fit in current Canadian treatment guidelines? Dr. Alan Bell, University of Toronto: Medical cannabis has yet to make significant inroads with treatment guidelines in Canada. This is largely due to a lack of the large randomized controlled trials that guidelines rely so heavily upon. However, itâ&#x20AC;&#x2122;s also clear that the deeply ingrained bias against cannabis among the public and within research, policy and clinical circles

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has obscured its potential utility in clinical practice. Earlier this year, the College of Family Physicians of Canada published guidelines(21) for prescribing medical cannabinoids to treat pain, chemotherapy induced nausea and vomiting, spasticity and other conditions in primary care. Unfortunately, these recommendations take a decidedly cynical approach to encapsulating and interpreting the accumulated evidence. The authors broadly advise physicians to limit medical cannabinoid use in general and, in bold type, specifically recommend against their use in each of these clinical areas. However, read past the topline recommendations and you will find that they acknowledge the potential of cannabinoids to treat refractory neuropathic and cancer pain, chemotherapy-induced nausea and vomiting and spasticity in multiple sclerosis and spinal cord injury. Unfortunately, they do so in a way that emphasizes potential harms and deemphasizes potential benefits. Regarding harms, it is important to remember that recorded experience concerning cannabis use disorder, psychosis, cannabis-induced vomiting and others are based on recreational, not medical, use. Current CPS guidelines(1) for the management of chronic neuropathic pain recommend cannabinoids as a third-line analgesic, up from fourth line in their previous recommendations. While that move is commendable, cannabinoids are preceded in the CPS algorithm by tramadol and controlled-release opioids. I would argue that high potency, high toxicity agents (opioids) may be better placed after lower potency, lower toxicity agents (cannabinoids). This is particularly true in a society facing an opioid crisis, for which the medical profession must take some responsibility.

Once recreational marijuana is legal, should patients using medical cannabis remain within the medical system for treatment and monitoring? Dr. Bell: It is critically important to maintain a two-stream system for recreational and medical use of cannabinoids. When prescribing cannabis, the goal is to find the optimal dose and combination of THC and CBD. A careful titration process, which requires cooperation between patient and health care professional, is needed to find the “sweet spot” that maximizes relief of the target symptoms and minimizes euphoria and other side-effects. In addition to affecting direct patient care, a single stream would have a significantly negative system impact. Obvious examples of this include medical users paying sales and “sin” taxes aimed at recreational users and major barriers to insured reimbursement of product costs. We could also expect to see a reduction in medical chemotype availability because commercial producers would have greater financial incentive to focus on producing recreational marijuana strains. Overall, we’d also see a reduction in funding for medical cannabis research, something all stakeholders agree is critical to advancing the science. In the absence of a medical stream, undergraduate programs and CME providers would be less inclined to offer education on cannabinoid use. Physicians would continue to be stigmatized for authorizing what would be considered a recreational substance. They would be forced to recommend potentially inappropriate cannabis chemotypes and dosing forms or forego authorizing it altogether. For patients, a single stream would further expose them to the stigma around cannabis use. It

would also put them at risk for developing serious side-effects such as psychosis, dependence and toxicity if their use of commercial cannabis is not medically supervised, or through increased use of illegal products. Are primary care physicians comfortable with prescribing medical cannabis to treat pain? Dr. Bell: Most clinicians have not been educated about the use of medical cannabis and the evidence behind it, and as such they are uncomfortable authorizing it. As with any treatment, incorporating cannabinoids into practice requires training. The good news is that there are many more education programs available today for clinicians to improve their knowledge and skills in this area. That said, accrediting bodies still seem to be more apprehensive about approving CME on cannabinoids versus other agents, again due to the pervasive stigma around it. There is a significant opportunity in Canada for physicians to acquire the knowledge to manage medical cannabis in appropriate patients. Cannabis is not a firstline treatment for any condition, but it is a valuable second- and third-line agent we can and should add to our clinical toolkit for pain and other conditions. Where does medical cannabis fit into the larger toolbox on a practical level? Dr. Blake Pearson, Greenly Medical: Cannabis is a reasonable alternative for chronic pain patients who have not had relief with their initial pain medications, as well as for those who are unable to tolerate certain medications due to side-effects, allergies or comorbid conditions. For me, it is a logical next step in some chronic pain diagnoses before trying opioids.

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Physicians considering cannabis as a pain management strategy may find reassurance in knowing that we often see good results using the non-impairing cannabinoid CBD in many chronic pain diagnoses, such as osteoarthritis. Prescribing a high CBD agent, containing only minimal amounts of THC, avoids the euphoric effects for which THC is responsible. Some diagnoses, such as neuropathic pain, tend to benefit more from THC. In these cases, clinicians could consider combining THC with CBD to mitigate some of THC’s euphoric effects. What considerations should be top of mind when assessing patients with chronic pain and selecting treatments? What are the considerations for selecting agents from the cannabinoid class? Dr. Pearson: When assessing patients with pain and selecting treatments, physicians should consider the diagnosis responsible for the pain, duration, therapies tried to date, medical history and current medications to determine if cannabinoid therapy is an appropriate option. If cannabinoid therapy is warranted, physicians must consider whether the patient needs treatment to be fast-acting or long-lasting. As Dr. MacCallum points out, inhaled cannabinoids have a rapid onset of action and may be more desirable in the management of acute symptoms such as chemotherapy-induced nausea or breakthrough pain. Inhaled cannabinoids should be vaporized rather than smoked to avoid the harmful by-products of combustion. Ingested cannabinoids are longer-lasting and more appropriate for the management of persistent symptoms such as chronic pain, insomnia or spasticity where longer duration is the priority.

What does follow-up, titration and treatment plan adjustment look like in the age of medical cannabis? Dr. Pearson: If I determine that cannabinoid therapy is a suitable treatment, I create the patient’s Medical Document Authorizing the use of Cannabis for Medical Purposes. A follow-up appointment is booked one month after starting treatment because there is a self-titration process — which generally starts at 2.5 mg of either THC or CBD or both, depending on condition (1.25 mg if young, elderly or there are other concerns) — that must be closely monitored in the beginning. The next appointment will take place at three months, at which point most patients will have reached their target therapeutic dose. Barring any changes in condition, I generally see them twice a year for follow-up. Since cannabis is a multi-modal therapy, around the three-month mark some patients may experience improvement in other symptoms unrelated to the original condition for which cannabinoid therapy was started. Some patients may want to wean other medications on their own once they have started cannabinoid therapy. It is imperative that physicians advise their patients not to begin the weaning process on their own. Once patients have reached their therapeutic goals, physicians can review medications and develop a polypharmacy reduction plan, as appropriate. This may require further titration of the cannabis. How does medical cannabis impact practice in issuing prescriptions, updating EMR and other considerations? Dr. Pearson: Initially, practicing cannabinoid medicine can be slightly intimidating because it involves a new and different process compared to our standard treatment

and prescription model. However, it really is quite straightforward and, once you handle a few cases, it will become second nature. Physicians can use any EMR and document cannabinoid therapy like any other treatment. Unlike traditional prescription medications that are dispensed directly from the pharmacy, medical cannabis must be ordered online from one of Health Canada’s approved licenced producers. Some producers have made the process easier for physicians by creating an online portal where you can quickly create the Medical Document. Once the Medical Document is created for a given patient, the renewal process is quick and simple. Doctors writing a Medical Document for cannabis must authorize a maximum number of grams per day. For a new patient, a reasonable amount would be 0.5 to 1.0 grams per day. The duration of therapy must also be specified; I always recommend a short period of two to three months for new patients to ensure adequate follow-up and to assess the efficacy of treatment. Once patients have reached their therapeutic goals, I recommend follow-up every six months. The maximum duration of a Medical Document is currently 12 months. Is pharmacy prepared for an increase in the use of medical cannabis? What is the pharmacist’s role in advising and supporting patients and consumers who use cannabis? Dr. Shelita Dattani, Canadian Pharmacists Association: Pharmacists continue to be approached by patients and prescribers with questions about the use of cannabis for various medical conditions. Public opinion polls confirm that patients want to talk to their

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pharmacist about this therapeutic entity, just like any other drug that they use as part of a treatment regimen. Patients who use medical cannabis often want —and they should have —the opportunity to consult with their pharmacist. Pharmacists are regulated healthcare professionals and trained medication experts who are the most accessible health care professionals across the country in all urban, rural and remote communities. Pharmacists are accustomed to advising and guiding patients and prescribers through complex drug regimens. Cannabis is often third- or fourth-line adjunctive therapy for many patients, and this compounds the potential for drug interactions and adverse effects with cannabis and other concurrent medication. Cannabis must be contextualized within the patient’s overall medication regimen. What role does pharmacy play in the larger medical cannabis system? Currently pharmacists do not have an opportunity at the point of dispensing to provide formal clinical oversight to patients as part of the circle of care. Dispensing a medication is a regulated act that must involve counselling about side-effects, interactions and appropriate use. We feel it is essential that patients have as much support from healthcare professionals as possible, especially with respect to medication safety. For all other prescription drug products there is a well-defined and highly accessible framework in which the circle of care includes the safety net of a pharmacist to provide support, support, insight, recommendations and authorization for controlled dispensing of a prescription order. All of this is predicated on patient safety. Many pharmacists already play a role in providing counselling and support to patients who use cannabis for medical purposes. We feel that the medical stream should be maintained and further strengthened by including us in the dispensing of medical cannabis so that we can review potential benefits and harms of medical cannabis on its own and within a patient’s broader therapeutic regimen. In the spirit of harm reduction, and knowing the expertise that pharmacists provide, we feel that the oversight of and collaboration with pharmacists is absent the way things stand now. The Canadian Pharmacists Association has taken a leadership role to develop evidence-based education and resources, such as an evidence guide and a product monograph on cannabinoids, to ensure that pharmacists can provide effective medication education to their patients—with respect to all medications, including cannabis. 8

References 1. Moulin DE et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manag 2014;19(6):328–335. 2. Hohmann AG et al. An endocannabinoid mechanism for stress-induced analgesia. Nature 2005;435(7045):1108-12. 3. Starowicz K, Finn DP. Cannabinoids and pain: Sites and Mechanisms of Action. Adv Pharmacol 2017;80:437-475. 4. Clapper JR et al. Anandamide suppresses pain initiation through a peripheral endocannabinoid mechanism. Nat Neurosci 2010 Oct;13(10):1265-70. Epub 2010 Sep 19. 5. Asmundson GJ et al. Understanding the co-occurrence of anxiety disorders and chronic pain: stateof-the-art. Depress Anxiety 2009;26(10):888-901. 6. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: The National Academies Press, 2017. Online https://doi. org/10.17226/24625 7. Health Canada. Information for health care professionals: cannabis (marihuana, marijuana) and the cannabinoids. Ottawa: 2013. https://www.canada.ca/content/ dam/hc-sc/migration/hc-sc/dhpmps/alt_formats/pdf/marihuana/ med/infoprof-eng.pdf 8. Ware MA et al. Cannabis for the management of pain: assessment of safety study (COMPASS). The Journal of Pain 2015;16(12):1233–42. 9. Herkenham M et al. Cannabinoid receptor localization in brain. Proc Natl Acad Sci 1990;87:1932–6. 10. Gable R. The toxicity of recreational drugs. American Scientist 2006;94(3):206–208.

11. Anthony JC et al. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology 1994;2(3):244–268. 12. MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med 2018;49:12-19. 13. Mcguire P et al. Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: a multicenter randomized controlled trial. Am J Psychiatry 2018;175(3):225–231. 14. Sellers EM et al. A multiple dose, randomized, double-blind, placebo-controlled, parallel-group QT/ QTc study to evaluate the electrophysiologic effects of THC/CBD spray. Clin Pharmacol Drug Dev 2013;2:285–94. 15. Devinsky O et al. Trial of cannabidiol for drug-resistant seizures in the Dravet syndrome. N Engl J Med 2017;376(21):2011–2020. 16. Abrams D et al. Vaporization as a smokeless cannabis delivery system: a pilot study. Clin Pharmacol Ther. 2007;82(5):572-8. 17. Nielsen S et al. Opioid-sparing effect of cannabinoids: a systematic review and meta-analysis. Neuropsychopharmacology. 2017;42(9):1752-1765. 18. Lucas P et al. Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients. Int J Drug Policy. 2017;42:30-35. 19. Ashley C et al. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. JAMA Intern Med. 2018;178(5):667672. 20. Bachhuber MA et al. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668-1673. 21. Allan GM et al. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician. 2018 Feb;64(2):111-120.

Colloquium Colloquium™ is a regular sponsored feature designed to provide Canadian physicians with the latest in clinical thinking and therapeutic practice. Before prescribing any mentioned medication, please refer to “Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids” Health Canada, 2013. The information and opinions contained herein reflect the views and experience of the authors and not necessarily those of the sponsor.

Group Brand Director/Healthcare: DONNA KERRY Senior Account Manager: NORMAN COOK Editor: DEIRDRE MACLEAN Project Editor: BRAD HUSSEY Art Direction: LINDA RAPINI This supplement is published by EnsembleIQ, 20 Eglinton Ave. W., Suite 1800 Toronto, ON M4R 1K8. Colloquium is a trademark of EnsembleIQ. No part of this publication may be reproduced, in whole or in part, without the written permission of the publisher. Copyright ©2018.

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BY DR. JOHN CROSBY

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Doctors are burning out more now than in the past

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have been a doctor for 45 years and I have never heard more about burnout than now. It affects half of us. If doctors had sick pay there would be a national crisis. Maybe in the olden days doctors didn’t talk about it or maybe they were more stoical; I don’t know and it’s hard to find out. Perhaps our more seasoned readers could enlighten us. I think unrealistic patient expectations

are really causing doctors more stress. In the good old days if someone really old died, it was “nature’s way.” Now the family wants to know why. They often think their loved one should have lived forever. We doctors are victims of our own success. People who would have died 20 years ago are still alive thanks to modern medicine but are frail and taking many medications; they require more and more care.

Patient volumes are higher. We used to see 20 patients a day and now we see 40. We do four times as much paper and computer work. Fifty years ago the physician I replaced had patient records on a recipe card, records featuring a diagnosis and any medications. I have a $47,000 computer system and type the equivalent of the Manhattan phone directory on each patient. Way back when, you varied your day by going to the hospital, covering the ER, delivering babies and doing house calls. Now we sit in our offices all day listening to people whine about trivial First-World problems. Doctors had a harder job in the good old days but it was much more varied, interesting and rewarding. You could actually fix someone by realigning a shoulder dislocation using your big toe. You didn’t just chat about cholesterol. When I first started general practice in the 1970s, my neighbour, Dr. John Whilaw, had been a GP since the late 1930s. I asked him how he coped. He said his wife took the phone calls after 5 p.m. and he was rarely called. If he was called, it was for something very important and he didn’t mind seeing the patient in his office or at the hospital. In July he covered another GP’s practice and in August that GP covered Dr. Whilaw. He said people tried home remedies before they bothered the doctor, especially in the nighttime. It cost money to see the doctor and cost more for after-hours care and/or a house call.

THE MEDICAL POST SEPTEMBER 2018 39

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Thankfully very few patients are seriously ill anymore and I haven’t seen a really sick child in years, which is wonderful. This is due to vaccines and better safety equipment, such as bicycle helmets. Children now have behaviour problems, which are more challenging but less gratifying than saving a life by treating pneumonia with penicillin. Old timey docs did not have to compete with Dr. Google or helplessly see themselves disrespected on Rate MD. They didn’t have patients take a phone call during a consultation. Today we are blamed for undertreating chronic pain or getting patients hooked on narcotics. I don’t recall any narcotic problems in the past. As an intern at the Wellesley Hospital in 1973 in downtown Toronto I never saw one narcotic problem; I never treated a victim of a shooting or a stabbing. Even as an emergency doctor from 1979 to 1992, I saw only one

shooting and one stabbing. There were only a few medications then; now we have more than 6,000 and many have two names—generic and brand. Doctors can do a great job with six million emergency patients per year but you only hear about the one that didn’t do well. It’s the same for cases of maternal mortality or damaged babies. I have never had a baby in my practice suffer anoxic brain injury but the media only grouses about high C-section rates. Another stress buster in earlier days was the doctors’ lounge. Family doctors seldom go now except in the smaller towns. In the doctors’ lounge we could meet our peers and get to know the specialists. We could complain about the government and have group therapy. We could help each other with difficult cases. Sharing is a great way to avoid burnout. Now we do it online; for example, with this blog.

I am lucky because my practice is made up of 60% seniors so I still get lots of respect and thanks. I even get paid in chickens, tomatoes, cakes and vodka. At age 71 I am a wise enough old geezer to know that we see the past without its warts, but I do think we have more doctor burnout today. MP DR. JOHN CROSBY

Cambridge, Ont.

is a family physician in

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Opal: Oncology Portal and Application

Each Merck Patient First Award winner is unique but they have one important thing in common: a commitment to delivering care that focuses on the patient, the family, and their concerns, interests and outcomes. We are honoured to recognize these great Canadian innovators who contribute to improving our health care system and making patient-centred care their priority. Find out more about this award and our winners’ inspiring stories at www.merckpatientsfirst.com.

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40 SEPTEMBER 2018 THE MEDICAL POST

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Doctors in a dangerous time Remembering when I should have spoken up over something a preceptor said BY DR. ERIC CADESKY

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fter my first week of rural rotation I felt pretty comfortable. As a medical student, it was my first time in Atlantic Canada and the elective was working out well. My preceptor, bespectacled and frosty-bearded, would pick me up in the morning and we would discuss my previous night’s reading. Upon arrival at the clinic bungalow, I was given my own fluorescent room in which to see patients before meeting back in the office with its dark leather chairs and large oak desk to discuss the case. Lunch was slow and social as we met other community doctors for educational talks. (For fear of the answer and the loss of plausible denial, I didn’t ask who sponsored those sessions.) The afternoon

repeated the morning’s clinical rhythm and my preceptor would drive me back to my host family’s home at the end of day, all the while recounting lessons learned from his decades of experience. Everything seemed fine until one late afternoon when, as we prepared to leave, the office assistant sheepishly knocked on the office door. A young woman had come to the clinic asking to be seen. “I told her we’re closed, but she insists on seeing you. She’s pregnant and doesn’t want to be.” My preceptor barely lifted his head and replied through terse lips, “Well, tell her we don’t tolerate that kind of thing around here. She can come back if she wants prenatal care. Eric, you ready to go?” And like that we left out the back and climbed into his car for

a silent ride home. We never saw that woman. We never spoke of it again. I often think of that moment and the emotions that followed: guilt about not speaking up, anger at my preceptor’s decision, depression over my apparent impotence, and denial that it was OK because she would have received care elsewhere, right? Acceptance has been a farther reach. Yes, my preceptor was my lifeline for education, evaluation, transportation, and social interaction. But I could have challenged him about his duty to care. I could have offered to see the woman. I could have done something. I could have done more. Medical school is a distant and complex memory and, as a practising physician, now I can do more. I can be aware of my body language and my choice of words. I can work with my colleagues to design a welcoming clinic and train staff to respect everyone who comes in. I can encourage learners to question what they have been told to just accept. I can be open to criticism and solicit feedback to understand the things that I don’t know I don’t know. Our behaviours and our systems and our attitudes tell others how we value their belonging in our world. There are and will continue to be many contentious issues that engender strong reactions because we care deeply. But we can strive to debate passionately about issues while respecting each other as people worthy of belonging. Because no matter our individual views on abortion, taxation, medical assistance in dying, substance decriminalization, and allocation of resources (to name a few), we all want the best for our patients, our communities, our families and ourselves. None of us is perfect, but we can learn from and forgive our mistakes and those of others. Because only by looking out for each other and creating safe spaces for diverse opinions can we truly be “Better Together.” MP is president of Doctors of BC and this item is courtesy of the British Columbia Medical Journal (or BCMJ).

DR. ERIC CADESKY

THE MEDICAL POST SEPTEMBER 2018 41

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What is the demonstrated safety profile of FLUZONE® High-Dose? The safety profile of FLUZONE® was demonstrated in 2 large clinical trials comparing FLUZONE® High-Dose and FLUZONE®, a standard-dose vaccine. Study 1 compared safety and immunogenicity in 3,833 individuals 65+:1§ • Within 6 months after vaccination, 6.1% of FLUZONE® High-Dose vaccine recipients and 7.4% of FLUZONE® vaccine recipients experienced a serious adverse event. Study 2 compared efficacy and safety in 31,803 individuals 65+ over two influenza seasons:1£ • Within 6 to 8 months after vaccination, 8.3% of FLUZONE® High-Dose vaccine recipients and 9.0% of FLUZONE® vaccine recipients experienced a serious adverse event.

Contraindications: • Known severe allergic reaction to egg protein or any component of the vaccine or after previous administration of FLUZONE® High-Dose or a vaccine containing the same components or constituents. Relevant warnings and precautions: • FLUZONE® High-Dose is not indicated for persons less than 65 years of age. • As with any vaccine, immunization with FLUZONE® High-Dose may not protect 100% of individuals. Protection is limited to those strains of virus from which the vaccine is prepared or against closely related strains. • Do not administer FLUZONE® High-Dose by intravascular injection. Do not administer into the buttocks. • Postpone vaccination in case of moderate/ severe febrile illness or acute disease. • Administer FLUZONE® High-Dose with caution in persons suﬀering from coagulation disorders or on anticoagulation therapy. • Immunocompromised persons (whether from disease or treatment) may not elicit the expected immune response. • Avoid vaccinating persons who are known to have experienced Guillain-Barré syndrome (GBS) within 6 weeks after a previous inﬂuenza vaccination.

For more information: Consult the product monograph at www. sanoﬁpasteur.ca/PM/ﬂuzoneHD_e for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available through our medical department. Call us at 1-888-621-1146. ‡ The pre-specified statistical superiority criterion for the primary endpoint (lower limit of the 2-sided 95% CI of the vaccine efficacy of FLUZONE® High-Dose relative to FLUZONE® > 9.1%; p-value against H0:VE ≤ 9.1% = 0.022 one-sided) was met. ¥ In a multicentre study (FIM12) conducted in the United States and Canada, adults 65 years of age and older were randomized (1:1) to receive either FLUZONE® High-Dose or FLUZONE® Trivalent. The study was conducted over two influenza seasons (2011–2012 and 2012–2013). FLUZONE® High-Dose contained 60 μg of HA per strain while FLUZONE® Trivalent contained 15 μg of HA per strain. The per-protocol analysis set for efficacy assessments included 15,892 FLUZONE® High-Dose recipients and 15,911 FLUZONE® Trivalent recipients. The primary endpoint of the study was the occurrence of laboratory-confirmed influenza, defined as a new onset (or exacerbation) of at least one of the following respiratory symptoms: sore throat, cough, sputum production, wheezing, or difficulty breathing; concurrent with at least one of the following systemic signs or symptoms: temperature > 37.2°C, chills, tiredness, headaches or myalgia. ¶ In the first year of the study, the influenza B component of the vaccine and the majority of influenza B cases were of the Victoria lineage; in the second year, the influenza B component of the vaccine and the majority of influenza B cases were of the Yamagata lineage. § Laboratory confirmation by culture or polymerase chain reaction. £ Randomized, double-blind, multicentre comparative trial with FLUZONE® High-Dose or FLUZONE® vaccine (2006-2007 formulation). Randomized, double-blind multicentre, efficacy trial with FLUZONE® HighDose or FLUZONE® vaccine (2011–2012 and 2012–2013 formulations).

References 1. FLUZONE® High-Dose vaccine. Product Monograph. Sanofi Pasteur Inc., May 2018. 2. DiazGranados CA, et al. Efficacy of high-dose versus standard dose influenza vaccine in older adults. N Engl J Med. 2014;371:635-645. 3. Schanzer DL, et al. Co-morbidities associated with influenza-attributed mortality, 1994–2000, Canada. Vaccine 2008;26:4697–4703. 4. Public Health Agency of Canada (PHAC). FluWatch. May 3 to May 9, 2015. 5. An Advisory Committee Statement (ACS)/National Advisory Committee on Immunization (NACI): Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2018–2019. 6. Gozalo PL, et al. The impact of influenza on functional decline. Am Geriatr Soc. 2012 July;60(7):1260–1267. 7. Canadian Lung Association. Chronic Obstructive Pulmonary Disease (COPD). https://www.lung.ca/ lung-health/lung-disease copd/flare-ups. Last updated: January 22, 2018. Accessed: June 13, 2018. 8. Centers for Disease Control and Prevention: Flu Symptoms & Complications. https://www.cdc.gov/flu/about/disease/ complications htm. Accessed: June 13, 2018. 9. CDC: The Pink Book: Course Textbook - 13th Edition (2015). Chapter 12 Influenza. https://www. cdc.gov/vaccines/pubs pinkbook/downloads/flu pdf. Last updated: November 15, 2016. Accessed: June 13, 2018. 10. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta analysis. JAMA 2013;310(16):1711-1720. 11. Grau AJ, et al. Influenza Vaccination Is Associated With a Reduced Risk of Stroke. Stroke 2005;36(7):1501-1506. 12. CDC Morbidity and Mortality Weekly Report. August 26, 2016; 65 (5). Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices– United States, 2016–17 Influenza Season. https://www.cdc. gov/mmwr/volumes/65/rr/rr6505a1.htm. Last updated: June 16, 2017 Accessed: June 13, 2018. 13. Husein N, et al. Influenza and Pneumococcal Immunization. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Journal of Diabetes 2013;37 (Suppl 1):S93. 14. Legrand J, et al. Real-time monitoring of the influenza vaccine field effectiveness. Vaccine 2006; 24:6605–6611. 15. Sanofi Pasteur Inc. Data on file. Fluzone High-Dose. Claim Confirmation Letter. December 11, 2015. 16. Sanofi Pasteur Inc. Data on file. Fluzone High-Dose. Doses Distributed Letter. June 11, 2018.

FLUZONE® is a trademark of Sanoﬁ Pasteur. Sanoﬁ Pasteur 1755 Steeles Avenue West, Toronto, Ontario M2R 3T4.

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The lure of the travelling circus We’ve all dreamed of a different practice in some exotic location, until the opportunity comes within grasp BY DR. TED JABLONSKI WANTED: Flame-eating jugglers for circus act, ability to ride a unicycle an asset. Only the most daring, bold and adventurous need apply.

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I have the 10-year itch. Every decade I get restless and feel like I need to change up what I am doing. Typically I am drawn to the classified ads in our medical journals and the Medical Post. What would it be like in another practice, another province, another country? The grass doesn’t just look greener, it looks downright seductive. I just happened to feel particularly adventurous one Saturday morning after a glorious summer run and I decided to answer one ad, which was so far-fetched in scope and location it was almost laughable. I whipped off an email with a compelling narrative, ending off with an unorthodox statement of why they really didn’t want me; part tongue-in-cheek, part contrarian strategy. I had nothing to lose and flexed my creative writing skills. Just a bit of amusement to cheer up the old, somewhat bored, doctor. All was good, and mostly forgotten until I received an email back from an admin person following up to request a resume and more information. I could have stopped right there. I should have stopped right there. But I felt the lure of the travelling circus coursing through my veins. Here’s the thing: I really do feel like I’m cut out for it. I can juggle three balls for a few seconds. I own a unicycle, a father’s day gift, though I admit I’ve never quite mastered riding it (it’s a steep learning curve). I manage very spicy food.

How much harder could flame eating be? How hard could any of this be? Refusing to admit my mistake, I giddily started my skid down the slippery slope. I updated my CV, sent in all the requested information and waited for the email telling me I was not even remotely qualified for the position. The overseas phone call from one of the principals of the international headhunting firm caught me totally off guard. I found myself in the middle of a busy clinic, conducting a “brief and informal” interview with what sounded like a very formal business savvy individual. In an instant, it was as if I was juggling four balls, while riding a unicycle through a burning hoop. What term of contract was I seeking? What was a reasonable salary expectation? When was the earliest I could move? How did I suddenly get here? As I was talking to this suave, silver-tongued devil, I could hear the voice of my wife screaming in my other ear. “You did what? Are you crazy?” I should have stopped things right there but I figured I hadn’t done a formal interview in decades and maybe this was a skill I should hone up on. Short-listed already, I thought I could fly to—well, let’s just call it “Sunny Dreamland” to do the final interview. It is, after all, a country I always wanted to see. Provide references? Certainly! I was sure I could find someone to write up a quick reference letter who wouldn’t also tell my wife just yet. I did plan to tell her myself, to sneak it into our next dinner conversation, perhaps a special night out to our favourite posh restaurant. I thought about getting some travel

brochures to Sunny Dreamland and leaving them out for her to see. “Look at what came in the mail yesterday,” I would tell her. “What do you think?” I had never stuck my head in a lion’s mouth, but I was beginning to know how it might feel. At the end of it all, I never did go for that interview. I didn’t need a new medical career, just a bit of a re-boot, something to dream about. When the travelling circus leaves town, life gets back to normal. Predictable, busy, somewhat mundane life. Isn’t it wonderful? The “circus” was unusually exciting while it lasted, but I had to be honest with myself. I really don’t like spicy foods that much. I get heartburn. I have decided, however, to dust off my unicycle so I’ll be prepared the next time a headhunter calls. MP is a singer songwriting family physician on the run in Calgary.

DR. TED JABLONSKI

THE MEDICAL POST SEPTEMBER 2018 45

ELIQUIS #1 DISPENSED NOAC IN CANADA1*

WHAT DO YOU CONSIDER IN THE PREVENTION OF STROKE AND SYSTEMIC EMBOLISM IN AF? BOTH EFFICACY AND SAFETY PROFILES?

Patients with prosthetic heart valves, or those with hemodynamically signiﬁcant rheumatic heart disease, especially mitral stenosis, were excluded from the ARISTOTLE and AVERROES trials, and thus were not evaluated. These trial results do not apply to these patients, with or without atrial ﬁbrillation. As with all anticoagulants, ELIQUIS should be used with caution in circumstances associated with an increased risk of bleeding. Bleeding can occur at any site during therapy with ELIQUIS. The possibility of a hemorrhage should be considered in evaluating the condition of any anticoagulated patient. An unexplained fall in hemoglobin and/or hematocrit or fall in blood pressure should prompt a search for a bleeding source. Patients at high risk of bleeding should not be prescribed ELIQUIS. Should severe bleeding occur, treatment with ELIQUIS must be discontinued and the source of bleeding investigated promptly. Close clinical surveillance for blood loss is recommended throughout the treatment period. This may include looking for obvious signs of bleeding, e.g., hematomas, epistaxis, or hypotension,

testing for occult blood in the stool, checking serum hemoglobin for significant decrease, etc., especially if other factors/conditions that generally increase the risk of hemorrhage are also present. Bleeding of any type was observed at a rate of 18% per year in AF patients. Common adverse reactions with ELIQUIS were epistaxis (6.2%), contusion (5.0%), hematuria (3.7%), hematoma (2.6%), hemorrhage (including eye [2.3%], gastrointestinal [2.1%], rectal [1.6%] and other [1.7%]) and gingival bleeding (1.2%). Indications and clinical use: ELIQUIS is indicated for the prevention of stroke and systemic embolism in patients with atrial fibrillation. Not recommended in children. Contraindications: • Clinically significant active bleeding, including gastrointestinal bleeding • Lesions or conditions at increased risk of clinically significant bleeding

Pﬁzer Canada Inc., Kirkland, Quebec H9J 2M5 Bristol-Myers Squibb Canada Co., Montreal, Quebec H4S 0A4 ELIQUIS and the ELIQUIS wave design are registered trademarks of Bristol-Myers Squibb Company used under license by Bristol-Myers Squibb Canada Co.

• Hepatic disease associated with coagulopathy and clinically relevant bleeding risk • Concomitant systemic treatment with strong inhibitors of both CYP3A4 and P-glycoprotein • Concomitant treatment with any other anticoagulant including unfractionated heparin, except at doses used to maintain a patent central venous or arterial catheter, low molecular weight heparins, such as enoxaparin and dalteparin, heparin derivatives, such as fondaparinux, and oral anticoagulants, such as warfarin, dabigatran, rivaroxaban, except under circumstances of switching therapy to or from apixaban Most serious warnings and precautions: • Bleeding: if severe, discontinue • Peri-operative spinal/epidural anesthesia, lumbar puncture: increased risk of hematoma • INR monitoring: not a valid measure to assess anticoagulant activity of ELIQUIS • Premature discontinuation: increases risk of thrombotic events

ELIQUIS was demonstrated to be SUPERIOR to warfarin for the following key study endpoints:2,3† Primary efﬁcacy endpoint: COMBINED STROKE AND SYSTEMIC EMBOLISM 1.27%/year vs. warfarin 1.60%/year; HR 0.79, 95% CI: 0.66-0.95, p=0.0114 • For systemic embolism: HR 0.87, 95% CI: 0.44-1.75

Primary safety endpoint: MAJOR BLEEDING‡ 2.13%/year vs. warfarin 3.09%/year; HR 0.69, 95% CI: 0.60-0.80, p<0.0001

Secondary endpoint: ALL-CAUSE MORTALITY§ 3.52%/year vs. warfarin 3.94%/year; HR 0.89, 95% CI: 0.80-1.00, p=0.047

For more information: Please consult the Product Monograph at https://www. bms.com/assets/bms/ca/documents/productmonograph/ELIQUIS_EN_PM.pdf or http://pﬁzer.ca/pm/en/ eliquis.pdf for important information relating to

adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-866-463-6267. NOAC = non-vitamin K antagonist oral anticoagulant, RRR = relative risk reduction, HR = hazard ratio, CI = confidence interval * Comparative clinical significance unknown. † Randomized, double-blind, parallel-arm, non-inferiority trial in 18,201 patients with nonvalvular, persistent, paroxysmal, or permanent atrial fibrillation or atrial flutter and ≥1 of the following additional risk factors: prior stroke, transient ischemic attack or systemic embolism, age ≥75 years, arterial hypertension requiring treatment, diabetes mellitus, heart failure (NYHA Class ≥2), decreased left ventricular ejection fraction. Patients received apixaban 5 mg BID (n=9,120; 2.5 mg BID in a subset of patients with ≥2 of the following criteria: ≥80 years, body weight ≤60 kg, or a serum creatinine level ≥133 µmol/L) or warfarin (n=9,081) at a target INR range of 2.0-3.0 for a median of 90 weeks for apixaban and 88 weeks for warfarin. The median time in therapeutic range for subjects randomized to warfarin, excluding the first 7 days of the study and excluding warfarin interruptions, was 66%. The primary objective of the study was to determine if apixaban was non-inferior to warfarin for the prevention of total stroke (ischemic, hemorrhagic, or unspecified) and systemic embolism. Key study outcomes were assessed by sequential testing strategy for superiority designed to control the overall type I error in the trial. The intention-to-treat (ITT) population was used for efficacy outcome testing, the on-treatment population for safety outcomes.

31% RRR

11% RRR

‡ Major bleeding was defined as clinically overt bleeding accompanied by a decrease in the hemoglobin level of ≥2 g/dL or transfusion of ≥2 units of packed red cells, occurring at a critical site, or resulting in death.2 Dataset includes events occurring on-treatment plus the following two days. Concomitant aspirin use with either ELIQUIS or warfarin increased the risk of major bleeding 1.5 to 2 times when compared with those patients not treated with concomitant aspirin. ELIQUIS should be used with caution in patients treated concomitantly with antiplatelet agents. § ELIQUIS is not indicated to reduce all-cause mortality. References: 1. IMS Brogan, Compuscript, January 2018. 2. ELIQUIS Product Monograph. Pfizer Canada Inc. and Bristol-Myers Squibb Canada. April 11, 2018. 3. Granger CB et al; for the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365:981-92.

PP-ELI-CAN-0173-EN

Other relevant warnings and precautions: • Caution when used with drugs that affect hemostasis • Not recommended in patients with prosthetic heart valves or with hemodynamically signiﬁcant rheumatic heart disease, especially mitral stenosis • Avoid use with strong inducers of both CYP3A4 and P-gp • Caution in patients with mild or moderate hepatic impairment (not recommended if severe) or elevated liver enzymes • Pre-operative/post-operative considerations • Renal impairment: not recommended if creatinine clearance <15 mL/min or dialysis; dosing adjustments may be required; renal function should be monitored • Not recommended in pregnant or nursing women

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Pharmacy Practice+ and Profession Sante 2018 / The Medical Post and Profession Sante 2018 – Survey on OTC Counselling and Recommendations Klein-Schwartz W. Toxicity of polysaccharide-iron complex exposures reported to poison control centers. Ann Pharmacother. 2000 Feb;34(2):165-9. Merriman, Todd N: An acute oral toxicity study in rats with polysaccharide iron complex – Final Report. Springborn Laboratories Inc., Spencerville Ohio, 1994,1-40 Calculated for an average 60 kg woman at 2-3 mg/kg/day Anemia Guidelines for Family Medicine (Toronto: MUMS Guidelines, 2014); 8. www.statcan.gc.ca/pub/82-003-x/2011003/article/11533/tbl/tbl1-eng.htm Mean height, weight, body mass index (BMI) and prevalence of obesity, by collection method and sex, household population aged 18 to 79, Canada, 2008, 2007 to 2009, and 2005. November 7, 2016. 6. BioSyent Inc. data on file

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SOLVE MY PROBLEM

How do you incentivize staff? MONTHLY GIFT CARDS

I have found that a gift card (from places such as Starbucks, Tim Hortons or the Keg) is always appreciated. You can set monthly goals and whoever reaches or surpasses them gets the monthly prize. Sort of like an employee of the month club but the prize is a gift card for stuff they will really use. It’s a low-cost way to lift spirits and set goals. —DR. DAN COHEN

PAY OVERTIME IF YOU NEED AN EXTRA OFFICE DAY

I find the best way is to create a favourable work environment—one where employees enjoy or at least don’t mind coming to work in the morning. I try to do this in several ways: 1. Deal with problems/issues promptly. Don’t let them fester. 2. Take the staff out to dinner regularly (every month or two). It’s a way of saying thank you. 3. Don’t be afraid to pick their brains. They may have ideas on how to improve your practice. Plus they feel involved and their work validated. 4. When the work piles up and you need to book an extra office day (say in the evening or on the weekend), give the staff the option to work it (at overtime rates). It’s beneficial for both parties. —DR. MICHAEL SIMON

TREAT THEM AS PART OF THE TEAM

Your staff are the window of your practice. They are the interface between “outside” and the doctor. Your staff face the same hassles as do you: unhappy patients, sick patients, no time. You and your staff are a team together. If you treat them as part of a team (with you) aimed at patient satisfaction, they will not look for the next incentive. They need to enjoy their work as much as you do. Incentives are the icing, not the cake. If you do not enjoy your own job, you cannot expect your staff to enjoy theirs and your patients will suffer.—DR. SELBY FRANK

DR. DAN COHEN An FP in Toronto who also does surgical assisting.

In the end, the best motivation can’t be bought—it comes from within! —DR. JESSE WHEELER

Next Problem DR. MICHAEL SIMON An FP in Saint John, N.B.

EXPRESS DAILY GRATITUDE

I accidentally told my friend about a well-known patient I saw. What should I do? Send solutions to cleslie@ensembleIQ.com by Sept. 25.

I would venture to suggest that it isn’t about “incentive” at all. Anyone, in any field, does best when they do work that gives them a sense of meaning, a sense of autonomy, and a healthy, daily, ongoing dose of gratitude. So here are my tips: • Spot your staff members’ strengths, and be sure to highlight it to them when you see their strengths in action. • Teach them and help them feel a sense of personal growth. • Express your gratitude for the little things they do that make your life and the lives of your patients easier. • Laugh together. Maybe even cry together. Vulnerability

is a catalyst of connection. • Notice the little things that tend to go unnoticed, and appreciate those things. What you focus on will grow. • And share stories with them of how the hard work they do ripples through your practice, and the lives of your shared patients.

DR. SELBY FRANK A semi-retired FP in Terrace, B.C.

DR. JESSE WHEELER An FP in Peterborough, Ont.

THE MEDICAL POST SEPTEMBER 2018 49

HUMOUR

Advanced Theatrical Life Support 101 Your introduction to the tried-and-true formula for resuscitating an action star BY DR. STEPHEN STARR

elcome to ATLS: Advanced Theatrical Life Support. By registering for this course you have already demonstrated that you are a caring healer, and that you probably have an idea for a screenplay you’re looking to peddle. The principles of Advanced Theatrical Life Support are the same as in Advanced Trauma Life Support: The ABCDEs. However, each letter stands for something completely different so, I guess it’s not really the same at all.

50 SEPTEMBER 2018 THE MEDICAL POST

Providers must adjust their approach when treating thespian patients. For example, in standard practice, “A” stands for “airway and cervical spine protection.” However, in this course, “A” stands for “awake.” It is axiomatic that a person will not die as long as they stay conscious. This can be achieved by shaking the patient and shouting, “Stay with me!” If violent shaking doesn’t work, proceed to slap the patient. One should, of course, continue yelling at the patient, ideally alternating slapping and yelling.

For example: (Forehand slap) “Don’t…” (backhand slap) “…you…” (forehand slap) “…dare…” (backhand slap) “… leave…” (forehand slap) “…me!” If there is still no response, the next step is for you, the rescuer, to beat your fists against the patient’s chest while swearing. “Goddamn you! Goddamn you! Don’t you dare leave me!” Studies have shown that the beating should progressively slow to a few feeble, desperate thumps followed by slumping and resting your forehead on the patient’s chest and weeping inconsolably. Should the patient awaken at any point, you may proceed to “B.” In other circumstances, “B” might signify “breathing.” However, for our purposes, “B” stands for “bullet.” If the patient has been shot, the bullet must be removed immediately by any means necessary. If you are practising in a tertiary care centre, the optimal treatment is to miniaturize a medical crew and submarine and inject them into the patient’s bloodstream to repair damaged tissue with a laser. If you are practising in the periphery, attempt to contact a crooked veterinarian, or break into a pharmacy to obtain supplies. If these options are unavailable, douse the wound with alcohol, urine or some other caustic substance, and use any grasping instrument at hand (a pair of pliers will do). Blindly probe the wound and extract the projectile. Once the bullet rattles in the pan (there is always a pan—they are included in the pliers package), you can be assured that your patient will be up and plotting their revenge in the next scene. In other courses, “C” stands for “circulation” and reminds practitioners to staunch bleeding. However, in today’s class, “C” stands for “close up.” This is to remind you that care must be provided not to the patient who needs it most, but to the patient who deserves it most. Participants may be familiar with the “Black, Red, Yellow, Green” system for triaging mass casualties. In Advanced Theatrical Life Support, the only colour that matters is “Gold”, as in box office receipts. The rescuer must attend to,

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and indeed, spend all their time with the lead actor. Before we move on, it is also important to clarify the definition of “shock.” In non-cinematic circumstances, shock may be hypovolemic, cardiogenic, obstructive or distributive. In theatre, “shock” is only emotional. It is generally caused by betrayal, a distressing telegram, or witnessing a gangland execution. Theatrical shock is a clinical diagnosis marked by staring into middle space, staggering, fainting or weeping. This is a true theatrical emergency. Treat immediately by slapping, shaking or throwing water into the patient’s face. “C” is also for “concussion.” It is vital to have a proper approach to the head-injured patient. Thespian patients may get “knocked out” by a judo-chop to the neck, a punch to the jaw, or after being clubbed across the occiput by an ashtray or a brick. In non-cinematic settings, these injuries usually result in depressed skull fractures, intracranial bleeding and uncal herniation of the brain—invariably requiring intubation, Mannitol, several weeks in the ICU, and months if not years of painful rehabilitation and retraining. However, private investigators, undercover cops and framed innocents who are trying to clear their names have no time for such coddling. The head-injured thespian will always wake up after 30 to 60 minutes, depending on what the plot demands. They will rub their “achin’ noggin” and ask, “Wh-where am I? W-what happened?” You should tell them that the witness, enamelled statuette, or microfilm is now in the hands of their assailant and that they said something about an abandoned warehouse down by the wharf. You should inform your patient that it’s too dangerous for them to pursue their quarry at this point from both a medical and logistical standpoint. Do not attempt to restrain the patient. They are almost certainly going after the bastard whether you like it or not. You might suggest backup, but expect them to refuse; after all, there is no time. At this point, standard practice demands that you extract a shotgun from your emergency kit, pump it with one hand,

“Theatrical shock is a clinical diagnosis marked by staring into middle space, staggering, fainting or weeping.”

and declare, “In that case, you’re gonna need my help!” Now, in other courses, “D” stands for “disability,” but in our course, “D” stands for “drag.” If you come across a road accident, the victim must be dragged a safe distance from the crumpled vehicle before it explodes. There is no time to worry about cervical spine protection or a backboard—that thing is gonna blow! “E” is for “exposure,” as in other resuscitation courses. However, here it refers to “exposure” in terms of publicity. How many times do we have to tell you? Treat the star! If you’re on set of Mission Impossible, you get that bullet out of Tom Cruise’s arm. Nobody cares about Simon Pegg’s leg amputation. Stop looking at Pegg. Let him scream. Take care of Mr. Cruise. “F” is for fluids. Proper fluid replacement is essential for a successful resuscitation. If you are dealing with an injured soldier, you must prop the GI up against a rock or the ruins of a wall and give him a swig of water from a rusty canteen. Important practice pearl: If your patient is being treated anywhere west of the Mississippi River circa 1901, they will only respond to whiskey. Other courses aim for ROSC (return of spontaneous circulation) as an indication of successful resuscitation. If you have followed all of these steps correctly in Advanced Theatrical

Life Support, your success will be determined further along in our alphabetic mnemonic. A competent rescuer will be out of the proverbial woods when they reach “S.” “S” may refer to suturing, which is performed while the patient is sitting on the edge of the back of an ambulance. This is the best time to close a wound, as the field of interest will be illuminated by flashing red emergency beacons. The rescuer should position themselves to the side of the patient to allow the approach of the inquisitive press followed by a gruff but affectionate commanding officer. “I should bust you down to buck private/meter maid,” they’ll say before promoting them. Rescuers should expect the patient to stand up, pull away from their needle driver, and brush past the press and the chief when they see their love interest. All you can do is shrug in the unfocused background. At this point, you might presume that “S” signifies “success,” but you’d be wrong. A cinematic resuscitation can only be judged effective in retrospect— when “S” stands for “sequel.” MP is a family physician who does rural locums. His home base is aisle six, seat E of the Cineplex Odeon in Victoria, B.C. where he pursues CME (Continuing Movie Education).

DR. STEPHEN STARR

THE MEDICAL POST SEPTEMBER 2018 51

At Week 12, TactuPump® FORTE demonstrated superior reductions in acne lesion counts vs. vehicle in patients with moderate and severe acne. • Mean reduction (and percent change—2° endpoint) in inflammatory lesions for TactuPump FORTE and vehicle: 27.8 (68.7%)* and 13.2 (39.2%), respectively. ®

• Mean reduction (and percent change—2° endpoint) in noninflammatory lesions for TactuPump FORTE and vehicle: 40.5 (68.3%)* and 19.7 (37.4%), respectively. ®

* p<0.001 vs. vehicle. Missing data was imputed using multiple imputation methodology, ITT population.

TactuPump® FORTE may also be considered for those patients who have moderate and severe acne vulgaris, who may have risk factors that worsen acne prognosis such as tendency toward cyclical relapses, pre-pubertal onset or long term history of acne, positive family/genetic history, those prone to or at risk for scarring, and those who may have intolerance or contraindication to systemic treatment. Clinical surveillance of these patients is recommended to ensure sufficient therapeutic response. Safety and effectiveness have not been established in geriatric patients (≥65 years). Contraindications: • Application to areas of skin affected by eczema or seborrheic dermatitis • Patients who are hypersensitive to adapalene, benzoyl peroxide or to any ingredient in the formulation or component of the container Most serious warnings and precautions: • For external use only, not for ophthalmic use • Should not be used by pregnant women: use only after contraceptive counselling in women of childbearing age Other relevant warnings and precautions: • Discontinue use if allergic/hypersensitivity reactions occur • Avoid contact with eyes, lips, angles of the nose, mucous membranes, abraded skin, open wounds, eczematous and sunburned skin • May bleach hair and coloured fabric; caution when applying near hairline

52 SEPTEMBER 2018 THE MEDICAL POST

• Not recommended with concomitant topical acne therapy or potentially irritating topical products • Avoid electrolysis, “waxing” and chemical depilatories for hair removal on skin treated with TactuPump® FORTE • Patients should be advised to use non-comedogenic cosmetics • Certain cutaneous signs and symptoms can be expected with use • Avoid excessive sunlight, including sunlamps (avoid exposure or use protection, avoid sunburned skin); weather extremes, such as wind or cold, may be irritating • Caution in nursing women For more information: Please consult the TactuPump® FORTE product monograph at https://www.nestleskinhealth.com/ sites/g/files/jcdfhc196/files/inline-files/TactuPump_TactuPump-Forte-PM-E.pdf for important information relating to adverse reactions, interactions and dosing information, which have not been discussed in this advertisement. The Product Monograph is also available by calling us at 1-800-467-2081. Study design: A multicentre, randomized, double-blind, parallel-group, active- and vehicle-controlled, 12-week study, comparing once-daily application of TactuPump® FORTE (n=217), TactuPump® (n=217) or vehicle gel (n=69) in moderate and severe acne patients 12 years of age and older. The co-primary endpoints were success rate defined as “Clear” or “Almost Clear” with at least 2-grade improvement in IGA (Investigator’s Global Assessment) score and mean absolute change from baseline at week 12 in both inflammatory and noninflammatory lesions. Reference: 1. TactuPump® FORTE Product Monograph, Galderma Canada Inc., May 19, 2017. ©2018 Galderma Canada Inc. TactuPump® FORTE is a registered trademark of Galderma Canada Inc.

2214-0518E

Indication and clinical use: TactuPump® FORTE (adapalene 0.3%/benzoyl peroxide 2.5%) Topical Gel is indicated for the treatment of moderate and severe acne vulgaris, characterized by comedones, inflammatory papules/pustules with or without occasional nodules in patients 12 years of age and older.

BACK PAGES

BOOKS

Medical pains

Dr. Frank Warsh’s memoir, The Flame Broiled Doctor, paints a funny, compassionate and relatable picture of life as a Canadian doctor BY TRISTAN BRONCA

I B:11.125”

T:10.75”

S:10.25”

have a bit of a confession: After working at the Medical Post for nearly five years, I don’t actually know what the average doctor—to whatever extent these things can be “averaged”—does every day. I have an idea, sure. I’ve talked to perhaps hundreds of them (you). I’ve visited offices, sat in on consultations, and tagged along on home visits. I know there are long stretches of drudgery after hours, forms to be filled out, and tons of other odd jobs that no one who’s never run a clinic would ever think of. I’ve reported on problems with regulators, administrators, and unruly patients but the fact is, I don’t really know what it’s like to deal with any of them. I mention this because in the time I’ve covered this profession, the closest I think I’ve ever come to really getting it was reading a book; namely, Dr. Frank Warsh’s memoir, The Flame Broiled Doctor. Dr. Warsh is an investigating coroner and former family doctor who now lives in London, Ont. He’s also a friend of the Medical Post (which is why I’ll make no attempt to hide my bias in this review). His articles are always thoughtful and profane. His is a voice that will resonate with any Canadian doctor who has ever been sold a spoonful of crap and told it was caviar. This book is further evidence of Dr. Warsh’s skill as a storyteller. Over some 200-odd pages, it’s an effortless

and constantly entertaining read. It begins with his boyhood reflections on his career choice and quickly moves into the early intimations that maybe medicine might not be right for him: From the debilitating stomach pains he suffered under the stresses of medical school, to the dressing-downs he received from his preceptors about his bedside manner. Still, there are at least a few reasons he stuck with medicine, about which Dr. Warsh is refreshingly honest. Being a self-professed wiseass, he has no qualms admitting one thing he’ll really miss about daily practice is the stories. They almost invariably make the doctor the most interesting person at a cocktail party. The book hosts a cast of aptly named characters such as Dr. Rolex, “whose watch came courtesy of a drug company, back when that sort of thing still happened”; Philosopher Phil, “a chap with alcoholic dementia”; and Mr. Johnson, whose “foreskin problem” will haunt my dreams for a very long time. These stories, I imagine, make up a good chunk of Dr. Warsh’s cocktail party fodder, but they also illuminate corners of medicine that would otherwise remain invisible to outsiders (I, for one, had no idea why orthopedic surgeons incurred higher malpractice fees before, nor would I have cared until Dr. Warsh made me realize it could one day affect my chances of getting a

surgery that would bring me desperately needed relief). But interspersed in these are other stories. These are the heavier ones. The ones that lead to career-shaping insights. The ones that expose the unrelenting burdens that turn healthy doctors into the flame-broiled kind. There are many of these moments in the book but to avoid spoiling the others, I’ll only mention one: Erica. Erica was a hypochondriac and one of the final patients Dr. Warsh saw in family practice before he ultimately left. In her final visit, she walked in with a stack of tests she wanted Dr. Warsh to have another look at, then utterly berated him for being condescending and dismissive in the years he treated her. Dr. Warsh understood she was dealing with a pretty distressing sense of abandonment at his leaving. He had been expecting the outburst. It was in this moment that an unusual thought occurred to Dr. Warsh: This is what it means for a doctor to play god. He was clear he wasn’t talking about the all-knowing, all-powerful man in the sky who decides who lives and dies, but more like a primitive god, possessed of the same human weaknesses, but whose vain or vengeful decisions in that moment could make a massive difference in another’s life. If he documented the visit in a way to make himself look good, he knew no one would believe Erica’s word over his. If he referred her to a “cold-hearted prick” instead of a “kind and sweet” consultant, as many doctors might feel she deserved, that would be his prerogative (for the record, he did not). “It was a power I had no interest in wielding ever again,” Dr. Warsh wrote. I may not know much about the practice of medicine, but it seems like every good doctor possess that kind of awareness. It never garners any applause or recongition, yet it can alter or inform any decision. And it’s precisely this awareness that makes these doctors uniquely vulnerable to the stresses that burn at them day after day. MP TRISTAN BRONCA

the Medical Post.

is the associate editor of

THE MEDICAL POST SEPTEMBER 2018 53

BACK PAGES

“It is important to talk about mistakes. We’re human and we work in a complex, challenging, dynamic environment,” said Dr. Shaw.

PRACTICE MANAGEMENT

What to do when you make a mistake All physicians make honest mistakes, so we spoke to a few of them about the healthiest ways to move forward BY ABIGAIL CUKIER

Dr.

Susan Shaw was once part of a team working to improve the treatment of sepsis in the ICU at Royal University Hospital in Saskatoon. The team assembled response kits filled with antibiotics that would be ready to give to patients immediately upon identification of sepsis. But using the kit meant bypassing the pharmacy—including its checks for proper dosing and records of patient allergies. “I used the kit without checking if the patient was allergic,” said Dr. Shaw, who is now chief medical officer for the Saskatchewan Health Authority. “The

54 SEPTEMBER 2018 THE MEDICAL POST

patient had an allergy to the antibiotic documented in her previous record but she was too sick to tell us. Luckily, she did not have an anaphylactic reaction.” “I felt horrible. I made sure the patient was OK. I told the family that I had made a mistake and that we were looking at how to improve our process. The family thanked me.” Dr. Shaw said she often thinks about that mistake, and how hard it would be to talk about if they didn’t revisit how it happened. The incident led to discussions on when to use the sepsis response kit. The team decided it would only be used when the pharmacy was not available.

According to the Canadian Medical Protective Association (CMPA), every physician in Canada is likely to be affected by a medico-legal issue at some point. About 2% of physicians are named in a legal action each year. “Far more are involved in a variety of other medicolegal difficulties,” it said in a publication on the CMPA website. “Patients or other parties may complain about a physician to a regulatory authority, hospital, privacy commissioner, or to the Human Rights Commission. Physicians could face college disciplinary hearings or have their practice reviewed... On occasion, criminal accusations are lodged against a physician.” Diagnostic error accounts for about one-third of legal cases. In almost half the cases of delayed, missed or wrong diagnosis, expert criticism centred on patient assessment. This could include inadequate review of medical records, failure to obtain an adequate patient or family history, inadequate physical examination or failure to include all relevant differential diagnoses. It may also include a failure to consult or refer to another healthcare professional. In more than one-third of cases, experts identified that there was a failure to or delay in ordering appropriate testing. Patient handover is another area vulnerable to error. For example, a 2012 report by the Joint Commission in the United States focusing on transitions of care estimated that 80% of medical errors involve miscommunication between healthcare providers during handoff. One in six patients hospitalized in Canada are due to a preventable, drugrelated morbidity. Of these cases, 8% are mild, 84% are moderate, 7% are severe, and 1% are fatal, according to another report, Patient Safety in Primary Care by the Canadian Patient Safety Institute and the B.C. Patient Safety and Quality Council. Causes included incorrect diagnosis, adverse drug interactions or allergies, improper drug selection,

Getty Images

A BREAKDOWN OF MISTAKES

BACK PAGES

“We’re human and we work in a complex, challenging, dynamic environment.”

incorrect prescription interpretation by the pharmacist, lack of patient adherence and inappropriate prescribing to older patients. Physicians may also make administrative or billing mistakes, including inadequate, missing or illegible record keeping, or adding information to the wrong chart. A doctor seeing a patient outside of their office, such as at a walk-in clinic or nursing home, may miss getting all of a patient’s demographic or health insurance information. So, what should a physician do after making a mistake?

ADVICE FOR MOVING ON

Dr. John Crosby, a family doctor in Cambridge, Ont., has served as a legal expert in many cases involving physician malpractice and college complaints. He said almost every one involved miscommunication between the doctor and patient. He recommended that physicians ensure patients understand what was discussed, talk slowly without using jargon, and inform patients of possible symptoms of illness or side-effects of treatment. “Advise patients to call you or go to the ER if this happens—and document this conversation in your notes,” he said. If you do make a mistake, Dr. Crosby said to apologize and tell the patient how you are going to make

things better. Dr. Rob Robson, principal adviser of Healthcare System Safety and Accountability Canada, agreed. “If something has happened, acknowledge it and take responsibility,” said Dr. Robson. “Patients are under standing and if we are honest, they are surprisingly willing to listen and work things out.”1 1 Dr. Robson, who served as chief patient safety officer at the Winnipeg Regional Health Authority, is also part of an international group of researchers involved in the Resilient Healthcare Network. There, he’s studying characteristics of healthcare teams that respond well when things go wrong. “Care is usually good and safe,” he said. “A small percentage of the time, there will be an adverse event but the people providing care are working under the same circumstances as when the care is good and safe. We need to pay significant attention to how it’s possible that things go wrong despite things being the same.”

Dr. Crosby remembers treating a patient for depression for three years. “He was commuting to Toronto and I thought (that’s why) he was stressed out,” Dr. Crosby remembered. “One day, he told me everyone in his family had thyroid issues. It turned out, it was his thyroid. I apologized and told him I’d missed it and I would get him on thyroid replacement. He did not hold it against me; he is still my patient 26 years later.”

Dr. Crosby also said doctors who have made a mistake that leads to an adverse event or a complaint should contact the CMPA for advice. He also warned to never alter a chart. “With electronic charts, they can be tracked to see if you have changed a previous note or lab result,” he said. Perhaps most importantly, Dr. Crosby said after a mistake, physicians need to change processes to prevent errors in the future. For example, he said family doctors in Cambridge used to have a lot of small on-call groups until they met and decided to share in a bigger group. Now, for more than two decades, more than 60 doctors have been part of the group. They’re on call far less frequently, which helps address the fatigue that can lead to errors. “Many mistakes are caught before they hit the patient,” said Dr. Shaw in Saskatoon. “You have to be the type of person who people can approach. Part of how you practise good medicine is working well with others and encouraging them to look out for you and saying, ‘If you see me doing something I shouldn’t, please tell me.’” And don’t endure mistakes alone. “We can beat ourselves up and hurt ourselves. But then we would miss the learning opportunity,” said Dr. Shaw. “If we don’t work in a learning system, it will happen again and again. It is part of our professional duty to discuss what happened and why.” MP

THE MEDICAL POST SEPTEMBER 2018 55

INTRODUCING SHINGRIX

HELP PROTECT YOUR PATIENTS AGED 50+ FROM SHINGLES 1

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SHINGRIX demonstrated >90% efficacy in all age groups studied vs. placebo1* Age

SHINGRIX (n/N)

Placebo (n/N)

50–59

3/3,492

87/3,525

60–69

2/2,141

75/2,166

70–79

19/6,468

216/6,554

≥80

6/1,782

68/1,792

% Efficacy (95% CI)

Data from ZOE-50†

Pooled data from ZOE-50 and ZOE-70†

SHINGRIX is indicated for prevention of herpes zoster (HZ, or shingles) in adults 50 years of age or older.1

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96.6%

(89.6, 99.4)

97.4%

(90.1, 99.7)

91.3%

(86.0, 94.9)

91.4%

(80.2, 97.0)

Most serious warnings and precautions: • Administration: Do not administer the vaccine intravascularly, intradermally or subcutaneously Other relevant warnings and precautions: • A protective immune response may not be elicited in all vaccinees • Not for prevention of primary varicella infection or treatment of HZ or postherpetic neuralgia • Postpone in those with acute severe febrile illness • Use with caution in those with thrombocytopenia or any coagulation disorder • Syncope following or before any vaccination as a psychogenic response • Use in special populations such as pregnant or nursing women or pediatrics (<18 years of age) has not been established • Limited data in immunocompromised adults 50 years of age or older

Adverse events: • Solicited local and general adverse reactions that occurred in clinical trials within 7 days of vaccination in subjects aged 50–69 and ≥70 years respectively were: pain (85.6%, 69.2%), redness (38.5%, 37.7%), swelling at the injection site (28.5%, 23.0%), myalgia (53.0%, 35.1%), fatigue (51.3%, 36.6%), headache (45.2%, 29.0%), shivering (33.1%, 19.5%), fever (25.9%, 14.3%), gastrointestinal symptoms (20.5%, 13.5%) • Unsolicited adverse reactions that occurred in clinical trials within 30 days of vaccination in ≥1% of subjects and ≥2-fold higher than placebo recipients included chills (3.5%), injection site pruritus (2.2%), and malaise (1.7%) For more information Please consult the product monograph at gsk.ca/ SHINGRIX/PM for important information relating to dosing and administration, adverse reactions, contraindications and drug interactions which have not been discussed in this piece. To request a product monograph, or to report an adverse event please call 1-800-387-7374.

* Two multi-centre, randomized, observer-blind, placebo-controlled trials in subjects 50 years of age and older who received two doses of SHINGRIX (n=14,645) or placebo (n=14,660) at 0 and 2 months. Primary efficacy analysis was of the Modified Total Vaccinated Cohort (mTVC): all subjects randomized who received a second dose of the vaccine and did not develop a confirmed case of shingles within one month after the second dose. Randomization was stratified by age in years: 50–59, 60–69, 70–79 and ≥80 in an 8:5:3:1 ratio (ZOE-50); 70–79, ≥80 in a 3:1 ratio (ZOE-70). Subjects were followed for the development of shingles for a median of 3.1 years (ZOE-50; range: 0–3.7 years) and 3.9 years (ZOE-70; range: 0–4.5 years). Primary endpoint was vaccine efficacy as measured by the reduction in herpes zoster risk. † Vaccine Efficacy (VE) adjusted by age strata and region. Reference: 1. SHINGRIX Product Monograph, GlaxoSmithKline Inc., October 13, 2017. Trademarks are owned by or licensed to the GSK group of companies. ©2018 GSK group of companies or its licensor.

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THE MEDICAL POST SEPTEMBER 2018 59

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is looking for family physician and/or specialist. Very busy front street location, modern office, full administrative support, best EMR, and very competitive split. Close to TTC/Viva with free parking lot. Relocate current practice or build from walk-in. Contact: Karen Tel. (416) 893-1472 karen@pureflowhealthcare.com www.pureflowhealthcare.com

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BACK PAGES

PICTURE YOURSELF

The end of 25 years of Picture Yourself Debuting in the early 1990s, Picture Yourself quickly

caught on with readers. In its heyday, physicians went to extraordinary lengths—or heights and depths—to make an impression in the pages of the Medical Post. We’ve run pictures of doctors reading the Medical Post while

skydiving and reading underwater in a scuba suit. We wrapped the feature up when the Medical Post switched to its current regular magazine size at the beginning of the year. Here are the final submissions we’ll run that we still had in our image bank. MP

⊳ L ast autumn, North Bay, Ont. family physicians Drs. Barry Birosh, Derrick Yates, and Terena Lam embarked on a nine-day hike through the alpine villages and snowy mountain passes of the Alps. Here they’re pictured on top of Mont Blanc, the highest mountain in the Alps situated between France and Italy.

⊳ M eanwhile, on the other side of northern Italy, some of Western University’s medical class of 1985 reunited for a week-long hike through the Dolomite mountains, a UNESCO World Heritage Site.

THE MEDICAL POST SEPTEMBER 2018 61

BACK PAGES

How B.C. doctors once got a 40% fee hike Originally from the U.K., Dr. Euan Horniman lived to see his ideas about physician contract negotiations spread across Canada BY COLIN LESLIE IN THE MID-20TH century, faced with a

shortage of family doctors, provincial governments recruited heavily in Great Britain. They found a receptive audience. Many British GPs were unhappy with how the National Health Service (NHS) was being run and the top marginal tax rate in the U.K. was 83%. Among the flood of British-trained GPs who came was Dr. Euan Horniman, who arrived in B.C. in 1958 (all of this history comes from Dr. Brad Fritz’s great book The BCMA, Then and Now—you can get a PDF from the Doctors of BC website, go to the top left and click “Who We Are,” then “Our History” and scroll down.) Dr. Horniman was a character: By his own admission he could be “abrasive” and he often personally attacked those he didn’t agree with. He started the District 6 Newsletter and quickly used it to challenge the more established British Columbia Medical Association board members. He and his followers became known as the Reformers (so named by

62 SEPTEMBER 2018 THE MEDICAL POST

Dr. Horniman, who referred to his opponents as “the Establishment”). Dr. Horniman became concerned the method the BCMA was using to negotiate fee increases was inadequate when he showed fee increases were well short of average pay increases across all other sectors in the province. “He suggested sending all proposed fee agreements to the general membership for a vote, which he believed would serve as an excellent negotiating tool, as a failed referendum would give the negotiators (at that time executive director and CEO Dr. E.C. ‘Tim’ McCoy and the president of the association) ammunition to press for a better settlement,” wrote Dr. Fritz. “In addition, he pushed for the creation of a negotiating committee.” His proposal was passed at the association’s 1972 meeting in Penticton, along with a motion to use a professional negotiator. Though many of Dr. Horniman’s ideas spread across Canada and are now standard in every provincial medical

1 Dr. Jory and a few other big names in B.C. medico-politics—Drs. John O’Brien-Bell and Ken Hill—were all “Reformers” and early followers of Dr. Horniman. The fight between the Reformers and the Establishment party ran all the way to the CMA when in 1979 the BCMA nominated Dr. Jory to be president-elect of the CMA but the CMA elected Dr. Bill Thomas, a candidate identified with the Establishment Group, and the Reformers walked out of the CMA General Council en masse.

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association, it took several years in the 1970s for his ideas—even when passed at the AGM—to be implemented by the BCMA as the Reformers and the Establishment group instead fought what Dr. Fritz called “a fierce war” between each other. But “with the end of Prime Minister Pierre Trudeau’s wage and price controls in 1978, the BCMA’s leadership saw an opportunity to present a strong, unified front and make up lost ground,” wrote Dr. Fritz. By this time, the Reformers and the Establishment had grudgingly declared a truce and the BCMA engaged lawyer Ben Trevino as an outside expert to help in the 1981 negotiations. The negotiations went on awhile—the BCMA began asking for a 41% hike with the government offering 15%—but in the end the association achieved “a significant win” as Dr. Fritz put it. Significant indeed! The B.C. government agreed to a 40% increase in across-theboard fees for B.C. doctors in 1981. But the early 1980s were a tough financial time for Canada and B.C., and the province was soon trying to undo part of the increase. “When the U.S. market for new homes collapsed in 1983, resulting in markedly reduced royalties for the province from the forest industry, Health Minister Jim Nielsen told the BCMA that he would unilaterally move to cut the payment schedule by 10%,” wrote Dr. Fritz. Then BCMA president Dr. Bill Jory1 didn’t care for that. Instead of cutting fees, he proposed that B.C. doctors would instead make a one-time gift of $30 million to the government. This solution was accepted by then Premier Bill Bennett. MP

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