Issuu

OMA & OSA’s spat over overhead 12

FEBRUARY 2021

30 most powerful doctors in Canada 18

5 clinical pearls for antidepressants 40

Now part of

N AC I

recommendations1,2

Your patients aged 10–25 may be at risk for MenB – because they share2,3

NACI recommends that TRUMENBA may be considered as an option for individuals 10–25 years of age who are not at higher risk of meningococcal disease than the general population, in a 2-dose schedule (0 and 6 months), to reduce the risk of invasive serogroup B meningococcal disease.

Serogroup B: The most common cause of IMD in Canadian adolescents and young adults (2012–2016)5

Serogroup B

Because it is not part of routine programs, it is up to you to discuss vaccinating against MenB with your patients aged 10–251,4

63% 37%

All other serogroups

Consider TRUMENBA in your adolescent and young-adult patients at risk for MenB TRUMENBA is indicated for active immunization to prevent invasive meningococcal disease (IMD) caused by Neisseria meningitidis serogroup B bacteria (MenB) in individuals 10 through 25 years of age. Contraindications: • Hypersensitivity to this vaccine or any ingredient in the formulation or component of the container • Severe allergic reaction (e.g., anaphylaxis) after any previous dose of TRUMENBA or to any component of this vaccine Relevant warnings and precautions: • As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of a rare anaphylactic event following the administration of the vaccine. • As with other injectable vaccines, syncope (fainting) can occur in association with administration of TRUMENBA. Procedures should be in place to avoid injury from fainting. • Do not inject intravenously, intradermally, or subcutaneously. • As with any vaccine, TRUMENBA will not protect 100% of those who receive it. • As with any intramuscular vaccine, TRUMENBA should be given with caution to individuals with thrombocytopenia or any coagulation disorder or to those receiving anticoagulant therapy, unless the potential benefit clearly outweighs the risk of administration.

• There

are no data available for immunocompromised individuals, including those receiving immunosuppressant therapy. • Individuals with certain complement deficiencies and individuals receiving treatment that inhibits terminal complement activation (for example, eculizumab) are at increased risk for invasive disease caused by Neisseria meningitidis serogroup B even if they develop antibodies following vaccination with TRUMENBA. • There are no data from the use of TRUMENBA in pregnant women. TRUMENBA should be used during pregnancy only if the potential benefits clearly outweigh the potential risks. • It is unknown whether TRUMENBA is excreted in human milk. TRUMENBA should only be used during breast-feeding when the potential benefits outweigh the potential risks. For more information: Please consult the Product Monograph at www.pfizer.ca/pm/en/Trumenba.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 on request by calling 1-800-463-6001 (Pfizer Medical Information).

References: 1. An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). The use of bivalent factor H binding protein meningococcal serogroup B (MenB-fHBP) vaccine for the prevention of meningococcal B disease. Can Commun Dis Rep. December, 2019; 1–89. 2. TRUMENBA® Product Monograph. Pfizer Canada ULC. 3. Government of Canada. Invasive Meningococcal Disease. Available at: https://www.canada.ca/en/public-health/services/ immunization/vaccine-preventable-diseases/invasive-meningococcal-disease/health-professionals.html. Accessed on August 15, 2017. 4. Public Health Agency of Canada. Canada’s provincial and territorial routine (and catch-up) vaccination routine schedule programs for infants and children. Available at: https://www.canada.ca/en/public-health/services/provincial-territorial-immunization-information/provincial-territorial-routine-vaccination-programs-infants-children.html. 5. An Advisory Committee Statement (ACS). Summary of the NACI statement on the use of bivalent factor H binding protein meningococcal serogroup B (MenB-fHBP) vaccine for the prevention of meningococcal B disease. Can Commun Dis Rep. February, 2020;46(2/3):36–39.

PP-TRU-CAN-0062-EN

NACI = National Advisory Committee on Immunization

Contents UPFRONT

BACK PAGES

Editorial

Are women physicians gaining power?

Editor-in-chief Colin Leslie looks at the role of journalism in helping doctors

Rounds

Looking at off-label use of COVID vaccines and nonessential travel

NEWS

Q: What is your process for creating a cover like you’ll be doing for the Medical Post all this year? For me, 90% of the process is in my sketchbook. I do lots and lots of sketches. Then, I choose two or three ideas that work well and present them to the client. The client chooses one and then I produce the final illustration in colour.

5 clinical pearls for antidepressants

Two experts run down their best tips

A fight over a study to help with relativity underlines an old problem

FPs are being called on to help even more

The Power List

The Medical Post’s list of the 30 most powerful doctors

Getting advocacy right

Doctors have never had more tools to try and influence those in power

Welcome to the first issue of the Medical Post of 2021. As you probably can tell from our cover, each year we choose a different cover artist to create all our covers as we work through the six themes we’ll look at this year. Our 2021 cover artist is Benoit Tardif of Montreal. Q: How did you become a magazine illustrator? I fell in love with editorial illustration when I was studying graphic design at Université du Québec à Montréal. After my studies, I started to create illustrations mostly for magazines. Now I still work for magazines but I have clients in many different domains.

THEME

Welcome 2021 cover artist

While they are very slowly taking on more leadership roles, the roadblocks are ever-present

Accurate overhead

Cover: Benoit Tardif, Photo: Cindy Boyce

VOLUME 57 NO. 1

Mental health care and the virtual visit

Solve my problem

How do you respond professionally if a patient makes a really inappropriate comment?

Medical history

International Physicians for the Prevention of Nuclear War

Next Issue

Cyber issue: the theme of our next issue of the magazine,

coming out in mid-April. CORRECTION

In “The Medical Post’s favourite charities” in the October issue, we incorrectly stated that Médecins Sans Frontières is headed by a Canadian: Dr. Joanne Liu. In fact, her term has ended.

THE MEDICAL POST FEBRUARY 2021 3

14-DAY TREATMENT FOR IBS-D 1 tablet three times per day

ZAXINE is indicated for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults Consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use. The Product Monograph is also available by calling 1-844-587-4623.

Learn more - Visit ZAXINE.CA / Password: Zaxine123 Reference: 1. ZAXINE Product Monograph. Salix Pharmaceuticals, Inc., February 11, 2019.

LUP20-203 ENG

EDITORIAL

On social media and journalism Ponderings on the purpose of the press during a time of change I spent the holidays reading books

and thinking about the purpose of journalism. One book that stuck out is the classic Elements of Journalism by Bill Kovach and Tom Rosenstiel. They argue that ever since newspapers began a few hundred years ago, there are 10 things that are the core purposes of journalism. Here are five of them: • Journalism’s first obligation is to

the truth.

• Its first loyalty is to citizens.

(For us, that means to doctors.)

• It must serve as a monitor

for power.

• It must provide a forum for

public criticism and compromise. • Citizens have rights and responsibilities when it comes to the news as well—even more so as they become producers and editors themselves.

THE MEDICAL POST SENIOR VICE PRESIDENT, CANADA Donna Kerry dkerry@ensembleiq.com VICE PRESIDENT, EVENTS Michael Cronin mcronin@ensembleiq.com SENIOR DIRECTOR AUDIENCE STRATEGY Lina Trunina ltrunina@ensembleiq.com EDITOR-IN-CHIEF Colin Leslie cleslie@ensembleiq.com

MANAGING EDITOR Martha Porado mporado@ensembeiq.com SENIOR DIRECTOR, DIGITAL CANADA & SPECIAL PROJECTS Valerie White vwhite@ensembleiq.com VICE PRESIDENT, PRODUCTION Derek Estey destey@ensembleiq.com PRODUCTION MANAGER Lisette Pronovost lpronovost@ensembleiq.com

PHYSICIAN ADVISORY BOARD DR. GILLIAN ARSENAULT DR. MARIO ELIA community medicine family medicine DR. BENJAMIN BARANKIN DR. FERRUKH FARUQUI dermatology family medicine DR. MELANIE BECHARD DR. SARAH GILES pediatrics family medicine DR. ALI DAMJI DR. COURTNEY HOWARD family medicine emergency medicine

The rise of social media in the past 15 years definitely means that some of what traditional journalism used to do exclusively is now being done by a wider range of people. And some “citizen journalism” is done very well. Several of the doctors on our 2021 Power List (page 18), such as Dr. Jennifer Kwan, Dr. Isaac Bogoch and others, have done an amazing job providing information and context about the pandemic on Twitter. At the same time, some of what we might call traditional media does not serve any of the core purposes of journalism. How can one possibly think that the paparazzi journalism of the U.K.’s Daily Mail (and others) does? After my recent period of reflection, I—unsurprisingly—came to the conclusion that for the Medical Post we should renew our emphasis on the core purposes of journalism. Now does doing a list of the 30 most powerful doctors in Canada match with the

CREATIVE DIRECTOR Nancy Peterman npeterman@ensembleiq.com GRAPHIC DESIGNER Erin McPhee SALES BRAND DIRECTOR Martin Rissin mrissin@ensembleiq.com ACCOUNT MANAGER Norman Cook ncook@ensembleiq.com ACCOUNT MANAGER Scott Tweed stweed@ensembleiq.com

CLASSIFIEDS Nancy Dumont ndumont@ensembleiq.com SALES COORDINATOR Kalli Sagos ksagos@ensembleiq.com CORPORATE OFFICERS CHIEF EXECUTIVE OFFICER Jennifer Litterick CHIEF FINANCIAL OFFICER Jane Volland

CHIEF INNOVATION OFFICER Tanner Van Dusen CHIEF HUMAN RESOURCES OFFICER Ann Jadown EXECUTIVE VICE PRESIDENT, EVENTS & CONFERENCES Ed Several SENIOR VICE PRESIDENT, CONTENT Joe Territo

COLIN LESLIE EDITOR-IN-CHIEF

journalistic purpose of being a monitor for power? Well, you have to know who has power to monitor them! Also, a magazine is a service you’re always trying to improve. As well, I think our story “Accurate overhead” on page 12 does a great job of trying to provide “a forum for public criticism and compromise” on a tough issue: relativity. Lastly I do think the Medical Post does well at consistently keeping its “first loyalty” to our readers, Canada’s doctors. The only lens we use to decide what our journalists will cover is that the stories and issues be interesting, informative and relevant to our readers.

SUBSCRIPTION SERVICES Phone toll-free: 1-877-687-7321 Fax: 1-888-520-3608 between 9 a.m. to 5 p.m. EST weekdays Email: medicalpost@canadianhealthcarenetwork.ca Online: www.CanadianHealthcareNetwork.ca/subscribe Subscription prices (PRINT): 1 year: $65; 2 years: $120 Outside Canada: $100 per year; 2 years: $185 Single copy price: $12; Groups: $46 per year; Outside Canada single copy: $16 Subscription prices (DIGITAL): 1 year: $60; 2 years: $95 REPRINTS, PERMISSIONS AND LICENSING Please contact Wright’s Media Email: ensembleiq@wrightsmedia.com Phone: 1-877-652-5295

DR. ALAN KAPLAN family medicine DR. CHRISTINE NICHOLAS plastic surgury DR. BRIDGET REIDY family medicine DR. FRANCO RIZZUTI public health

DR. DUNCAN ROZARIO general surgery DR. DAVID SATOK family medicine DR. PUNEET SETH hospitalist DR. MIKE SIMON family medicine

DR. CHRISTOPHER SUN family medicine DR. HIROTAKA YAMASHIRO pediatrics

FIND US ONLINE

The Medical Post’s online home is CanadianHealthcareNetwork.ca. Registration is free and easy. Medical students and residents welcome.

@MedicalPost

Contents copyright © 2021 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: 2000 rue Peel, Bureau 760, Montréal, Quebec, H3A 2W5. Printed in Canada at Transcontinental Printing.

THE MEDICAL POST FEBRUARY 2021 5

G J K G The ﬁrst-ever combination acetaminophen + ibuprofen pain reliever available in Canada.

Indication1: COMBOGESIC® (acetaminophen 325 mg + ibuprofen 97.5 mg) is indicated in adults over 18 years for the short-term management of mild to moderate acute pain and the reduction of fever. For more information: Consult the Product Monograph at https://pdf.hres.ca/dpd_pm/00054759.PDF for important information regarding adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling BioSyent Pharma Inc. at 1-888-439-0013 or at combogesic.ca. Reference: 1. COMBOGESIC® Product Monograph. BioSyent Pharma Inc. ©2021 BioSyent Pharma Inc.

CO-2012-07

Combogesic.ca

Feedback Fairness of FFS vs. FHT payment questioned during pandemic

Fee-for-service fights on (Oct.) Dr. Perry Mayer of Hamilton argued that doctors working in capitated models such as Family Health Teams are getting a financial advantage over fee-for-service doctors during the pandemic. “The Ministry of Health didn’t tell docs to close their office, just work a blended practice of virtual and in-person care.” Dr. Mayer argued it can be done safely with PPE. “PPEs are the price of doing business and the FHT doctors have plenty of cash to pay for these items. The FFS docs should be the ones getting a break on those items. The FFS docs are going broke and (some) FHT capitated docs are still pulling in their full wages but are only working a partial week. . . . Patients are not getting appropriate access to their primary care physicians,

not ‘because of COVID,” but because the docs are not stepping up to the plate and making it happen.” PMHx: A tale of three serpents (Oct.) “Very interesting but I think this symbol may go back even further than 3,000 years,” wrote Dr. Edward Hillary of Surrey, B.C. “Some scholars assert that the Rod of Asclepius actually represents a parasitic worm coiled around a stick. In ancient times, people used to be commonly infected by parasitic worms like the guinea worm. The physicians treated them by piercing the skin and extracting the worms underneath by wrapping them on a rod or stick. The physicians are believed to have advertised this service by putting up the sign of a worm on a stick.”

“The ‘year of COVID’ has reminded us—in a rather harsh manner— that we do not practise medicine in a vacuum.”

richest lives now.” “When I began my career I took over the practice of another who wanted to slow down. He was 52 then. I took over the expenses and he stayed on for 10 years and helped cover our practice one or two half-days per week except when he wintered in Florida,” wrote Dr. Carlos Yu of Ajax, Ont. “So I had planned to retire when I got to 52. Well, here I am working more than ever and loving it. I have learned to be grateful and curiously open to possibilities.”

Thinking about instant retirement? Not so fast (Oct.) “While there are no easy answers to the difficult dilemma of deciding when to retire, I found two books helpful: Life after Medicine by Alan Roadburg and Die with Zero by Bill Perkins,” wrote Dr. Wayne Manishen of Winnipeg. “Ultimately, there is never a perfect time to retire. Once financial targets are within reach, identifying Roadburg’s retirement ‘pull and push factors’ and heeding Perkins’s advice against ‘over saving and under living’ are key lessons on living our

Editorial: The growth debate (Dec.) “The ‘year of COVID’ has reminded us—in a rather harsh manner—that we do not practicse medicine in a vacuum,” wrote Dr. Harry Zeit of Toronto. “As a recent editorial in The Lancet emphasized, we are dealing with a syndemic rather than a pandemic. That global crisis or syndemic will continue to challenge us (whether with pandemics, climate change, refugee crises, mental health issues) until we begin to address these larger issues. So yes, this piece is a welcome call to keep the larger picture in view. We can, I think, address these causal and contributory issues without being overwhelmed.”

THE MEDICAL POST FEBRUARY 2021 7

Rounds COVID-19

South Africa, India and the U.K.: top sources of IMGs BY COLIN LESLIE

International Medical Graduates (IMGs) make up just over one-quarter of licensed doctors in Canada. Saskatchewan has the largest proportion of internationally trained physicians (51%), while Quebec has the smallest (9%). Here are the top 10 countries of MD graduation for IMGs licensed in Canada, 2019: COUNTRY

FAMILY MEDICINE

South Africa India U.K. Ireland U.S. Egypt Pakistan Nigeria Iran Poland

1,911 1,021 1,057 840 590 693 595 519 405 296

SPECIALISTS

741 1,083 883 670 578 424 425 334 338 246

Source: Scott’s Medical Database, Canadian Institute for Health Information

8 FEBRUARY 2021 THE MEDICAL POST

We’re doing what? Going off-label on vaccines? Canadian doctors take pride in practising evidence-

based medicine, yet the race to administer COVID-19 vaccines has led to a straying from the evidence. Some question if this is wise. For example, outside of clinical trials, mRNA vaccines have never been tried on humans before. “We should not, therefore, lightly tamper with approved protocols that are based on rigorous experimentation,” wrote Dr. Alan Bernstein and colleagues in a Globe and Mail opinion piece. The changes include extending the time between doses, causing some to worry that the level of protection will be weaker than in clinical trials. People who believe themselves to be immune could have low levels of neutralizing antibodies, creating an environment where resistant variants could flourish, Dr. Bernstein and colleagues wrote. Doses should be administered 21 (Pfizer/ BioNTech) and 28 (Moderna) days apart, but the U.K. and Quebec will allow up to 90 days between doses. Canada’s National Advisory Committee on Immunization (NACI) does not give a maximum time between doses, but WHO recommends an extension of up to 42 days, a length seen in clinical trials. In contrast, the U.S. Food and Drug Administration said on Jan. 4 that changing dosing schedules at all is, “premature and not rooted solidly in the available evidence,” and without supporting data, “we run a significant risk of placing public health at risk.” Both vaccines provide protection with the first dose, leading NACI to recommend maximizing the number of first doses by delaying the second dose in the context of limited supply. NACI said that “principles of immunology, vaccine science and historical examples” show a delay between doses doesn’t result in lower antibody concentrations or a shorter duration of response later on. Still, there remain unknowns, such as how long protection from the first dose lasts.

Getty Images

VITALS

ROUNDS

AUSCULTATIONS

“Trying to secure blocks of votes to pass motions is not a modern way to deal with issues.”

“I have received the COVID-19 vaccine.” —Dr. Dalhia Chiche-More in a blog for the Medical Post. Simple words but one many doctors have been glad to say and tell their patients.

—Dr. Sohail Gandhi, past-president of the OMA, after OMA Council voted to cut the number of OMA doctor board members from 25 to eight and end OMA Council itself (It will be replaced with a Priority and Leadership Group with a max of 125 doctors)

“Some of us miraculously lead while working more than full-time and juggling family.” —Dr. Melissa Yuan-Innes in a column on page 36 about women doctors and leadership.

Source: All from CanadianHealthcareNetwork.ca, the online home of the Medical Post.

NACI also approves giving the vaccines to populations not included in trials—pregnant or breastfeeding women and immunocompromised people—in cases where the risk of getting COVID-19 outweighs the risk of possible complications from the vaccine. Straying from the evidence is usually a no-no, but when navigating vaccination protocols during a pandemic when vaccine supply is limited, we need to trust NACI to steer us down the most appropriate path. —KYLIE TAGGART

TRAVEL

Different definitions of ‘essential’ “I regret this non-essential travel and I’m sorry.”

So said Dr. Tom Stewart, who lost his job as CEO of the Niagara Health System and St. Joseph’s Health System, after taking a vacation in the Dominican Republic over the holidays.

He wasn’t alone. Dr. Paul Woods was fired as president and CEO of London Health Sciences Centre after it was reported that he’d travelled to the U.S. a number of times since March 2020 to see family. The federal government has been advising Canadians for nearly a year to avoid all “nonessential travel” but the truth is many Canadians were flying for vacations in the last part of last year. A CBC investigation reported on Jan. 16, 2021, that “Canadian air carriers operated more than 1,500 flights between Canada and 18 popular vacation destinations since Oct. 1, 2020.” The state of Hawaii tracks visitors entering and between Dec. 1, 2020 and Jan. 7, 2021 more than 4,000 Canadians entered the state. But as 2021 began the federal government moved to place more restrictions on travel: As well as the 14-day mandatory quarantine, air travelers who enter Canada must now show proof of a negative test result for COVID-19 taken within 72 hours of departure. Prime Minister Justin Trudeau said in a tweet: “Let me be very clear: Nobody should be taking a vacation abroad right now. If you’ve got one planned, cancel it.” He also indicated that “new measures” could be brought in without warning. —COLIN LESLIE

THE MEDICAL POST FEBRUARY 2021 9

RYBELSUS®—The first and only oral GLP-1 RA*

about

What is the mechanism of action of RYBELSUS ? RYBELSUS® contains the drug semaglutide that has 94% sequence homology to human GLP-1. It binds to the GLP-1 receptor and stimulates insulin secretion and lowers glucagon secretion in a glucose-dependent manner. RYBELSUS® has also been found to cause a delay in gastric emptying.1* ® †

How is RYBELSUS® absorbed?† RYBELSUS® is co-formulated with salcaprozate sodium (SNAC), which facilitates the absorption of semaglutide after oral administration. RYBELSUS® absorption predominantly occurs in the stomach† and is decreased if taken with food. The estimated absolute bioavailability of semaglutide is approximately 1% following oral administration.1 How did RYBELSUS® compare to Januvia® in terms of A1C reduction and weight change in the PIONEER 3 trial? RYBELSUS® (added to metformin ± sulfonylurea) demonstrated significantly greater A1C reduction compared to sitagliptin (added to metformin ± sulfonylurea) from baseline at 26 weeks (primary endpoint). RYBELSUS® was also associated with a significantly greater weight change (secondary endpoint). 2‡

BASELINE: 8.1%

-1.3%

-0.9%*

†

(p<0.0001 vs. JARDIANCE®)

RYBELSUS® 14 mg (n=411)

JARDIANCE® 25 mg (n=410)

Mean change in weight from baseline at week 26 versus Jardiance® (Both + Metformin)3

-1.3%*

BASELINE: 91.9 kg

MEAN CHANGE IN WEIGHT FROM BASELINE (KG)

What are the indications for RYBELSUS®? Pr RYBELSUS® (semaglutide tablets) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus:1 • as monotherapy when metformin is considered inappropriate due to intolerance or contraindications • in combination with other medicinal products for the treatment of diabetes (see clinical trials in the Product Monograph for patient populations and drug combinations tested)

Mean change from baseline in A1C at week 26 vs. Jardiance® (Both + Metformin)3

MEAN CHANGE IN A1C FROM BASELINE (%)

A quick summary of this option in the treatment of adult patients with type 2 diabetes

BASELINE: 91.3 kg

* vs.-3.7 kg -3.8* kg (p<0.01 JANUVIA®)

* (p=NS vs. JARDIANCE®)

RYBELSUS® 14 mg (n=411)

JARDIANCE® 25 mg (n=410)

Added to metformin

RYBELSUS is not indicated for weight reduction. ®

What were the results of the PIONEER 6 study? RYBELSUS® demonstrated no increased risk in MACE (defined as cardiovascular death, non-fatal myocardial infarction or non-fatal stroke), relative to placebo (both in combination with standard of care treatment), during the 16 month mean observation time. 4§ Treatment effect for the primary composite endpoint, MACE, and its components

Full analysis set

HAZARD RATIO RYBELSUS® PLACEBO (95% CI) N (%) N (%) 1591 1592 (100) (100) 0.79 (0.57-1.11)

61 (3.8)

76 (4.8)

Cardiovascular death

0.49 (0.27-0.92)

15 (0.9)

30 (1.9)

Non-fatal stroke

0.74 (0.35-1.57)

12 (0.8)

16 (1.0)

Non-fatal MI

1.18 (0.73-1.90)

37 (2.3)

31 (1.9)

Primary endpoint: MACE Components of MACE

Mean change from baseline in A1C at week 26 vs. Januvia®2 (All + Metformin ± sulfonylurea) - Primary Outcome

Mean change in weight from baseline at week 26 versus Januvia®2 (All + Metformin ± sulfonylurea)

-1.3%* -1.0%* -0.8%* * ( p<0.01 vs. JANUVIA®)

* ( p<0.01 vs. JANUVIA®)

RYBELSUS® RYBELSUS® JANUVIA® 14 mg (n=465) 7 mg (n=465) 100 mg (n=467)

-1.3%*

BASELINE: 91 kg BASELINE: 91 kg BASELINE: 91 kg

MEAN CHANGE IN WEIGHT FROM BASELINE (KG)

MEAN CHANGE IN A1C FROM BASELINE (%)

BASELINE: 8.3% BASELINE: 8.4% BASELINE: 8.3%

* (p<0.01 vs. JANUVIA®)

-3.1 kg* -2.2 kg* -0.6 kg * ( p<0.001 vs. JANUVIA®)

* ( p<0.001 vs. JANUVIA®)

0.2 FAVOURS RYBELSUS® 1

FAVOURS PLACEBO

Adapted from product monograph.

RYBELSUS® is not indicated for cardiovascular (MACE) reduction. RYBELSUS® RYBELSUS® JANUVIA® 14 mg (n=465) 7 mg (n=465) 100 mg (n=467)

Added to metformin with or without sulfonylurea

RYBELSUS is not indicated for weight reduction. ®

How did RYBELSUS® compare to Jardiance® in terms of A1C reduction and weight change in the PIONEER 2 open-label trial? RYBELSUS® (added to metformin) demonstrated significantly greater A1C reduction compared to Jardiance® (added to metformin) from baseline at 26 weeks (primary endpoint). It did not demonstrate superiority in weight change compared to Jardiance® (secondary endpoint).3¶

* Comparative clinical significance has not been established. † Clinical significance unknown. ‡ The PIONEER 3 trial evaluated the randomized addition of RYBELSUS® or sitagliptin 100 mg to patients with type 2 diabetes uncontrolled with metformin with or without sulfonylurea.2 ¶ The open label PIONEER 2 trial compared the addition of RYBELSUS® versus empagliflozin in people with type 2 diabetes and an A1C of 7.0-10.5% receiving a stable dose of metformin.3 § PIONEER 6 study was to confirm that treatment with RYBELSUS® added to standard of care treatment does not result in unacceptable increase in CV risk compared to placebo added to standard of care treatment (i.e. rule out 80% excess risk) in patients with type 2 diabetes at high cardiovascular risk (age of ≥50 years with established cardiovascular or chronic kidney disease, or age of ≥60 years with cardiovascular risk factors only).4 This was done by demonstrating that the upper limit of the two-sided 95% confidence interval (CI) of the hazard ratio for RYBELSUS® versus placebo is less than 1.8 when comparing time to first occurrence of a major adverse cardiovascular event (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke).

What were the most common adverse effects reported with RYBELSUS®? The most frequently reported adverse reactions in clinical trials were gastrointestinal disorders, including nausea, diarrhea and vomiting. More patients taking RYBELSUS® versus comparator drugs had severe or serious adverse event and/or discontinued treatment due to gastrointestinal disorders. In general, these reactions were mild or moderate in severity and of short duration.1 Adverse reactions in placebo-controlled trials reported in ≥ 1% of RYBELSUS® treated patients with type 2 diabetes1a RYBELSUS® RYBELSUS® Placebo 7 mg 14 mg (n=356) (n=356) (n=362) % % %

RYBELSUS® RYBELSUS® Placebo 7 mg 14 mg (n=356) (n=356) (n=362) % % %

EYE DISORDERS

Dry eye Diabetic Retinopathy

INJURY, POISONING AND PROCEDURAL COMPLICATIONS

1.7 3.7

0 2.8

Contusion Fall

0.3 2.8

11.0 8.7 6.2 5.9 10.1 1.7 1.7

19.7 10.1 8.4 5.3 10.7 2.8 2.2

6.4 4.1 3.0 2.5 4.1 1.1 0.3

0.6 1.7 1.7 3.1

2.0 1.1 1.7 0.6

0 0 0.8 0.6

Cholelithiasis Weight Decreased Blood Creatinine Phosphokinase Increased Lipase Increased

1.1

0.6 1.1

1.4 1.4

0.3 0

2.8

1.1

0.3

METABOLISM AND NUTRITIONAL DISORDERS

Decreased Appetite

0.8 3.7

1.7 2.8

1.1 0

2.2

3.9

3.6

1.7 3.4

3.7 3.4

3.3 2.5

5.9

9.0

0.8

4.5 2.8 1.4

3.9 2.2 0

NERVOUS SYSTEM DISORDERS

Headache Dizziness Vertigo

4.8 1.1 1.4

RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS

Pharyngitis Sinusitis Respiratory Tract Infection Viral Upper Respiratory Tract Inflammation

INFECTIONS AND INFESTATIONS

Upper Respiratory Tract Infection Urinary Tract Infections Influenza

0.8 0.3

INVESTIGATIONS

GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS

Pyrexia Fatigue

2.2 0.6

HEPATOBILIARY DISORDERS

GASTROINTESTINAL

Nausea Diarrhea Vomiting Constipation Abdominal pain Abdominal Distension Gastroesophageal reflux disease Eructation Flatulence Gastritis Dyspepsia

0.6 1.1

1.7 2.5 0

2.0 1.4 1.1

1.7 1.9 0.8

1.1

0.8

0.3

The values are proportions of subjects with at least one event from a pool of two clinical trials, PIONEER 1 (26 weeks) and PIONEER 8 (52 weeks). a

• Gastrointestinal events were the most frequently reported adverse reactions in patients receiving RYBELSUS®. The majority of the reported incidences of nausea, vomiting and/or diarrhea occurred during dose escalation.1 Hypoglycemia adverse reactions in placebo-controlled trials in patients with type 2 diabetes mellitus1

Monotherapy (26 weeks) Severea (Level 3) Clinically significantb (Level 2) Moderate renal impairmentc (26 weeks) Severea (Level 3) Clinically significantb (Level 2) Add-on to insulin with or without metformin (52 weeks) Severea (Level 3) Clinically significantb (Level 2) a b c

Placebo

RYBELSUS® 7 mg

RYBELSUS® 14 mg

N=178 0% 1.1% N=161 0% 2.5% N=184 0.5% 27.2%

N=175 0.6% 0% N=181 0% 25.4%

N=175 0% 0% N=163 0% 5.5% N=181 1.1% 26.5%

“Severe” hypoglycemia adverse reactions are episodes requiring the assistance of another person. “Clinically significant” hypoglycemia adverse reactions are episodes with a plasma glucose of < 3.0 mmol/L. As an add-on to metformin and/or sulfonylurea, basal insulin alone or metformin in combination with basal insulin.

• RYBELSUS® 7 mg and 14 mg monotherapy has comparable rates of hypoglycemia compared to placebo.1 What is the recommended dose and dosage adjustment?1 • Start with 3 mg once daily for 30 days. • Increase the dose to 7 mg once daily for at least 30 days, and then maintain dose. • If additional glycemic control is needed after at least 30 days on the 7 mg dose, you may increase the maintenance dose to 14 mg. This regimen is intended to mitigate gastrointestinal symptoms during dose escalation. No dose adjustment of RYBELSUS® is recommended based on age, sex, race, ethnicity, upper gastrointestinal disease, or hepatic, and renal impairment.1

How can a patient take RYBELSUS®? Patients can take RYBELSUS® according to the following instructions:1 • Take on an empty stomach upon waking. • Swallow tablet whole with no more than half a glass of water (up to 120 mL). Patients can be counselled to swallow the tablet whole with a sip of water. A larger volume of water is likely to decrease the amount of RYBELSUS® absorbed. • Wait at least 30 minutes before eating, drinking, or taking any other oral medication. Waiting <30 minutes is likely to decrease the amount of RYBELSUS® absorbed. Tablets should not be split, crushed or chewed.1 How should RYBELSUS® be stored? RYBELSUS® must be stored in the original blister packaging to protect from moisture and light. Take the tablet directly after removing from blister card.1 Clinical use: RYBELSUS® is not indicated for use in type 1 diabetes or for the treatment of diabetic ketoacidosis. RYBELSUS® is not indicated for use in pediatric patients. Greater sensitivity of some older individuals cannot be ruled out. Therapeutic experience in patients ≥ 75 years of age is limited. Contraindications: • Personal or family history of medullary thyroid carcinoma (MTC), or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) • Pregnancy or breastfeeding Most serious warnings and precautions: Risk of thyroid C-cell tumours: In both genders of rats and mice, semaglutide caused treatment-dependent thyroid C-cell tumours at clinically relevant exposures. It is unknown whether semaglutide causes thyroid C-cell tumours in humans. Patients should be counselled regarding the risk and symptoms of thyroid tumours. Relevant warnings and precautions: • Hypoglycemia with concomitant use of insulin secretagogues or insulin • Driving and operating machinery • CV effects: increased heart rate; PR interval prolongation • Pancreatitis • Hypersensitivity • Diabetic retinopathy: In patients with history of disease, monitor for worsening • Renal insufficiency: Severe GI adverse reactions warrant monitoring of renal function; acute renal failure and worsening of chronic renal failure have been reported • Fertility • Hepatic impairment For more information: Please consult the Product Monograph at RYBELSUSPM-E.ca for more information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this advertisement. The Product Monograph is also available by calling us at 1-800-465-4334. References 1. Novo Nordisk Canada Inc. Rybelsus Product Monograph. Novo Nordisk Canada Inc; 2020. Accessed April 1, 2020. https://www.novonordisk.ca/content/dam/Canada/AFFILIATE/wwwnovonordisk-ca/OurProducts/PDF/Rybelsus-PM-EN-monograph.pdf 2. Rosenstock J, Allison D, Birkenfeld AL, et al. Effect of Additional Oral Semaglutide vs Sitagliptin on Glycated Hemoglobin in Adults With Type 2 Diabetes Uncontrolled With Metformin Alone or With Sulfonylurea: The PIONEER 3 Randomized Clinical Trial. JAMA. 2019;321(15):1466-1480. doi:10.1001/jama.2019.2942. A 78-week, double-blind trial to compare the efficacy and safety of RYBELSUS® vs. Januvia®. A total of 1864 patients with type 2 diabetes were randomized to receive RYBELSUS® 3 mg (n = 466), RYBELSUS® 7 mg (n = 465), RYBELSUS® 14 mg (n = 465), or sitagliptin 100 mg (n = 467) once daily, all in combination with metformin alone or metformin and sulfonylurea. The primary endpoint was change in A1C from baseline to week 26. 3. Rodbard HW, Rosenstock J, Canani LH, et al. Oral Semaglutide Versus Empagliflozin in Patients With Type 2 Diabetes Uncontrolled on Metformin: The PIONEER 2 Trial. Diabetes Care. 2019;42(12):2272-2281. doi:10.2337/dc19-0883. A 52-week, open-label trial (26-week primary endpoint) to compare the efficacy and safety of RYBELSUS® vs. Jardiance®. A total of 821 patients with type 2 diabetes were randomized to receive RYBELSUS® 14 mg (n = 411) once daily or empagliflozin 25 mg (n = 410) once daily, both in combination with metformin. 4. Husain M, Birkenfeld AL, Donsmark M, et al. Oral Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med. 2019;381(9):841-851. doi:10.1056/ NEJMoa1901118. A 15.9 month, double-blind trial to compare the cardiovascular outcomes of RYBELSUS® compared to placebo. A total of 3183 with type 2 diabetes who were at high cardiovascular risk (age of ≥50 years with established cardiovascular or chronic kidney disease, or age of ≥60 years with cardiovascular risk factors only) were randomized to receive RYBELSUS® 14 mg (n=1591) or placebo (n=1592). The primary endpoint was the time from randomization to the first occurrence of a major adverse cardiovascular event, a composite of death from cardiovascular causes (including undetermined causes of death), nonfatal myocardial infarction, or nonfatal stroke. All trademarks and registered trademarks are the property of their respective owners. RYBELSUS® is a registered trademark of Novo Nordisk A/S and used under license by Novo Nordisk Canada Inc. Novo Nordisk Canada Inc., Tel: (905) 629-4222 or 1-800-465-4334. www.novonordisk.ca

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. © 2021

CA20RYB00043E

NEWS

ACCURATE OVERHEAD

aking sure doctors are paid equally and fairly— regardless of the doctor’s practice circumstances—is the Holy Grail of a publicly funded healthcare system, at least it is from the doctor’s point of view. This goal is called relativity, and it has been the cause of muddied white coats for decades. “I think that anybody who gets into relativity is on a merry-go-round that just never stops. You can never win the relativity argument,” said Kevin Chapman, director of partnerships and innovation for Doctors Nova Scotia. It is tough going for medical associations, Chapman said, because they’re comparing one member to another member. Still, some medical associations have made bold statements, such as the Ontario Medical Association’s (OMA)

12 FEBRUARY 2021 THE MEDICAL POST

council voting in 2010 to solve the relativity issue by 2024. One component of relativity is physicians’ practice overhead costs. There’s considerable variation in how much physicians pay to carry out their practice. Costs for administrative staff, front desk staff, rent, IT support, supplies and PPE differ depending on location, specialty and how the practice is run.

HOW TO FIGURE OUT OVERHEAD COSTS

In order to offset overhead costs in a fair way, medical associations and provincial and territorial governments need to know the amounts involved. What then, is the best way to calculate overhead costs? 1. Survey: One is to simply survey physicians on how much they spend on

overhead. Doctors of BC did this in its most recent overhead study conducted in 2019 (they’ve conducted three studies in the past 30 years). The survey was geared to find the average overhead cost for each specialty. The OMA and others have done this too. Dr. Alykhan Abdulla, section chair for general and family practice at the OMA, noted that the survey method of estimating overhead costs is efficient and uses a method familiar to physicians. “The con is that it may not be 100% accurate and there is going to be a little bit of discrepancy between what people think is going on and what the accountant knows,” said Dr. Abdulla, medical director of the Kingsway Health Centre in Ottawa. The accuracy of this method came under fire in Ontario during negotiations

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A recent spat between the OMA and a specialists’ group over a study to help with relativity underlines an old problem BY KYLIE TAGGART

NEWS

of the Physician Service Agreement, which ended in a binding arbitration framework. The Ontario Ministry of Health and Long-term Care rejected the OMA’s position that physicians, on average, must use 30% of their wages to cover practice overhead costs. The ministry said the 30% figure, “was the result of a small sample size and flawed survey methodology,” according to the February 2019 report of the arbitration board’s binding arbitration award. “Survey participants clearly understood that their self-interest would be maximized by overstating their overhead and thereby understating income,” the report reads. The ministry suggested the cost was closer to 20%. 2. Model Office: A model office is usually prepared by an accountant or other financial professional and itemizes the overhead costs physicians of different specialties pay, based on market prices. A number of medical associations have used this method, including Doctors of BC, Doctors Nova Scotia and the OMA. “The model office study allows one to determine overhead costs for different practice sizes and location if reliable cost data are available from published sources,” the Doctors of BC negotiations committee told the Medical Post. However, it is not always accepted as a robust method to assess overhead costs. The OMA’s relativity advisory committee used the model office in one of their past tools used to calculate relativity, but noted in a 2019 report that the model office “is based on the assumptions about what a typical physician should spend on overhead, not what the overhead actually is.” In Ontario, the model office was not accepted as an appropriate way to measure overhead costs by OMA members or the arbitrator. 3. Analysis by Statistics Canada: In the search for more objective data, the OMA introduced the idea of using tax data to get actual overhead costs. They entered into discussions with Statistics Canada to carry out a study on physician overhead costs by specialty, using the best data available.

Eighty-five per cent of OMA members who attended a November 2020 open town hall meeting endorsed proceeding with the study. “We informed our members that the purpose of this study is to obtain objective, accurate and arms-length information that will help direct our discussions with government on relativity and negotiations for a new Physician Services Agreement,” said Dr. Jim Wright, chief of economic policy and research at the OMA. Having good data is important in arbitration. “Arbitration means that accurate information has to go to a third party, and a third party will look at it and see if it is reasonable and acceptable,” said Dr. Abdulla. “In that circumstance, you want to be as reasonable, as transparent, as clean in your paperwork and your presentations as you can,” he said. The initial proposals used language that could be misinterpreted to mean that the OMA itself wanted to access confidential tax information. This language, used in the October 2019 relativity advisory committee’s report on its new relativity tool, worried OMA members and the Ontario Specialists Association (OSA). The OSA initiated a petition and letter-writing campaign to protest the proposed Statistics Canada study. “Voice your objection to the release of your personal tax info to the OMA. Sign the petition,” the OSA website said in January 2021, after repeated reassurances by the OMA and Statistics Canada that releasing raw data from the Canada Revenue Agency (CRA) was never in the cards, and is prohibited by federal law. “Any personal information acquired by either federal agency is governed by the Privacy Act,” wrote Dr. Pierre Desrochers (PhD), director of the office of privacy management and information coordination at Statistics Canada, and Maxime Guénette, chief privacy officer of the CRA in their January 5, 2021, letter to the OSA’s lawyer. They also confirmed that “no information about Ontario Specialist Association members has been disclosed to the Ontario Medical Association (OMA) by Statistics Canada or the CRA.”

“No personal tax records will be accessible in any fashion,” Dr. Wright wrote to the Medical Post in November. “The only information provided to the Ontario Medical Association by Statistics Canada would be completely anonymous overhead data aggregated by section.” The OSA is also concerned that the study results would be shared. Since the study would be conducted by a federal government agency, it would be made publicly available. “If it goes ahead, the results will be made public, just like for all projects carried out at Statistics Canada,” a Statistics Canada spokesperson wrote to the Medical Post in November. The OSA also believes that the data from the CRA would be flawed, and not a proper representation of overhead costs, providing more harm than benefit in negotiations with the Ontario Ministry of Health and Long-Term Care. The OSA has yet to propose an alternate source of data. The OSA still hopes to block the proposed study. Dr. Desrochers repeated the Statistics Canada position that, “We have communicated to the OMA that we will not proceed with the project until the concerns of their members are addressed and all parties agree on a way forward,” in his Jan. 5, 2021, letter. The OSA made the assumption that the study will not proceed. “Based on the feedback of thousands of family practice physicians and a broad cross-section of specialists (beyond the OSA’s own member specialties), we do not foresee that occurring,” it said in a press release about the letter. Previously, the OSA took Dr. Desrochers’ November message about not proceeding until all parties agreed and called it: “Project stopped pending investigation,” in their press release. The Ontario specialists’ concern about protecting information on individual physician’s overhead costs is a far cry from a 2020 trend in Alberta where doctors were posting their overhead costs on social media and sharing it with the mainstream press. Of course, these were anecdotal numbers but the disclosures were made to help educate the public on the true take-home pay of physicians after the province said it would publish the gross billings of Alberta physicians.

THE MEDICAL POST FEBRUARY 2021 13

NEWS

“Most family doctors have an office out in the community and they’re responsible for the costs of their office no matter where they go and earn their income.”

HOW DO OVERHEAD COSTS FIGURE IN NEGOTIATIONS?

Wouldn’t it be great if physicians could enter a code for their type of practice (including overhead costs) into the fee schedule, and then the fees would be calculated appropriately? This differentiation requires a willing partner motivated to accept accurate information, motivated to develop a system to ensure equitable distribution of pay, and motivated to provide fair remuneration, Dr. Abdulla noted. Healthcare is the highest expenditure for every provincial and territorial government, and asking them to allocate funds to offset costs that doctors have already been subsidizing is a hard sell. Recently, Doctors of BC was able to inform the province on rising overhead costs. “For negotiations, the issue of business cost increases is of most importance. Therefore, we look at the increases that physicians have experienced and estimate this using published data on lease costs, salaries, and other overhead costs,” the Doctors of BC negotiations committee told the Medical Post. “We rely on sources such as Statistics Canada for this information,” they wrote. As of April 2020, British Columbian physicians in certain geographic areas have been able to claim a business cost premium on fees to offset the rising property costs faced by communitybased practices. Another way overhead costs are changing is that many family physicians now also work outside

14 FEBRUARY 2021 THE MEDICAL POST

of the office, whether they have academic appointments, do surgical assisting in hospital, engage in hospital administrative work, take shifts in the emergency department or work in specialty clinics. That skews the overhead cost calculation, because while the physician pays overhead seven days a week, he or she may not be in the clinic every one of those days. Some may even be paying overhead twice. “It is one of the new realities with family physicians that we’re all going to see across the country,” Chapman said. “We’re trying to figure out a way around that.” “Most family doctors have an office out in the community and they’re responsible for the costs of their office no matter where they go and earn their income,” Dr. Abdulla explained. Alberta physicians pointed this out to their government when it proposed cancelling a stipend that paid overhead costs for physicians working at Alberta Health Services facilities. Many of the physicians affected had offices in the community that they still needed to support on days when they were working at AHS facilities. Around five years ago, Doctors Nova Scotia looked at its fee schedule in terms of relativity, with the help of other provincial medical associations, “but it sort of hit the rocks and got nowhere,” Chapman said. “We hoped that it would revamp the fee schedule,” he said. Examining the issue of relativity was a big body of work, with a lot of money and hours spent on it between 2012 and 2018. In the latest negotiations with the

province, the focus was on retention and recruitment of physicians. Fees were compared to those in other provinces, instead of within-province comparisons, and Chapman said that there wasn’t much pushback from Doctors of Nova Scotia members. In Nova Scotia, when a fee is developed, the fee committee (made up of Doctors Nova Scotia, Nova Scotia Health and the Department of Health and Wellness) uses a matrix to calculate an acceptable fee. They come up with a base fee based on an hour of work, and then adjust it based on various factors, such as the medical qualifications needed and the length of time of the procedure or visit. “We don’t really look at overhead, per se,” said Derek Law, compensation manager at Doctors Nova Scotia. “But we believe in the base there is a component that would be a portion for overhead.” Chapman said that “where we’ve struggled is a differential.” He gave the example of ophthalmology, a specialty with high overhead costs. Although those practising in the community have higher overhead costs compared with those practising in the hospital, they both get paid the same fee. “It has been something that we’ve bounced around and something that we’ve talked about, but because the fee committee only has a limited number of dollars to work with, and demand far exceeds supply—everybody wants a new fee or a fee adjusted—this one hasn’t made its way anywhere with any traction, even though it is something we’ve heard about,” he said. It seems that to address physicians’ overhead costs and calculate fees appropriately, there needs to be motivation—and energy—from all sides to move forward, and there must be robust and objective data to support any decisions made. Call it evidencebased equity. With those two factors, perhaps physicians can put on clean, unmuddied white coats, a positive attitude and look forward to fair compensation for all physicians working to provide quality and accessible patient care to Canadians.

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THE MEDICAL POST FEBRUARY 2021 15

NEW 2-in-1 SUVEXX®

(85 mg sumatriptan/500 mg naproxen sodium tablets)

One pill that takes on migraine attacks with both a 5-HT1B/1D-receptor agonist and an NSAID1

• Significantly more patients achieved pain relief 2 hours after treatment vs. placebo – 65%, SUVEXX vs. 28%, placebo, p<0.0011† • Significantly more patients receiving a single dose of SUVEXX remained pain-free through 24 hours* without use of other medications vs. patients taking sumatriptan or naproxen alone – 25%, SUVEXX 85/500 mg vs. 16%, sumatriptan 85 mg (p=0.009) and 10%, naproxen sodium 500 mg (p<0.001)1† • Convenient: Recommended dose is 1 tablet‡ – Maximum recommended dosage is 2 tablets/day, taken at least 2 hours apart – See Product Monograph for complete dosing recommendations

Try NEW SUVEXX for the acute treatment of migraine pain.

85 mg/500 mg

Indications and clinical use: SUVEXX (sumatriptan succinate and naproxen sodium) is indicated for the acute treatment of migraine attacks with or without aura in adults. SUVEXX is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic, basilar, or ophthalmoplegic migraine. Safety and efficacy of SUVEXX has not been established for cluster headache, which is present in an older, predominantly male population. SUVEXX should only be used if a clear diagnosis of migraine headache has been established. The safety and efficacy of SUVEXX in pediatric patients (<18 years) and the elderly population (>65 years of age) have not been established. SUVEXX is not indicated for use in pediatric patients. Contraindications: • Ischemic coronary artery disease (CAD) (angina pectoris, history of myocardial infarction, or documented silent ischemia) or coronary artery vasospasm, including Prinzmetal’s angina. • In the setting of coronary artery bypass graft (CABG) surgery. • Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders. • History of stroke or transient ischemic attack (TIA) or history of hemiplegic, basilar, or ophthalmoplegic migraine because these patients are at a higher risk of stroke. • Peripheral vascular disease. • Ischemic bowel disease. • Uncontrolled hypertension. • Recent use (i.e., within 24 hours) of ergotamine-containing medication, ergot-type medication (such as dihydroergotamine or methysergide), or another 5- hydroxytryptamine1 (5-HT1) agonist. • Concurrent administration of a monoamine oxidase (MAO)-A inhibitor or recent (within 2 weeks) use of an MAO-A inhibitor. • History of asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid (ASA) or other NSAIDs. Severe, sometimes fatal, anaphylactic reactions to NSAIDs have been reported in such patients. The potential for cross-reactivity between different NSAIDs must be kept in mind. • Third trimester of pregnancy (>26 weeks of gestation). • Breastfeeding women. • Moderate or severe hepatic impairment or active liver disease. • Severe uncontrolled heart failure. • Active gastric/duodenal/peptic ulcer, active GI bleeding. • Cerebrovascular bleeding or other bleeding disorders. • Inflammatory bowel disease. • Severe renal impairment (creatinine clearance <30 mL/min or 0.5 mL/sec) or deteriorating renal disease (individuals with lesser degrees of renal impairment are at risk of deterioration of their renal function when prescribed NSAIDs and must be monitored. • Known hyperkalemia. Most serious warnings and precautions: Risk of cardiovascular adverse events: Sumatriptan, a component of SUVEXX, can cause coronary artery vasospasm. SUVEXX is contraindicated in patients with uncontrolled hypertension, ischemic coronary artery disease, cardiac arrhythmias, and those with history of myocardial infarction. SUVEXX is not recommended in patients with family history or risk factors predictive of coronary artery disease. Naproxen sodium, a component of SUVEXX, is a non-steroidal anti-inflammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) which can be fatal. The risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Caution should be exercised in prescribing NSAIDs such as naproxen sodium, which is a component of SUVEXX to any patient with ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina), cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) and/or congestive heart failure (NYHA II-IV). Use of NSAIDs, such as naproxen sodium, which is a component of SUVEXX, can promote sodium retention in a dose-dependent manner, through a renal mechanism, which can result in increased blood pressure and/or exacerbation of congestive heart failure. Risk of gastrointestinal (GI) adverse events: Use of NSAIDs, such as naproxen sodium, which is a component of SUVEXX, is associated with an increased incidence of gastrointestinal adverse events (such as peptic/duodenal ulceration, perforation and obstruction of the upper and lower gastrointestinal tract, and gastrointestinal bleeding). These events can occur at any time during use and without warning symptoms. Elderly patients and those with history of peptic ulcer disease and/or GI bleeding are at greater risk for serious Gl events. Other relevant warnings and precautions: • Use only when clear a migraine diagnosis has been established. • Use in cluster headache. • Psychomotor impairment. • Use in medication overuse headache. • Not recommended for use with other NSAIDs, except low-dose ASA for cardiovascular prophylaxis. • Serious cardiac events and fatalities associated with 5-HT1 agonists. • Cerebrovascular events and fatalities with 5-HT1 agonists. • Other vasospasm-related events. • Increased blood pressure; use with caution in patients with controlled hypertension. • Congestive heart failure and edema. • Interference of platelet function. • Use with anticoagulants. • Anti-platelet effects. • Blood dyscrasias. • Increased liver enzymes; evaluate patients with signs of liver dysfunction. • Hypersensitivity and anaphylactoid reactions. • Do not use in ASA-intolerance. • Cross-sensitivity to other NSAIDs. • Masking of inflammation and fever. • Excluding other neurologic conditions. • History of seizures. • Serotonin syndrome; monitor patients on other serotonergic treatments. • Blurred and/or diminished vision. • Renal impairment; use with caution in patients with severe dehydration or pre-existing kidney disease. • Sodium retention and hyperkalemia. • ASA-induced asthma. • May impair fertility; not recommended in women trying to conceive. • Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis and erythema multiforme). • Use with caution during first and second trimesters; evaluate risk-benefit. • Not recommended during labour and delivery. • Use in breastfeeding women. For more information: Please consult the Product Monograph at health-products.canada.ca/dpdbdpp/index-eng.jsp for important information relating to adverse reactions, drug interactions, and dosing information that has not been discussed here. The Product Monograph can also be obtained by calling Aralez Medical Information at 1-866-391-4503.

* Defined as a reduction in headache severity from moderate or severe pain to no pain at 2 hours post-dose without a return of mild, moderate, or severe pain and no use of rescue medication for 24 hours post-dose. † Randomized, phase 3, double-blind, parallel-group, single-dose study of 1,461 patients with acute migraine with or without aura utilizing placebo and each individual active component of SUVEXX as comparisons (SUVEXX, n=370; placebo, n=365; sumatriptan succinate 85 mg, n=365; naproxen sodium 500 mg, n=361). Co-primary endpoints were superiority of SUVEXX over placebo at 2h post-dose for the following endpoints: pain relief (no or mild pain); incidence of photophobia, phonophobia and nausea; and superiority of SUVEXX vs. the individual components for sustained pain-free at 24 hours. ‡ The safety of treating an average of more than 5 migraine headaches in a 30-day period has not been established. Reference: 1. SUVEXX™ (sumatriptan/naproxen sodium tablets) Product Monograph. April 3, 2020.

FEATURE

THE MEDICAL POST’S 2021

Power List

Power is inherently subjective. This

2021 Power List was put together the same way we did the last one just over five years ago: Medical Post journalists reached out to talk off-the-record to doctors in the power structure and asked them which doctors they think have power. What purpose does putting together a Power List serve? Well, it can help focus Canada’s community of doctors on the question of who among them does have

18 FEBRUARY 2021 THE MEDICAL POST

power. What do those people believe is the way ahead for Canada’s healthcare system—and Canada’s doctors? A power list can influence doctors who are ambitious. And being ambitious, particularly when you are young, is a good thing. For those physicians looking ahead, it can help them figure out how the 30 doctors on our Power List got there. This 2021 Power List is about the

future as well: Some big-name Canadian doctors who have long had significant sway—such as Dr. Carolyn Bennett, federal minister of Crown-Indigenous relations, and Dr. John Haggie, former CMA president and longtime health minister for Newfoundland and Labrador—have not been included. Here, now, is the Medical Post’s 2021 Power List. . . . — COLIN LESLIE, EDITOR-IN-CHIEF

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Canadian doctors who have ‘sway’ — we’ve ranked the top 30

FEATURE

1: DR. THERESA TAM Chief Public Health Officer of Canada

There’s a well-worn saying in public

health that if everything is working according to plan, you’ll hardly realize they’re there at all. During the pandemic, the inverse became true: The people overseeing this infrastructure were rocketed from their positions behindthe-scenes into briefings and press conferences where their audience—from the lay public to the prime minister— hung on their every word. So given the circumstances, the choice for the most powerful doctor in the country right now is obvious. Dr. Theresa Tam, the nation’s top public health doctor, has been the leading guide for our country’s top political figures trying to pilot us through this pandemic. Through praise and wicked backlash, she’s remained a steady presence, constantly reasserting her commitment to the best available evidence, even as it seemed to change by the day. —TB

province of Alberta: serving more than four million Albertans with a budget of more than $15 billion. To be sure, there’s a lot of tension between Alberta doctors and the provincial government right now, but Dr. Yiu has run AHS with a sure hand. She has made substantial contributions in moving the organization forward, including implementing a single EMR for the province (two phases of the nine now complete), and leading AHS to be recognized as one of Canada’s Top 100 Employers, a national competition that was founded in 1999, for four consecutive years. Dr. Yiu was born in Hong Kong and earned her MD and FRCPC in pediatrics from the University of Alberta. Beginning in 2000, she started rising through various senior positions at the dean’s office at U of A, and then to interim dean before joining AHS in 2012, starting out as VP of quality and chief medical officer. Prior to the pandemic, Dr. Yiu continued her practice as a pediatric nephrologist at the Stollery Children’s Hospital and intends to return to clinical practice once the pandemic subsides. She is also a professor of pediatrics in the department of pediatrics at the faculty of medicine/ dentistry at U of A. —CL

3: DR. SAMIR SINHA Influencer on seniors and COVID issues

Long respected as a leader in geriatric

2: DR. VERNA YIU CEO of Alberta Health Services Political insiders say Dr. Verna Yiu

has been a stabilizing influence on the massive Alberta Health Services (AHS) since she took over as president and CEO in 2016. AHS is a single-integrated health system delivering care for the

health, Dr. Samir Sinha has become a go-to expert during the COVID-19 pandemic, advocating for seniors and the need for drastic changes to longterm care in Canada. Media outlets regularly call on him to speak about the pandemic and he uses social media to ask governments to prioritize seniors in policy-making.

The director of Geriatrics at Mount Sinai Hospital and the University Health Network in Toronto, Dr. Sinha is cochair of the National Institute on Ageing at Ryerson University and was the architect of Ontario’s Senior Strategy. He advises hospitals and health authorities in Canada, Britain, the United States and China on innovative models of geriatric care that reduce disease burden, improve access and promote health. —AC

4: DR. ANDREW FUREY New premier of Newfoundland Dr. Andrew Furey gets things done.

He is an orthopedic trauma surgeon and assistant professor at Memorial University of Newfoundland Faculty of Medicine. He also founded Team Broken Earth to provide medical relief after the 2010 earthquake in Haiti and published a book about that experience last year. Oh yeah, Dr. Furey is also premier of Newfoundland and Labrador. Since becoming premier in August, Dr. Furey has promised solutions to Newfoundland’s $2-billion deficit, ushered in 8,000 $25-a-day daycare spaces across the province and is committed to finding innovative, costeffective ways to deliver healthcare. (Newfoundland has an election now scheduled for Feb. 13.) Through Team Broken Earth, more than 1,500 volunteers from across Canada, the U.S. and U.K. have participated in medical missions to Haiti, Bangladesh, Ethiopia, Guatemala and Nicaragua. In 2018, Dr. Furey cofounded the A Dollar A Day Foundation, which raises funds to support frontline mental health and addictions programs across Canada. —AC BY TRISTAN BRONCA, ABIGAIL CUKIER, LOUISE LEGER AND COLIN LESLIE

THE MEDICAL POST FEBRUARY 2021 19

FEATURE

5: DR. GIGI OSLER Former CMA president and equity and diversity champion When Dr. Gigi Osler was elected the

president of the CMA in 2018, she was the first woman of colour and the first female surgeon to take on that important role. The Winnipeg-based ENT surgeon has left the position but her widespread influence continues. Today she is a high-profile champion of equity, diversity and physician wellbeing. Dr. Osler is the new chair of the Canadian Medical Forum, which brings together medical leaders to strategize on priority healthcare issues. She is also the incoming president of the Federation of Medical Women of Canada. And, in a year when policy around virtual care has become an essential, urgent issue, she co-chairs the Virtual Care Task Force, a collaboration among medical leaders across the country. —LL

6: DR. JANE PHILPOTT Former cabinet minister, dean at Queen’s medical school It was an enviable resume to begin

with, and this year FP Dr. Jane Philpott took on another formidable role. The former cabinet minister, global health advocate and educator was appointed dean of the Queen’s University Faculty of Health Sciences and director of the

20 FEBRUARY 2021 THE MEDICAL POST

school of medicine, the first woman ever to hold that position. In that role, she has publicly vowed to increase inclusivity, equity and justice in medicine, and to expand the university’s already robust research footprint. Also this year, the Ontario government appointed Dr. Philpott as the special advisor to support the design and implementation of the new Ontario Health Data Platform, which will provide recognized researchers and health system partners access to anonymized health data that will allow them to better detect, plan, and respond to COVID-19. —LL

7: DR. DIANE FRANCOEUR Head of Federation of Specialist Physicians of Quebec Since 2014, when Dr. Diane Francoeur

became the first woman to lead the federation that represents Quebec specialists and negotiates their compensations, it has been a bumpy time. The province’s specialists (family doctors negotiate fees separately in Quebec) had been poorly compensated compared to specialists in other provinces, but after a bitter three-year negotiation period, Dr. Francoeur closed a deal that got big increases for her members. Perhaps too big: The rise in specialist compensation became a campaign issue in the 2018 Quebec election with several parties threatening to tear up the already negotiated fee deal. Indeed, after the election, when the Coalition Avenir Québec led by François Legault won a landslide victory, under pressure, the federation agreed to roll back some of its members’ compensation. Still, the agreement also led to the creation of the Institute of Relevance, making the federation part of the conversation about what medical services should be reimbursed. —CL

8: DR. BRETT BELCHETZ Co-founder & CEO of Maple With the surge in

virtual healthcare services, private providers like Maple are soaring. ER physician Dr. Brett Belchetz is co-founder & CEO of the company, which offers app-based medical services—most delivered by secure text messaging and available 24/7. Since the pandemic began, more than a million new patients have been served by the company. Maple has more than 1,500 physicians on its roster who are paid feefor-service. While patient-paid virtual services are controversial and fall into a grey zone, Dr. Belchetz has indisputably brought virtual care to a new level of usage. He has created partnerships with benefits providers, and brought Shoppers Drug Mart onboard with a $75-million investment. —LL

9: DR. DANYAAL RAZA Chair of Canadian Doctors for Medicare

Dr. Danyaal Raza is both an outspoken

fan and a critic of Canadian public health. Even before he became chair of Canadian Doctors for Medicare, he was an advocate for filling the holes in Canada’s healthcare system. The family physician at St. Michael’s Hospital and assistant professor at the University of Toronto focuses his advocacy work on single-payer healthcare, the intersection of public-private healthcare and the social determinants of health. He is a regular op-ed writer and has appeared in influential print media, including the Toronto Star, the Globe & Mail and Maclean’s, and regularly provides local and national TV and radio commentary. In the past year, he has also turned his attention to advocating for keeping profit out of our troubled long-term care facilities. —LL

10: DR. DAVID JUURLINK Pharmacologist and internist

Dr. Juurlink is a go-to head of clinical

FEATURE

pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto and staff internist. The professor of medicine, pediatrics and health policy at the University of Toronto is also a medical toxicologist at the Ontario Poison Centre at the Hospital for Sick Children and a scientist at the Institute for Clinical Evaluative Sciences. Dr. Juurlink maintains an active research program in the field of drug safety. His areas of particular interest include adverse drug events, the consequences of drug-drug interactions in clinical practice, and the epidemiology of suicide and deliberate self-poisoning. He has been a critic of the regular prescribing of opioids and last year quickly and publicly pointed to the potential harms of chloroquine and hydroxychloroquine, antimalarial drugs promoted by Donald Trump for the treatment of COVID-19. —LL

11: DR. RYAN MEILI Leader of the Saskatchewan NDP Dr. Ryan Meili’s

philosophy has long been that keeping people healthy is a better investment than trying to heal them later, a view that he expressed while on the campaign trail during last year’s lead-up to the Saskatchewan election. Though the Leader of the Opposition failed to gain enough ground over the Saskatchewan Party by October’s vote, Dr. Meili has continued to advocate on behalf of healthcare and Canada’s disadvantaged and vulnerable populations. To that end, Dr. Meili, an FP and MLA for Saskatoon Meewasin, has founded a number of healthcare-related initiatives such as the Student Wellness Initiative Toward Community Health (SWITCH), the University of Saskatchewan’s Making the Links College of Medicine program, and Upstream, a national project of the Canadian Centre for Policy Alternatives that draws attention to the social determinants of health. —LL

Power Couple

12 & 13: DRS. TARA KIRAN AND IRFAN DHALLA Drs. Tara Kiran and Irfan Dhalla

have each distinguished themselves with an abundance of wide-ranging contributions to healthcare across research, policy-making and clinical care. The married couple first met in medical school and had their first real conversation while travelling to Saskatoon for a meeting of the Canadian Federation of Medical Students. A renowned primary-care researcher, Dr. Kiran has a passion for improving the system she works in. She practises family medicine at St. Michael’s Hospital in Toronto and is the Fidani chair in improvement and innovation and vice-chair of quality and innovation at the department of family and community medicine at the University of Toronto. Much of her research has focused on evaluating the impact of Ontario’s primary care reforms on quality of care. She believes patients should be more involved in shaping the way the healthcare system works and has partnered with patients to inform her research, design changes to care delivery, and set improvement

14: DR. JENNIFER KWAN Family physician, heavy hitter on Twitter

When she’s not working at her family physician practice

in Burlington, Ont., Dr. Kwan is often creating detailed, colourful graphs

priorities. She says one of the most gratifying aspects of her work has been mentoring others—many of whom are now in leadership roles trying to make the health system better. Dr. Dhalla is a general internist and vice-president at Unity Health Toronto, which includes St. Michael’s, St. Joseph’s Health Centre and Providence Health Care. For the last few months, he has co-chaired the federal COVID-19 Testing and Screening Expert Advisory Panel. Since the beginning of the pandemic, he has championed a more effective pandemic response, writing articles in journals, newspapers, advising governments, and contributing to the conversation on Twitter. Dr. Dhalla is also an associate professor at U of T and a scientist at the Institute for Clinical Evaluative Sciences. While they don’t collaborate on any particular projects (besides raising three children together), Dr. Dhalla says that he and Dr. Kiran have an “ongoing philosophical collaboration” that includes a passion for healthcare quality improvement and healthcare inclusivity, that informs, underpins and supports the work they each do. —LL

and charts on Ontario’s COVID-19 statistics, and posting them for her hefty Twitter following of 45,000. By posting these stats—every day—and putting information in context, Dr. Kwan has helped physicians and the public understand the virus’s impact in the province. She is also one of the advocates behind Masks4Canada,

THE MEDICAL POST FEBRUARY 2021 21

FEATURE

a group of physicians, media and others, whose mission is to inform and educate governments and the public on the critical role of masks to reduce COVID-19 transmission. Dr. Kwan also advocates for PPE for frontline workers in hospitals, as well as outpatient clinics, and created a centralized list of Ontario hospitals accepting donations. As one of the directors of the Halton Region Chinese Canadian Association, she has assisted in the donation of over 5,000 masks. —LL

15: DR. ALIKA LAFONTAINE Indigenous health advocate, anesthesiologist

Dr. Alika Lafontaine

is an expert on Indigenous health systems and health policy, institutional bias, racism and reflective practice. A candidate this year for CMA presidentelect, Dr. Lafontaine uses his voice quietly but persistently to create spaces where Indigenous communities can work with physicians, politicians and policy-makers to improve Indigenous healthcare. Dr. Lafontaine is an anesthesiologist at Queen Elizabeth II Regional Hospital in Grande Prairie, Alta. Dr. Lafontaine lectures across the country, sharing his own experiences as a Cree-Ojibwe-Polynesian and telling stories from his practice on how bias, discrimination and racism impact patient care—and why addressing these issues is at the core of improving the health of First Nations, Metis and Inuit Peoples. —LL

16: DR. ISAAC BOGOCH Epidemiologist, public health consultant, general internist

When COVID-19 first arrived in this

country, Canadians were anxiously glued to their TV screens in an effort to understand what this frightening new virus meant for them. There, looking back at them, they found Dr. Isaac Bogoch, a voice of clear information, calm and reason. Since then, the

22 FEBRUARY 2021 THE MEDICAL POST

infectious diseases specialist and general internist at the Toronto General Hospital has continued almost daily TV appearances. He tirelessly offers the public sound data and answers viewer questions on everything from masks and bubbles to testing and transmission, vaccines and variants. Dr. Bogoch also actively shares pandemic perspectives in print media and via social media, with 72,000 Twitter followers. —LL

17: DR. SAMANTHA HILL President of the Ontario Medical Association Leading the largest

physician association in the largest province in the country has always been a distinguished role. But in the last five years, the occupant of that role has spent much of their time fending off unwelcome legislation and pay cuts—that is, maintaining the status quo. But after years of work, Dr. Samantha Hill and the current OMA leadership have been able to implement the most significant governance changes in the association’s 138-year history, intended to free up the decision-making apparatus to have greater impact on the health of Ontarians. Dr. Hill will be instrumental in shaping that process. —TB

18: DR. BRENDAN CARR CEO of Nova Scotia Health Authority Dr. Brendan Carr

became president and CEO of the Nova Scotia Health Authority (NSHA) at a time when the organization was responding to criticism of its governance and operational oversight. After the province’s nine district health authorities merged in 2015, a 2017 report by a group of Nova Scotia medical professionals said the organization wasn’t agile enough to respond to local needs and was subject to political interference. Dr. Carr started just at the end of 2019. An ER and family doctor, Dr. Carr had spent most of his medical career in Nova Scotia before leaving for a post as

president and CEO of the Vancouver Island Health Authority. Recruited back to Nova Scotia, Dr. Carr is tasked with helping improve the organization and overseeing implementation of a province-wide EMR system. —CL

19: DR. KAMRAN KHAN CEO and founder of BlueDot, infectious disease thinker Working on the

frontlines during the 2003 SARS epidemic inspired Dr. Kamran Khan to develop BlueDot, a global early warning system for infectious diseases. An infectious disease physician at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, Dr. Khan saw the potential for artificial intelligence to make it possible to intervene quickly to change the course of an outbreak. The team at BlueDot predicted the worldwide spread of influenza and tracked the spread of Ebola and the Zika virus. On Dec. 31, 2019, BlueDot notified its customers about a mysterious, pneumonia-like illness in Wuhan, China—nine days before the World Health Organization did. The BlueDot platform combines natural language processing and machine learning to comb the Internet for news related to infectious diseases, often well before it is officially reported. The Canadian government is now using BlueDot’s platform to monitor the spread of COVID-19 and analyze anonymous data from mobile devices to evaluate the impacts of public health measures. —AC

20: DR. SARITA VERMA Dean of the Northern Ontario School of Medicine

Delivering highquality medical care in the rural

parts of this country is one of the great challenges. At the centre of the interminable effort to this are institutions like NOSM. Of all the doctors who’ve chosen to practise in Ontario’s north over the last 15 years,

FEATURE

the lion’s share have come through NOSM. Dr. Verma is the recently appointed dean of the medical school and, as one of the profession’s most recognized champions of diversity, she brings valuable new perspectives to the question of how to meet the needs of these unique patient populations. —TB

21: DR. CHRIS SIMPSON Executive vicepresident, medical, at Ontario Health

With Health Quality Ontario and Cancer Care Ontario all

now rolled into the new “super agency” Ontario Health, Kingston, Ont.’s Dr. Chris Simpson is stepping into a big role: executive vice-president, medical, for Ontario Health. He’ll be the only doctor on the senior leadership team. As his hiring blurb explains, “he will help define, develop and evaluate programs and models of care consistent with Ontario Health’s mandate and priorities.” Dr. Simpson, who was previously a CMA president, is currently the vicedean (clinical) at the Faculty of Health Sciences at Queen’s University. —CL

22: DR. ANDREAS LAUPACIS Editor-in-chief of the CMAJ Progressive doctors

cheered when Dr. Andreas Laupacis became editorin-chief of the Canadian Medical Association Journal in the fall of 2019. That probably had a lot to do with the reputation that the website Healthy Debate had—of which Dr. Laupacis was founder. A year ago, Dr. Laupacis had the CMAJ drop its paywall. Readership has increased threefold since 2019/20. While this can be attributed to easier access to CMAJ articles that were previously behind the gate, there has also been an increase in content that was always public. The CMAJ had a 70% increase in submissions over this past year and managed to deal with those with the same amount of staff as they had before—with a slight decrease in turnaround time for manuscripts. Dr.

Laupacis has a background in clinical epidemiology and health services research and was a general internist until he stopped practising when he got the CMAJ gig. —CL

23: DR. SACHA BHATIA Virtual care champion Long before the

COVID-19 pandemic caused a massive shift toward virtual care, Dr. Sacha Bhatia has advocated for digital healthcare delivery as a way to increase access to care, save costs and improve the patient experience. Director of the Institute for Health System Solutions and Virtual Care at Women’s College, Dr. Bhatia is also a cardiologist at Women’s College Hospital and University Health Network. Recently he co-authored a C.D. Howe Institute report, Canada’s Virtual Care Revolution: A Framework for Succession, which argues that a move toward an almost equal ratio of physical to virtual interactions would reduce infection risk, decrease healthcare costs, increase patient convenience and create health system capacity. —AC

24: DR. DAVID NAYLOR Co-chair of COVID-19 Immunity Task Force Dr. David Naylor

headed the federal inquiry into Canada’s response to SARS in 2003. The resulting report led to the formation of the Public Health Agency of Canada and the appointment of Canada’s first chief public health officer. In April 2020, the government of Canada called on Dr. Naylor again, this time to co-chair its COVID-19 Immunity Task Force. Dr. Naylor’s name came up many times as the Medical Post worked on this list. Often referred to as a visionary, he is recognized for vast contributions to health research, education, administration and policy. Dr. Naylor is a professor of medicine and president emeritus at the University of Toronto, where he served as president and dean of medicine. —AC

25: DR. SUZANNE STRASBERG Chair of the CMA Board of Directors It was while she

was chair for MD Financial Holdings from 2014 to 2018 that Dr. Suzanne Strasberg’s leadership skills at the Canadian Medical Association really stood out. So perhaps it isn’t surprising that when B.C.’s Dr. Brian Brodie ended his term after six years as chair of the CMA board that Dr. Strasberg would be tapped to take over. Those who know her say she’s a “doctors’ doctor” and a straight shooter. Dr. Strasberg works in Toronto as a member of the Jane Finch Family Health Team and previously had a number of positions with the OMA, including board chair and president. Dr. Strasberg took over the board a year and a half ago and is very committed to modernizing CMA’s board governance, including ensuring the board composition reflects the diversity of the association’s membership and the physician community. —CL

26: DR. LISA CALDER President and CEO of the Canadian Medical Protective Association

It’s an open secret that most physician

organizations in this country have a conflicted relationship with their memberships. Physician issues are, after all, complicated, high-stakes and largely polarizing. Malpractice issues are no different, yet the CMPA boasts an unusually high approval rating among its membership. That lends unique influence to the voice at the head of the organization. Dr. Calder is an emergency physician, researcher and teacher who became the first female head of the CMPA in the organization’s history. She took over in Aug. 2020 and, though she is relatively new to the role, her tenure could prove to be enormously consequential for the association. —TB

THE MEDICAL POST FEBRUARY 2021 23

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FEATURE

27: DR. MAMTA GAUTAM Physician wellness advocate More attention is

finally being paid to high rates of stress, burnout and depression among physicians—an issue that the COVID-19 pandemic has only magnified. And Dr. Mamta Gautam, an influential force as an advocate for physician health and wellness, has answered the call. A psychiatrist who has treated only physicians for 30 years, Dr. Gautam set up a free virtual support network for Canadian doctors to share their experiences of working during the pandemic. Her influence also reaches beyond Canada. Dr. Gautam has conducted webinars for physicians at the United Nations and physician leaders through the American Association of Physician Leaders. —AC

28: DR. CHIKA STACY ORIUWA Viral valedictorian and CMAJ board member

A psychiatry resident

at the University of Toronto, and now CMAJ advisory board member, Dr. Chika Stacy Oriuwa was valedictorian of the school’s faculty of medicine 2020 graduating class, becoming the first black woman recognized as sole valedictorian. In her online valedictory address, Dr. Oriuwa talks about the fear she felt over becoming an ambassador for the Black Student Application Program, which was developed in response to the low number of black students admitted to the school. The only black student in a class of 259, Dr. Oriuwa realized it was important to share her story, including experiences of isolation and encountering discrimination. “I did not want my story to be written by others,” she said. “I did not want to be inaccurately defined on my own journey and knew that I had to reclaim my narrative.” Dr. Oriuwa’s speech has more than 30,000 views on YouTube and garnered much media attention. Prime Minister Justin Trudeau even tweeted his congratulations, including, “This is only the beginning of

an incredible journey, I’m sure.” We are inclined to agree, Mr. Trudeau. —AC

29: DR. SUSAN SHAW CEO of Saskatchewan Health Authority

When the Medical Post named 20 Doctors to Watch back in 2015, Dr. Susan Shaw was on that list. It looks like we knew what we were talking about. A critical care physician and anesthesiologist, Dr. Shaw is the Saskatchewan Health Authority’s chief medical officer. Throughout the COVID-19 pandemic, Dr. Shaw continues to take ICU shifts and uses her experiences to inform Saskatchewan residents about topics such as the importance of wearing masks and the toll the virus is taking on the healthcare system. Dr. Shaw also chairs the Saskatchewan Health Quality Council and is recognized as a leader in patient and family-centred care and continuous improvement in Canada. —AC

30: DR. JAMES MAKOKIS Two-spirit and Indigenous role model

In a year of increased calls for reconciliation and attention to the barriers faced by people based on their race, sexual orientation or gender identity, Dr. James Makokis is recognized as a role model. A two-spirit doctor in Kehewin Cree Nation with a subspecialty practice in transgender health in south Edmonton, Dr. Makokis consults with organizations on mental health, diversity and culturally sensitive medicine. People from around the world seek his care in the areas of gender transitioning and transgender health. Chair of a National Expert Physician Panel on Indigenous Health, Dr. Makokis is also running to become president-elect for the Canadian Medical Association. In 2019, Dr. Makokis and his husband, Anthony Johnson, became the first Indigenous, two-spirit couple to win The Amazing Race Canada. —AC

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THE MEDICAL POST FEBRUARY 2021 27

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FEATURE

GETTING ADVOCACY RIGHT Doctors have never had more tools to try and influence those in power BY LOUISE LEGER

Getty Images

t’s no secret that physicians are in a unique, and some would say powerful, position to effect change in Canadian healthcare and in the lives of patients. But in a politically complex world and a rapid-fire, multiplatform media landscape, embarking on a campaign championing a new cause or stepping up existing advocacy work can be daunting and rife with potential landmines. Not to mention, it can be challenging to add “activist” to the long list of roles many physicians already play. The Royal College of Physicians and Surgeons of Canada CanMEDS framework lists “advocacy” as one of seven required competencies or roles, stating: “Improving health is not limited to mitigating illness or trauma, but also involves disease prevention, health promotion and health protection. Improving health also includes promoting health equity.” So while physicians are no strangers to advocating on behalf of patients, many are uncertain about how to embark on more public advocacy work. For them, there are resources available, including those from provincial health organizations and the Canadian Medical Protective Association (CMPA). The CMPA website provides articles on advocacy, guidelines for engaging the media and tips for developing an online presence and using social media. The CMPA’s Dr. Todd Watkins, associate executive director and managing director of enterprise services, said calls to the CMPA looking for guidance on advocacy are growing in frequency. “Generally, physicians are concerned about the health system— emergency room overcrowding, patient safety, access to resources for patients,

public safety issues and certainly issues related to COVID-19,” he said in an email interview. “In light of COVID-19, we’re seeing an increase in advocacy as physicians strive to address medical misinformation and advocate for vulnerable patients and regulatory or policy changes to ease the burden on the healthcare system.”

QUESTIONS TO ASK

Advocacy can take many forms. Physicians may want to address a myriad of issues. They may choose to write op-eds, join the board of a non-profit, approach governments or community organizations, give speeches, speak to the media, or engage on social media or create podcasts. In all these cases, it’s a good idea to start by addressing some key questions.

What is the issue and why are you advocating about it?

Being able to distill and articulate simply what you are trying to achieve will keep you on track and serve as a beacon when in the midst of developing your message and navigating politics, challengers and the media. It can also mitigate the risk of getting caught up in sideline causes or taking on too much. Are you well-informed on advocacy guidelines?

When becoming an advocate, doctors are advised to familiarize themselves with the programs policies, or statements about advocacy provided by their provincial/territorial college of physicians and surgeons, medical association or federation—especially policies or guidelines related to advocacy on social

THE MEDICAL POST FEBRUARY 2021 29

FEATURE

media channels, a platform that is new to some MDs. Dr. Watkins advises that physicians consider the appropriateness of the advocacy campaign, and their role in it. “Determine if you need to discuss your planned activity with others who may be affected (e.g., patient/family, other members of the care team, clinic, hospital, health authority, etc.),” he said. “It is good practice for physicians working in hospitals to notify their administration before beginning advocacy efforts. Some hospitals require that the physician obtain hospital permission before engaging in activities that could be interpreted as directly involving the hospital.” Who are you serving?

Dr. Naheed Dosani is a Toronto palliative care physician and health justice activist, who especially advocates on behalf of those experiencing homelessness. His advocacy efforts include education and research, a large and active social media presence and coverage in print and broadcast media. He frequently presents to medical students, physicians, interprofessional colleagues and the public. “The first step really needs to be to listen to your community’s needs,” said Dr. Dosani. “Aggressively take steps to better understand the voices of the people you serve. Without that first step I think we can really go awry and lose perspective of what we’re doing and why we’re doing it.” What are your strengths?

Dr. Dosani said that the next thing to think about is one’s own strengths, skills and talents—then match that to the approach or the vehicle or platform that one decides to use. For some people, writing is a forte. For others, it’s public speaking. Some like using online platforms and social media. “Find your match and make it work for you and the population you serve.” How do you define success?

Dr. Dosani measures success by the changes he sees and recommends other physician advocates do the same. “In my

30 FEBRUARY 2021 THE MEDICAL POST

advocacy, I really try to define successes as changes, as action in policy and the improvement of person-centred care for the people I advocate for. So how are we actually measuring success and what does that look like in the short-, medium- and long-term?” Who are your allies?

Many issues are interconnected, especially as they relate to COVID-19, and experienced advocates say there is strength in numbers. “It’s really important to connect with the community, with your circle of advocates within your community,” said Dr. Dosani. “Building bridges with other advocates, building alliances and relationships with other areas and threads of advocacy, so that we’re not advocating in silos.” Do you have the time?

“Advocacy work tends to take time and failure to influence change can lead to frustration, cynicism, and complacency,” warned Dr. Watkins. Best to make sure now is the right time to take on extra work.

TALKING TO THE MEDIA 101

The CMA, the Royal College and provincial health organizations offer information and/or courses for physicians on social media and traditional media. At the Alberta Medical Association (AMA), Shan Rupnarain, assistant executive director of public affairs, works together with author, former journalist and media trainer Grant Ainsley to offer programs in media relations for doctors. Rupnarain said that while it used to be mostly physician association executives who would be trained, these days more community doctors and grassroots groups are coming in for help. Some, she said, are taking up advocacy causes while other physicians just want to be informed and prepared in case they need to speak to the media. Ainsley said in a phone interview that he sees a lot of apprehension and uncertainty among doctors around speaking to the media. “Once they understand what to expect, how to

prepare for an interview, how to stay on message, how to deal with difficult questions, most of them are extremely, extremely good at dealing with the media.” But here is one common pitfall among doctors that Ainsley sees: TMI (Too Much Information). “Doctors think a little bit differently than others because I think they’re trained in school to gather a lot of information, do tests, do a lot of research and background, etc., and then come to a conclusion. When I do media training with them, I have to keep reminding them that the media doesn’t want all that. They don’t have time. They just want the stuff at the beginning.” In other words, keep it simple. Still, preparation is extremely important. Ainsley helps physicians write down three key messages they want to get across. Of those, he recommends choosing the number-one, final, bottom line message. “What’s the one thing you want everyone to take away?” he said. Media trained or not, to help physicians get prepared, Rupnarain recommends they seek out information from their medical associations on the topic at hand, especially where the associations have taken a position. “Call your provincial or territorial medical association. They may have research or policy material for you, depending on your topic,” she said in a phone interview. “(Their messaging) doesn’t ever bind you to a position . . . but at least you’re aware of (what is being said) and you don’t get caught by surprise. Also, I (or another association communications person) can offer support and tell a physician, ‘Oh, here’s how this reporter normally works,’ so we can give them some insight.” Ainsley said that one of the key techniques they work on in training is “bridging,” for when a physician faces a reporter who is trying to take them off track. One line he recommends doctors use is, “Let me tell you what goes on in my practice.” “Bang, right away you can start them talking about what you’re seeing in your practice,” he said. “You’re speaking from

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FEATURE

the standpoint of somebody who’s in the trenches, who’s there every day doing it. From there, you can bridge back to your key messages.”

SOCIAL MEDIA

While social media shares many of the same rules and guidelines of traditional media, it has some of its own, too. The CMPA website contains several articles, tools and tips for developing an online presence and using social media. Dr. Watkins emphasizes the importance of always maintaining professionalism and integrity. “It is easy to get carried away on social media, but keep the language professional and respectful, and make sure you review the entire thread of a conversation or any embedded links before retweeting,” he said. He urged physicians to keep in mind that advocating in a personal capacity or repeating the comments of others can lead to scrutiny by regulatory authorities and/or hospitals, particularly when the comments could reflect negatively on the medical profession. “Physicians who retweet misinformation about purported cures or treatments can expect questions from their college or hospital,” he said. Dr. Watkins also pointed out that in social media, as with traditional media interviews, op-eds, and speeches, physicians will always be seen as a physician—even if they are advocating in a personal capacity. Dr. Dosani, who has more than 19,000 followers on Twitter, 12,000 on TikTok and more than 4,000 on Instagram, puts it this way: “Being a physician is a great privilege and with that great privilege comes immense responsibility, and this notion is not different when using social media.” He believes if physicians centre their social media communications around the people they care for, they will never stray away from their purpose. “It’s not about followers. It’s not about the number of shares. Let patient care and issues around the people we care for be our moral compass and let that guide us. And keep that near and dear to your heart and soul as you do this important work.”

32 FEBRUARY 2021 THE MEDICAL POST

THE SCOOP

Dreams of beaches and hearing ocean waves every day BY DR. BENJAMIN BARANKIN

DR. LAWRENCE WONG is a cardiologist

in private practice in Vancouver. He graduated from UWO medical school, then did a cardiology fellowship at the Ottawa Heart Institute. He is married and has four children. What is your favourite book?

Around the World in 80 Days. It captures the essence of exploration, which is what every human being is born to do. I have re-read this book many times over the span of the past 30 years. What’s your most recent favourite TV show or movie? What’s one of your top movies?

The Queen’s Gambit on Netflix. Fight Club. It’s so raw. It examines existential issues that every man and woman would face sooner or later in life.

Dr. Lawrence Wong

If you could live anywhere in the world, where would it be?

Somewhere hot, by the beach, where I’d be able to hear the ocean waves every single day. What’s the best restaurant you’ve been to?

Hot steamy shower. It relaxes me with 100% effectiveness.

Thai Tom. 4543 University Way NE in Seattle. You watch the whole process: from how your dish is made from scratch, to how your dishes are cleaned!

Which three people would you like to have dinner with? What topics to discuss and where?

What’s been your greatest travel experience? Where do you hope to travel next?

Do you have any morning rituals?

• Beethoven: about his deafness, by his piano • Lao Tzu: about gardening, at his home • Werner Forssmann: about his self-catheterization, in his lab where he did it

If you weren’t a physician, what do you think you’d love to do instead?

Writing. Writing is arguably the most accessible means for one to maintain an active internal life. It helps the writer to reflect critically, to re-align jumbled thoughts, and to project what can be possible. It’s one of those things that abides by the Pareto principle I think.

Hôtel de Glace (in Quebec). Amongst many things, the sleep within ice blocks was phenomenal. It was so inhumanely cold that we all slept so well. St. Petersburg. I have always wondered what Russia is like. What would you tell your children about going into medicine today?

You gotta love it. The long days, long nights, and many sacrifices that one makes would not be tolerated unless you love what you are doing. What is one of your favourite quotes?

“The things you used to own, now they own you.”

Helping to deliver

The broadest indicated serotype coverage of any pneumococcal conjugate vaccine, including serotypes 3, 6A and 19A1,2*†

A t

t g n t

ut tt m d

d nu t

Prevnar + Prevnar 13: The Prevnar Franchise • >13 years on immunization programs in Canada 3 • >4.5M Canadian children immunized since 20014 >9 years for Prevnar 13 3

Thanks to healthcare professionals like you, Canadian babies can complete the recommended 3-dose schedule of Prevnar 135‡ Prevnar 13 (Pneumococcal 13-valent Conjugate Vaccine) is indicated for active immunization of infants and children from 6 weeks to 5 years of age (prior to the 6th birthday) for the prevention of invasive pneumococcal disease (including sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia) and acute otitis media caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. Consult the Product Monograph at https://www.pfizer.ca/pm/en/Prevnar.pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available on request by calling 1-800-463-6001. IPD: invasive pneumococcal disease. * Data from separate product monographs. † Comparative clinical significance unknown. ‡ Children at high risk for IPD may require a 4-dose schedule. Prevnar (Pneumococcal 7-valent Conjugate Vaccine) has been discontinued in Canada. References: 1. Prevnar 13 Product Monograph. Pfizer Canada ULC. 2. Synflorix Product Monograph. GlaxoSmithKline Inc. August 31, 2018. 3. Public Health Agency of Canada. National Laboratory Surveillance of Invasive Streptococcal Disease in Canada. Annual Summary 2016. 4. Data on File. Pfizer Canada ULC. 2019. 5. Health Canada. Canadian Immunization Guide Part 4 – Active Vaccines: Pneumococcal Vaccines. Available at: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html#a7.

Vaccines

about FETZIMA® 80 mg and 120 mg: Demonstrated significant functional improvement, SDS total score (secondary endpoint)1,3‡

FETZIMA® FOR MDD

FETZIMA® demonstrated superiority over placebo in functional improvement as measured by mean change from baseline to Week 8 in the SDS total score (FETZIMA® 80mg and 120mg -9.7 vs placebo -7.2, p<0.05). • The Sheehan Disability Scale (SDS) is a validated scale that measures the extent emotional symptoms disrupt patients functioning in 3 life domains: work/school, social life and family life.

What is FETZIMA®?

FETZIMA® is an SNRI that preferentially inhibits reuptake of norepinephrine over serotonin by approximately 2-fold.1*

In a flexible-dose study of 429 patients, FETZIMA® demonstrated improvement in the Motivational and Energy InventoryShort From (MEI-SF) (additional endpoint)

What is FETZIMA® indicated for?

Why consider FETZIMA® for your patients with MDD?

FETZIMA® has demonstrated antidepressant efficacy in clinical trials, including symptoms of low motivation and energy.1,2†

How effective was FETZIMA® in clinical trials? Demonstrated antidepressant efficacy as measured by MADRS FETZIMA® significantly improved MDD symptoms vs. placebo at 40 mg, 80 mg and 120 mg doses.1,3‡ MADRS total score mean change from baseline to Week 8 (modified ITT population) 0

Fetzima® 40 mg

Fetzima® 80 mg

Fetzima® 120 mg

LSMD

-1 -2 -3

-3.23

-4

-3.99

-5 p=0.0186

p=0.0038

-4.86 p=0.0005

Adapted from Product Monograph. MADRS: Montgomery-Åsberg Depression Rating Scale. LSMD: least squares mean difference. LS mean difference (95% confidence interval [CI]) from placebo in change from baseline in MADRS total score was -3.23 (-5.92, -0.54) at 40 mg/day, -3.99 (-6.69, -1.29) at 80 mg/day, and -4.86 (-7.59, -2.12) at 120 mg/day.

FETZIMA® significantly improved patient motivation and energy compared to placebo by Week 8, as measured by the MEI-SF.2† MEI-SF improvements at Week 8 Change from baseline (MMRM)

FETZIMA® (levomilnacipran extended-release capsules) is indicated for the symptomatic relief of major depressive disorder (MDD) in adults.1

23.4*

Fetzima® 40-120 mg/day, n=215 Placebo n=214 *p=0.05

18.3

8.0* 5.1

MEI-SF Total score

6.5*

MEI-SF Social subscale

5.9

MEI-SF Cognitive subscale

Adapted from Sambunaris et al.

What is the mechanism of action of FETZIMA®?

FETZIMA® is a potent and selective serotonin and norepinephrine reuptake inhibitor (SNRI). The exact mechanism of the antidepressant effect of levomilnacipran is unknown but is thought to be related to the potentiation of these neurotransmitters in the central nervous system.1§

What is the selectivity of FETZIMA® for norepinephrine (NE) vs. serotonin (5-HT)? Levomilnacipran inhibits the uptake of both NE and 5-HT in vitro and in vivo; preferentially inhibiting reuptake of NE over 5-HT by approximately 2-fold.1§

FETZIMA®

What is the recommended dosing for FETZIMA®? FETZIMA® provides once-daily dosing and flexible titration.£

INITIATE x2 days

20mg

40mg

80mg

120mg

TITRATE

Periodically reassess and increase by increments of 40 mg daily based on clinical judgment

Initial treatment1 • The recommended dose range for FETZIMA® is 40 mg to 120 mg once daily. • FETZIMA® should be initiated at 20 mg once daily for 2 days and then increased to 40 mg once daily. • In clinical studies, added benefit was not consistently demonstrated for doses greater than 40 mg/day. If the physician, based on clinical judgment, decides a dose increase above 40 mg/day is warranted for an individual patient, the dose may be increased in increments of 40 mg. • The maximum recommended dose should not exceed 120 mg/day. Maintenance/continuation/extended treatment1 Long-term efficacy of FETZIMA® for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was established in a placebo-controlled trial. It is generally agreed that acute episodes of MDD require several months or longer of sustained pharmacologic therapy. Physicians choosing to use FETZIMA® should periodically reassess patients to determine the need for continued treatment. * Comparative clinical significance has not been established. † Sambunaris et al. A phase III, double-blind, placebocontrolled, flexible-dose study comparing 40 to 120 mg/d of Fetzima® with placebo in adult MDD patients. Patients were randomly assigned to received placebo (n=220) or Fetima® (n=222). Patients received Fetzima® were initiated at 20 mg/d for days 1 and 2, and 40 mg/d on day 3. Dosage increase form 40-80 mg/d was allowed at the end of week 1 or 2, and an increase from 40 to 80 mg/ day or 80 to 120 mg/day at the end of week 4, based on patient response and tolerability. ‡ Asnis et al. An 8-week, multicentre, randomized, doubleblind, placebo-controlled, parallel-group, fixed-dose study conducted in adult MDD outpatients (age 18-65). Patients were randomly assigned to receive placebo (n=176) or once-daily Fetzima® 40 mg (n=178), 80 mg (n=179) or 120 mg (n=180). Patients had a mean baseline SDS score of 21.1,3 § Clinical significance has not been established. £ Please see the Product Monograph for complete dosing and administration instructions.

FETZIMA® demonstrated an excellent tolerability profile in clinical trials (40–120 mg/day). A total of 895 patients were exposed to FETZIMA® for at least 6 months and 367 were exposed for one year.1 The most commonly observed adverse events (incidence ≥ 5% and at least twice the rate of placebo) were: nausea (17%), heart rate increased (6%), erectile dysfunction (6%), hyperhydrosis (9%), constipation (9%), tachycardia (6%), vomiting (5%) and palpitations (5%).1 In the short-term placebo-controlled pre-marketing studies for MDD comparing FETZIMA® (n=1,583) to placebo (n=1040):1 • 9% of FETZIMA® patients discontinued therapy due to adverse events compared to 3% for placebo. • The most common adverse event leading to discontinuation was nausea (1.5%). Drug-food interactions Although food has no clinically meaningful effect on the bioavailability of FETZIMA®, vomiting and nausea were markedly reduced when FETZIMA® was taken with food.1 Cardiovascular Inhibition of the reuptake of norepinephrine (NE) and serotonin (5-HT) can lead to cardiovascular effects. Patients with severe cardiac function impairment or with an identified risk of a serious cardiac arrhythmia, uncontrolled hypertension, or severe or unstable coronary heart disease were excluded from clinical trials with FETZIMA®. SNRIs, including FETZIMA®, have been associated with increased heart rate. FETZIMA® is contraindicated in patients with a history of myocardial infarction or cardiac intervention (within past 12 months), NYHA Class III or IV congestive heart failure, uncontrolled tachyarrhythmia, uncontrolled hypertension, or a history of cerebrovascular accident (see fair balance below). Blood pressure and heart rate should be measured prior to initiating treatment and periodically throughout treatment with FETZIMA®.1 Weight In short-term clinical studies, FETZIMA® patients experienced a mean weight loss of 0.59 kg compared to a gain of 0.02 kg for placebo-treated patients. The proportion of patients with a weight gain >7% was 0.6% in the FETZIMA® group and 0.9% in the placebo group. No dose-related weight changes were observed. Results from a one-year open-label study were consistent with the findings from the placebo-controlled studies.1

Indication and clinical use: FETZIMA® (levomilnacipran extended-release capsules) is indicated for the symptomatic relief of major depressive disorder (MDD) in adults. The efficacy of FETZIMA® was established in randomized, double-blind, placebo-controlled trials of up to 8 weeks. The efficacy of FETZIMA® in maintaining an antidepressant response for up to 26 weeks following response during 20 weeks of acute, open-label treatment was demonstrated in a placebo-controlled trial. Caution should be exercised in treating patients >65 years of age with FETZIMA®. FETZIMA® is not indicated for use in patients under the age of 18. Contraindications: • Patients who are currently taking, or within two weeks of terminating MAOIs including linezolid or methylene blue due to risk of serotonin syndrome • Patients who have a history of myocardial infarction or cardiac intervention (within 12 months) • Patients with NYHA Class III or IV congestive heart failure • Patients with uncontrolled tachyarrhythmia • Patients with uncontrolled hypertension • Patients who have a history of cerebrovascular accident Most serious warnings and precautions: Behavioural and emotional changes: The use of SSRIs and other newer antidepressants in patients under the age of 18 may be associated with behavioural and emotional changes, including increased risk of suicidal ideation and behaviour. Rigorous clinical monitoring for suicidal ideation or other indicators of potential for suicidal behaviour is advised in patients of all ages. Patients, their families and their caregivers should be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, other unusual changes in behaviour, worsening of depression and suicidal ideation, especially when initiating therapy or changing dose or dosage regimen. Discontinuation symptoms: Patients should not discontinue FETZIMA® abruptly, due to risk of discontinuation symptoms such as dysphoric mood, irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus and seizures. When discontinuing FETZIMA®, reduce the dose gradually whenever possible. Other relevant warnings and precautions: • Bone fracture risk • Cardiovascular issues such as elevated blood pressure, hypertension and increased heart rate • Dependence/tolerance

• Diabetic patients on insulin or other antidiabetic drugs • Urinary hesitation, retention and dysuria • Hyponatremia • Abnormal bleeding • Seizures • Serotonin syndrome • Narrow angle glaucoma • Activation of mania/hypomania • Dosage adjustment is necessary in patients with renal impairment • Sexual Function/reproduction • Pregnant or nursing women • Labour and delivery • Monitoring and laboratory tests: self-harm, heart rate and blood pressure, serum cholesterol, serum glucose For more information: Consult the Product Monograph at www.allergan.ca/FetzimaPM/Eng/101 for important information regarding adverse reactions, drug interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling Allergan Inc. at 1-800-668-6424.

FETZIMA® and its design are registered trademarks of Pierre Fabre Medicament S.A.S., used under license by Allergan Inc., an AbbVie Company.

References

1. FETZIMA Product Monograph. Allergan Inc., 2019 2. Sambunaris A, Bose A, Gommoll CP, Chen C, Greenberg WM, Sheehan DV. A Phase III, Double-Blind, PlaceboControlled, Flexible-Dose Study of Levomilnacipran Extended-Release in Patients With Major Depressive Disorder. J Clin Psychopharmacol. 2014;34(1):47-56. doi:10.1097/ JCP.0000000000000060 3. Asnis GM, Bose A, Gommoll CP, Chen C, Greenberg WM. Efficacy and Safety of Levomilnacipran Sustained Release 40 mg, 80 mg, or 120 mg in Major Depressive Disorder: A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study. :7.

CA-FTZ-2050040

What is the safety profile of PRFETZIMA®?

Back Pages

COLUMN

Are women physicians gaining power?

s of 2019, 43% of Canadian physicians were female. Yet women aren’t taking over the highest leadership positions according to a 2018 review by the CMAJ. Sure, we are making significant strides (see the Medical Post's Power List, page 18), but there is still much room for improvement. Why are more women not in the

36 FEBRUARY 2021 THE MEDICAL POST

higher leadership roles in medicine? I asked some physicians I know and found there are four key roadblocks.

THE OLD BOYS’ CLUB

“Women who excel or speak out are seen as troublemakers and threats to typical people in charge,” said Dr. Anonymous. “Women are told to be happy with what they have and practise mindfulness.”

“Unconscious bias is common amongst male physician leaders,” said Dr. Courtney Howard, the Yellowknife ER physician who came third in the 2020 Green Party leadership race. “Female leaders are often explicitly welcomed, but when our comments and priorities become inconvenient, we are gaslit or sidelined.” One B.C. physician said: “Unless one

Getty Images

While they are very slowly taking on more leadership roles, the roadblocks are ever-present

BACK PAGES

BY DR. MELISSA YUAN-INNES

spoke very loudly, older male physicians interrupted a lot. I got very good at cutting them off.” “The arrogance of the old boys’ club was a big turnoff to continuing in medical politics,” said Dr. Gabrielle Ledger, a psychiatrist and former medical school leader. “The Ontario Medical Association folks were fine, but the actual politicians were gross.” “Even with COVID, some hospital heads only call upon the same five males, creating fewer opportunities for women: ‘Apply, apply, no reply,’” said Dr. Jemy Joseph. “You would not believe the hoops I had to crush just to become lab med director!” said Dr. Kona Williams, a Sudbury forensic pathologist.

FAMILY RESPONSIBILITIES

“Domestic servitude. Full stop,” said Dr. Anonymous II, about why women aren’t taking leadership roles. “We still carry much of the work at home. This needs to change,” said Toronto anesthesiologist Dr. Anahi Perlas. “Society strongly suggests that our giving up precious time with our kids to work makes us bad mothers, whereas men giving up precious time with their kids makes them good physicians,” said Dr. Anonymous III. “I suspect male physicians are more likely to have a stay-at-home or part-time working partner,” said Dr. Anonymous IV. “Although my husband does a lot, I still shoulder the mental work of organizing everything for our family,” said Dr. Lori Wik, a B.C. internist. “Women who reach for leadership can pay many non-monetary penalties at home and in society—disapproval, family

“Women are told to be happy with what they have and practise mindfulness.”

and marital discord, and shame,” said Dr. Anonymous V. “Addressing inequality at home takes time, energy and emotion— which detracts from work performance.” Women must choose between leadership and time with their small children. “I had lofty goals prior to and even during medical training,” said Dr. Michelle Liebregts, ER physician. “Then I became a mom and everything changed. My daughter needs me more than anyone else in the world. She does not see me as interchangeable with Dad. That means not taking on roles to gain experience in leadership or academics or whatever the case may be.” The patriarchy gloats: “See, that’s why we can’t hire women!” No. Some of us might choose to lead less during those years. Some of us miraculously lead while working more than full-time and juggling family. Partners need to step up. Society needs to throw parades instead of guilt.

LACK OF PAYMENT

“Leadership roles in medicine are frequently unpaid or severely underpaid. As chief of the department, I made about $20 per hour,” said Dr. Anonymous VI. “I have been offered multiple leadership roles that are unpaid or require a 30% or more pay cut. No man in my department would even consider

doing them,” said Dr. Anonymous VII. It’s even worse for more marginalized groups. “I find women physicians, especially those who are BIPOC—Black, indigenous, people of colour—are asked to take on many positions but are unpaid for the time and work involved,” said Dr. Williams. Many women pointed out such intersectionality. “When women dominate, the pay will decline even more,” said Dr. Teela Johnson, a Toronto hospitalist. “We aren’t in the habit of valuing our work to the same degree as men. Despite it often being much higher quality.” “These positions are time-consuming and either unpaid or underpaid,” said Dr. Lisa Iannattone, Montreal dermatologist. “We already make less than our male colleagues. Sometimes it’s by choice to balance work and family, but most of the reason is due to the gender pay gap. We disproportionately take on more complex cases and patients that take more time for less pay. If we fix the gender pay gap, I think we’d see more women in these roles.” “My worry is that women are taking over the power positions of medicine but are not historically geared toward fighting for financial compensation,” said Dr. Christine Johns. “Governments are delighted to have women take over social programs paid out of the public purse

THE MEDICAL POST FEBRUARY 2021 37

BACK PAGES

because women demand less money.” “We’re seeing an increase of women in the lower roles that, often, are unpaid or paid lower than clinical work, so it’s still a loss of income to do the work,” said Dr. Anonymous VII.

THE PATH LESS ACCEPTED

“When my daughter is older, I’ll happily spend more of my time doing education/ research/leadership. I wish that was a more accepted path,” said Dr. Julia Traer, an ER physician. But some see that path as less than ideal. “Would I be out of the track by then because I haven’t engaged as fully during the years when my kids are quite young?” asked Dr. Jennica Platt, a Toronto plastic surgeon. “It’s harder to enter leadership later, when your equally aged male counterparts are now more experienced,” said Dr. Christina Raimondi, a Winnipeg FP. “We need flexible roles with better pay,” “You’ve not demonstrated interest, or you have a gap in experience,” said Dr. Liebregts. “It’s OK to not do everything, as long as there’s an opportunity to jump back in the path when you’re ready. Maybe this winding path is good for men, too.”

OK TO NOT WANT TO BE PM

“I dislike admin and committee meetings. I stick to patient care and recreational activities I enjoy,” said Dr. Anonymous VIII. “Women are moving mountains, just one pebble at a time,” said Dr. Nathalie Slaney, a Sudbury FP. “Leadership does not always require a title. Women are changing medicine 100%. Many of us are leaders simply by way of being female physicians,” said Dr. Anonymous IX. “Formal leadership remains important. While we advocate for better representation, we need to celebrate the leadership we bring to the work we do every single day.”

WHERE DO WE GO NOW?

Several doctors mentioned the importance of redefining leadership. “Draw a distinction between the low/mid-level leadership positions (committee work, clinic medical

38 FEBRUARY 2021 THE MEDICAL POST

“Women who reach for leadership can pay many non-monetary penalties at home and in society— disapproval, family and marital discord and shame.”

director, smaller academic positions) and the really high ones like CEOs,” said Dr. Anonymous VII. “We’re seeing an increase of women in the lower roles that, often, are unpaid or paid lower than clinical work, so it’s still a loss of income to do the work.” “Consider the different types of hospitals—i.e., size, downtown academic vs. community—since their impact on the medical/research community is quite different,” said Dr. Joan Cheng, who will become Chief of Emergency Medicine at Unity Health-St. Joseph’s Health Centre. “Get away from the idea that having women in leadership is a checkbox that means an organization has dealt with gender bias,” said Dr. Lesley Barron, a general surgeon and 2019 federal Liberal candidate who has relocated to Australia. “Most women who are allowed into leadership positions in medicine are the least vocal about gender issues, and that’s not an accident. It’s why there are rarely policy changes made to improve sexism in medicine.” “If they’re having ‘a hard time’ looking for qualified women, they aren’t looking hard enough or making the job palatable enough,” said FP Dr. Sandy Tecimer. Dr. Venus Valbuena, a hospitalist at Guelph General Hospital, in Ontario, suggests integrating questions into interviews, such as, “Give examples of when you supported gender diversity or the advancement of women in your

current or past workplace.” Representation varies with geography. Dr. Lynora Saxinger, an infectious diseases physician, describes “a lot of female leadership at the University of Alberta.” Yet two hours away, another colleague noted the “wall of white men” at the University of Calgary. It also varies with medical specialty. Dr. Connie Nasello, an obstetriciangynecologist, noted that, including retired MDs, every surgical specialty is 74% to 95% male, except obstetrics and gynecology. “The OMA has changed since I got involved, largely due to the people who got involved,” said Dr. Nadia Alam, 2018/19 OMA president. “The OMA today is much more responsive and more connected to its members than in the past. But there is always room to grow, as we have seen.” “It is sloooowly shifting, but we need to be relentless in our push to keep advancing ourselves forward. You can’t be it if you can’t see it,” said Dr. Cheng. Dr. Howard agrees. “We know that an increased proportion of female decision-makers is associated with more health, environmental, and familyoriented policy. We all have a stake in having more women around the table.” Some comments have been edited for length and clarity. DR. MELISSA YUAN-INNES is

an emergency physician in Alexandria, Ont.

ABOUT what is new in eosinophilic esophagitis (EoE) treatment • Due to its effervescence, which starts after JORVEZA comes in contact with saliva, JORVEZA stimulates further saliva production.1 • The orodispersible tablets deliver budesonide to the esophageal mucosa by utilizing this saliva production.1†

Budesonide Mucosa Saliva

Introducing JORVEZA The first and only medication indicated for induction of clinico-pathological remission in adults with eosinophilic esophagitis (EoE).1* What is JORVEZA? JORVEZA™ (budesonide orodispersible tablet) is a locally-acting corticosteroid.1†

Indication JORVEZA is indicated for induction of clinico-pathological remission in adults with eosinophilic esophagitis (EoE).1

Please consult the Product Monograph for complete dosing and administration instructions.

What is the dosing for JORVEZA? JORVEZA provides convenient BID dosing.1 • The recommended daily dose is 2 mg budesonide as one 1 mg tablet in the morning and one in the evening. • The usual duration of treatment is 6 weeks.

What patients were shown to be diagnosed with EoE? EoE is a frequent diagnosis in patients with dysphagia.2 • 33%-35% of patients with dysphagia are diagnosed with EoE. • EoE is more common in patients with a history of food allergies or asthma.

What is the mechanism of action of JORVEZA?1† • Budesonide acts primarily as anti-inflammatory via binding to the glucocorticoid receptor. • The exact mechanism of action in the treatment of EoE is not fully understood. • JORVEZA may inhibit antigen-stimulated secretion of many pro-inflammatory signal molecules, which may result in a significant reduction of the esophageal eosinophilic inflammatory infiltrate.

What is new about this budesonide formulation? Convenient JORVEZA orodispersible tablet is a new formulation of the active ingredient budesonide. • JORVEZA dissolves slowly in the mouth – usually in about 2 minutes.1

Pack of 90 tablets

Please consult the Product Monograph for complete dosing and administration instructions. * Comparative clinical signiﬁcance is unknown. † Clinical signiﬁcance has not been established.

Clinical use: Not authorized for pediatric (<18 years of age). Not been adequately studied in the elderly (≥65 years of age). Contraindications: • Uncontrolled infections • Active tuberculosis Relevant warnings and precautions: • Avoid concomitant treatment with ketoconazole or other CYP3A4 inhibitors • Monitor patients with tuberculosis, hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma, cataract, family history of diabetes or family history of glaucoma for systemic glucocorticosteroid adverse reactions • Supplementary systemic glucocorticoid treatment is recommended for patients subject to surgery or other stresses

• Systemic effects of steroids may occur, particularly when used at high doses and for prolonged periods • Exercise particular care in patients transferred from glucocorticosteroids with higher systemic effects. Tapering of dose and monitoring of adrenocortical function may be needed • Feeling of being unwell during withdrawal, or flare up of allergies previously controlled by the conventional systemic corticosteroid • Rare cases of general insufficient glucocorticosteroid effect • Do not use in patients with hepatic impairment • Symptomatic candidiasis of the mouth and throat can be treated with topical or systemic anti-fungal therapy while continuing JORVEZA treatment • Check vaccination status in patients who have not had chickenpox, herpes zoster, or measles. Consider reduction or discontinuation of glucocorticoid treatment if patients are infected or suspected of being infected. • Avoid co-administration of live vaccines. Antibody responses to other vaccines may be diminished. • If symptoms such as blurred vision or other visual disturbances occur, refer patient to an ophthalmologist • Particular care is required in patients with current or previous history of severe affective disorders, or such history in any first-degree relatives • Use caution in patients with mild to moderate renal impairment. Not recommended in severe renal impairment • Avoid use in pregnancy • Take into account benefits/potential risks of breast feeding for the child and the benefit for the woman For more information: Please consult the product monograph at http:// www.avirpharma.com/pdf/Product-MonographJorveza.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 1-800-363-7988. References: 1. JORVEZA™ Product Monograph. Avir Pharma Inc. November 5, 2019. 2. Liu LWC et al. Clinical practice guidelines for the assessment of uninvestigated esophageal dysphagia. J Can Assoc Gastroenterol 2018;1(1):5-19. doi: 10.1093/jcag/gwx008. eCollection 2018 Apr. AVIR Pharma Inc., Blainville (QC), Canada, J7C 3V4 www.avirpharma.com JORVEZA™ is a trademark of Dr. Falk Pharma GmbH, used under license by AVIR Pharma Inc.

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5 clinical pearls for introducing antidepressants Two experts run down their best tips BY KYLIE TAGGART

here are guidelines on how to introduce antidepressants in patients with clinical depression, but doing it successfully goes far beyond knowing clinical trial results. Here are five “clinical pearls” on how to introduce antidepressants in a primary care setting from Dr. David Goldbloom and Dr. Jon Davine, who together co-edited a pocket guide to psychiatry for primary care practitioners. Dr. Goldbloom is a psychiatrist and senior medical advisor at the Centre for Addiction and Mental Health in Toronto, and Dr. Davine is an associate clinical professor in the departments of psychiatry and family medicine at McMaster University in Hamilton.

40 FEBRUARY 2021 THE MEDICAL POST

1. MEASURE SUCCESS

Measurement-based care has been shown to be effective for treating clinical depression, Dr. Goldbloom said. “You’re going to get a better lay of the landscape by using measurement rather than your gut feel,” he said. Rating scales such as the Patient Health Questionnaire-9 (PHQ-9) or the General Anxiety Disorder questionnaire-7 (GAD-7) can be used to track progress. To help manage time, Dr. Davine suggests getting patients to fill out assessments at home prior to an appointment. He noted that the rating scales are only adjuncts to the clinical interview. There are other ways to meaningfully

2. BRING HOPE AND TRUST TO THE THERAPEUTIC RELATIONSHIP

Dr. Davine said it is important to remind patients that, in general, treatment does work well. Tell them that things will get better and to remember that on the darker days, he said. Patients should also understand that antidepressants do not change who they are and are not addictive, he said. It can be challenging to discuss sideeffects without discouraging patients, but make sure the conversations emphasize hope and support, Dr. Goldbloom said. He suggested saying: “You may experience some of them, or you may experience none of them, but in either case, I’ll be monitoring your treatment closely.” “I think it is worth stating what the common ones are, but also really worth stating that you’re going to keep an eye on the patient for side-effects, so that the burden of self-monitoring isn’t exclusively borne by the patient,” Dr. Goldbloom said. Dr. Goldbloom said frequent meetings in the early stages of the treatment process help cement the relationship

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CLINIC

measure progress. One is simply to ask people who live with the patient or know the patient. “The reason that I emphasize that is that for some patients with depression, their perception of improvement is coloured by the fact that they’re living in their own skin 24/7, whereas people who are encountering them intermittently are more likely to pick up early signs of change,” Dr. Goldbloom said. For example, a person with depression may say they are no better, yet a family member may counter that the patient is more engaged. Their comments may herald early signs of response, Dr. Goldbloom said. Ask the patient about people they are connected to and who know them best. “Even people who live alone, at least some of them, are connected virtually with other people,” he said. For example, even if someone just communicates with the patient through phone, text or email, the speed at which the patient answers could be a clue that the medication is having an effect.

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between doctor and patient. “It is also building in trust, hope and a sense to the patient that they are in the hands of someone who knows what they are doing,” he said. The frequency of appointments is up to the physician, but there should be more regular check-ins if the patient is having suicidal thoughts. If someone is safe, Dr. Davine said that he’d certainly see them at least once a week at first for a number of weeks. “They can be brief interviews,” he said. These early-stage weekly checkins allow a physician to monitor the emergence of side-effects and the beginnings of clinical response. They also help reduce “the isolation and anxiety of people who are struggling with depression and who are feeling ashamed or unworthy, or any of those kinds of feelings that are part of being depressed,” Dr. Goldbloom said.

3. WATCH FOR RED FLAGS

Ask patients of all genders taking antidepressants about decreases in sexual function or interest—a side-effect of a number of antidepressants—even if the conversation may be uncomfortable. “What makes this tricky is that depression has its own negative effect on sexual drive. So really what you are looking for is a worsening since starting the medication,” Dr. Goldbloom said. There are other red flags to watch for, such as extreme agitation or emotional numbing. Dr. Goldbloom said getting information from people close to the patient will help identify these problems. “Again, this is where collateral from people who are with the patient more than the physician can make the difference,” he said.

4. DON’T FORGET ABOUT OTHER THERAPY

Studies have shown that both counselling and medical treatments are more successful in treating clinical depression when combined, Dr. Davine noted. Online programs are making counselling more accessible, Dr. Davine said. “I think that is where we are going to be heading in today’s world,” he said. He cited examples such as Ontario’s

BounceBack program, moodgym from Australia, and apps such as MoodKit or Anxiety Canada’s MindShift. Dr. Davine also said that regular exercise should also be combined with medical treatment for clinical depression.

5. ENCOURAGE YOUR PATIENTS TO KEEP TAKING THEIR ANTIDEPRESSANTS

Encourage patients to take the medication regularly to avoid discontinuation syndrome, a common issue with some antidepressants. “You don’t want to stop these pills abruptly. It is not a dangerous thing, but it is uncomfortable,” Dr. Davine said. Discontinuation syndrome involves flulike symptoms, nausea, insomnia and the feeling of electric shocks in the head. The symptoms go away when antidepressants are resumed. Patients may be tempted to stop treatment when they experience sideeffects. “It is important to say that for most of them, if they’re not horrible, to hang on for a few days,” Dr. Davine said. For many antidepressants, initial sideeffects disappear after a few days. A lack of response may also make patients want to discontinue antidepressants. Dr. Davine said family physicians should make it clear to patients that, “If we start you on a certain dose and it doesn’t help you, don’t stop it, because what we might want to do is go higher,” he said. Physicians should also inform patients that another medication can be added to augment the response. “If the patient has not shown any response after six weeks at a reasonable and tolerable therapeutic dose, the return on investment of that medication is going to dwindle exponentially,” Dr. Goldbloom said. While it is not impossible that they may respond after six weeks, it is less likely. Also, the patient may feel a sense of hopelessness about treatment. “At that point I think it is reasonable, if they’ve had a partial response, to look at augmentation strategies, and if they’ve had no response, to look at switching,” he said. Once a patient is feeling like themselves again, ask them to continue

“You don’t want to stop these pills abruptly. It is not a dangerous thing, but it is uncomfortable.” taking the antidepressants for at least six months, Dr. Davine said. This is because there is a risk of relapse if they stop the medications too soon. If they have a second episode, Dr. Davine said he would recommend staying on the medications for 12 to 18 months after a response could be considered. For patients with recurring episodes, maintenance can be extended, and in some cases, left open-ended, Dr. Goldbloom said. However, the evidence showing medication prevents relapses is less strong for longer treatment times. Of course, the length of treatment also depends on the patient’s wishes and priorities. “We also have some very good evidence about non-pharmacological treatment such as mindfulness-based cognitive therapy in preventing relapse in those who experienced benefit from medication,” he added. When discontinuing medication, make sure you have a plan. It is helpful to discuss the patient’s own early warning signs that they are getting sick, Dr. Goldbloom said. “For lots of patients, their own experience of depression has a tell-tale signature.” For some it is a sudden loss of sleep, a feeling in the pit of their stomach, or a loss of zest for life that is out of character. Knowing their own symptoms of depression, writing it down and acting on them is helpful. Physicians and patients can plan on what to do if symptoms reoccur. For example, the physician can say: ‘Call me if this starts to happen.’” “We know that for many people, unfortunately, depression is a recurring illness,” Dr. Goldbloom said. Having a plan on how to recognize a relapse will allow patients to get the help they need more quickly, hopefully putting them on the road to another recovery.

THE MEDICAL POST FEBRUARY 2021 41

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PRACTICE MANAGEMENT

Mental health care and the virtual visit

t is well-known that the pandemic has led to increased or worsening mental health in Canada. A recent poll from Mental Health Research Canada found 22% of surveyed Canadians reported they had been diagnosed with depression, with another 20% saying they had received an anxiety disorder diagnosis. Both of those rates are the highest MHRC has measured, and both are four percentage points higher than before the pandemic. Self-reported feelings of anxiety and depression were also found to be at all-time highs. The pandemic has (and undoubtedly will continue to) increase the workload of psychiatrists—and for FPs, who are often the first point of contact when mental health issues emerge. Dr. Gail Beck, clinical director of the

42 FEBRUARY 2021 THE MEDICAL POST

Youth Psychiatry Program at the Royal Ottawa Mental Health Centre, pointed out, “It’s often easier to speak with the family doctor you’ve known all your life than to a psychiatrist you’re just meeting.” Fortunately, virtual care has proliferated during the pandemic and is a reasonably good conduit of mental health care. “People are becoming emotionally exhausted, irritable and have less to give each other—both at work and at home,” said Dr. Mamta Gautam, an Ottawa-based psychiatrist, pointing out that while FPs can and do play an important role in mental health care during virtual and in-person visits, any increased expectation to spot and treat mental illness can be difficult for already overburdened FPs.

“The full mental health impact of the pandemic is still ahead, escalating as we lose loved ones, get sick or know those who are sick, and deal with the ongoing uncertainty,” she said. “As people struggle, we can see the impact in poor interpersonal communication and collaboration. The mental health of the carers—physicians—needs to be supported as a priority too.” At a time when mental health needs are higher than before, mental health providers have been able to step up the delivery of mental health services virtually. “While lots of medical services requiring physical interaction have obviously been decreased, we’ve seen sustained, or even increased, provision of psychiatric care to our patients in

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As an increasing number of Canadians suffer from mental illness, FPs are being called on to help even more BY LOUISE LEGER

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need,” said Dr. K. Sonu Gaind, associate professor of psychiatry at the University of Toronto and chief of psychiatry at the Humber River Hospital. “While virtual care can have its own challenges, it still allows us to do a lot to meet population needs, including to populations otherwise isolated by geographic barriers,” said Dr. Gaind. Dr. Beck sees many advantages with virtual care for delivery of mental healthcare. “The wide acceptance of virtual care in mental health has benefitted youth with mental health problems,” she said. “My colleagues and I are noting good attendance and participation in virtual assessment and therapy sessions. Virtual care also has benefits for parents as they no longer have to spend as much as half a day getting their child to and from an appointment. There’s no time off work, less time off school, no worries about childcare for siblings, no transportation costs and no parking fees.” Another positive, she said, is that since ”stigma is real,” it’s much easier for patients to meet with her virtually than to walk into the often-dreaded psychiatric hospital. On the other hand, said Dr. Gautam, “Virtual care prevents seeing patients in person, seeing body language and nuanced responses. And patients may not have privacy to speak—I have many patients who are in their car when I call them. Ensuring privacy and confidentiality to provide safe space is key.” Dr. Beck agreed: “When I am seeing a young person for treatment, my greatest worry is that it’s easier for others to listen in on a virtual session than it is behind the closed door of my office.” To offset this, Dr. Beck said she always asks a youth where they are and whether they are confident that they are able to speak privately. “This is not a guarantee of privacy, but it is a reminder that privacy is best. I have had parents tell me they want to be present and I remind them that this will limit my capacity to provide the best assessment and treatment. I also confirm that I am not recording a session and ask that the patient confirm this as well.”

VIRTUAL CARE HOW-TO

Dr. Gautam suggested that when physicians think a patient may be experiencing mental health issues, they should normalize it, asking key questions like the following: • “Many people are finding it difficult to cope emotionally as the pandemic continues. How are you managing?” • “I am hearing from my patients about how hard it is to work and home school. How are you managing all that?” • “Many people are having trouble falling asleep or are waking up during the night. How are you sleeping?” Not surprisingly, experts warn that those who are particularly susceptible to mental illness during the pandemic are youth, those living alone, single parents, those with pre-existing mental illness and the elderly (who often also live alone). “Even before the pandemic, loneliness in the elderly had increasingly been considered a disease,” said Dr. Gaind. “You can imagine how much worse pandemic distancing restrictions have made things for our elderly. At the other end of the spectrum, a key part of helping children and adolescents with mental health needs has always been integrating them with strong community supports and programs, said Dr. Gaind, “and most of these have now been suspended. So while kids are now cooped up at home, immersed in what could be called ‘family dynamics on steroids,’ they have also lost community supports that could otherwise help them.” For those who had existing mental illness, Dr. Gaind said, “from increased worry and ruminations if you already suffered from an anxiety disorder, to social isolation fuelling withdrawal if you already had depression, pandemic changes can play into the very symptoms of patient illnesses.” Therefore, Dr. Gaind encourages physicians to check on people in those at-risk categories and also, where possible, to ask about changes in habits. “People react in different ways to stress, especially prolonged stress, and if we’re not careful we can miss harmful behaviour changes since they get written off as ‘habits,’ or are not

“People react in different ways to stress, especially prolonged stress.” reported,” he said. “For example, alcohol and substance use are up even in people who have not previously had substance use problems. Rates of domestic violence have increased. Binge TV watching and unhealthy eating behaviours are on the rise. So while we obviously have to monitor for worsening symptoms in patients with known mental illness, if we only focus on illness symptoms, we can miss these other more insidious changes.” Meanwhile, Dr. Beck said many patients have reached out for help during the pandemic, but she is most concerned for those who haven’t. “These are the youth with severe anxiety disorders, developing psychoses and serious depressive symptoms.” Her message to the many primary doctors caring for youth in their practices is, “if they get a chance, to reach out—or have someone in their practice reach out—to those who have not called. However, with everything expected of family physicians, this is going to be difficult. So . . . I am grateful to each of them for their kindness and devotion to the youth they care for.” On the positive side, technologies like Zoom that have risen during the pandemic have proven to be advantageous to group mental health programs. Physicians or other healthcare providers can hold information sessions for patients who might be struggling, said Dr. Beck. Patient groups can also be formed or encouraged to offer peer support and reduce isolation. Dr. Gautam, in fact, has set up such a peer-support daily Zoom meeting for physicians. After all, the carers need care, too.

THE MEDICAL POST FEBRUARY 2021 43

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SOLVE MY PROBLEM

How do you respond professionally if a patient makes a really inappropriate comment? IGNORE THEM, OR. . .

I often just ignore patients who make a sexist or racist comment. But a patient once commented that we were wasting money on the war zone refugees, while she could not get coverage from the government to pay for extra home care that she wanted after she had knee replacement surgery. I could not help myself: I said to her, “Those are lives, surely a compassionate and religious person like you would never have said that if you were feeling well.” She never did again.—DR. XIN CHONG

‘CALLING IN,’ NOT ‘CALLING OUT’

I say, “I’m sorry, I think I missed what you said. I heard something really troubling and I’m sure you didn’t say that.” This can be a way of “calling in” rather than “calling out.” I’m slowly learning that “calling out” people on their comments leads them to become more firmly entrenched in their position. In reading the book White Fragility: Why it’s so Hard to Talk to White People About Racism, I learned quite a bit about how white people react to being called racist— it almost never goes well. By giving people an out, it seems to give people a way to save face and maybe, just maybe, rethink what they were saying.—DR. SARAH GILES

44 FEBRUARY 2021 THE MEDICAL POST

EXPRESS DISAPPOINTMENT

As a much older GP (I liked being called a GP, because I always looked after more than just “families”), in past years when in practice I would have responded something like: “That thought you mentioned disappoints me. Consider that many of the greatest achievements in science, medicine and world leadership and much more, have been made by many of these (insert group) that you have just mentioned.” Simple, but was always effective. That said, when an elderly patient (who I thought was a very “wonderful” person) took me to task for having sent her to a black specialist, we parted ways very quickly.

DR. XIN CHONG A family physician in Niagara Falls, Ont.

DR. SARAH GILES A remote and rural family/ emergency doctor

—DR. FRANK POCE

DELIBERATELY MISUNDERSTAND

Interview/consultation with a patient in the old days was a personal and sometimes intimate one-onone experience. There were, and still are, boundaries which, especially on the part of the physician, must not be breached. Sometimes the patient is just being naughty, looking to elicit a shocked response from the doctor. The risk the doctor takes in responding in kind could lead to (horrors) college complaints. Responding

“My advice is simply to deliberately misunderstand the comment and continue with another subject.” with a short lecture on propriety risks damaging a doctor-patient relationship. My advice is simply to deliberately misunderstand the comment and continue with another subject. For the author to have to explain the comment might well be an embarrassment to be avoided. The doctor only runs the risk of being thought slightly dense. One can live with that. —DR. SELBY FRANK

DR. FRANK POCE A semi-retired GP in Kingston, Ont.

Next Problem

What methods does your practice use to track and encourage appropriate vaccinations?

DR. SELBY FRANK A retired family physician in Terrace, B.C.

Send solutions to lleger@ensembleiq.com by March 15. (Need a solution to a problem or have an idea for a question? Send it along!)

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Painting a picture of the end In 1985 a group of doctors won the Nobel Peace Prize for showing the world the medical consequences of nuclear weapons The 1985 Nobel Peace Prize acceptance

speech contained a few statistics that, in the recipient’s words, the human mind finds difficult to comprehend. Here are a few of them. During the Cold War, roughly 10 new nuclear warheads appeared on Earth every day. The amount of firepower in the U.S. and Soviet stockpiles was roughly equal to “one million Hiroshimas.” That is, enough firepower to produce an estimated two billion victims, and cause injuries that would require more than 30 million physicians and 100 million nurses and technical personnel to treat. The total number of doctors and nurses working in the world at that time was just one-tenth of that.

46 FEBRUARY 2021 THE MEDICAL POST

These figures came from Dr. Yevgeniy Chazov, a Soviet cardiologist and one of the founders of International Physicians for the Prevention of Nuclear War (IPPNW), a group on whose behalf he was accepting the Nobel. The purpose of the speech, like much of the group’s work, was to convey to the public what it was too often denied: a medically accurate picture of the unimaginable consequences of nuclear war. Dr. Chazov’s co-president was Dr. Bernard Lown, an American cardiologist who, in addition to his advocacy, was well-known for contributing several breakthroughs in his specialty. Dr. Lown and Dr. Chazov (both are still alive and in their 90s) met as

—TRISTAN BRONCA

CMY

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PMHx

cardiologists, the former the head of a U.S. task force and the latter the head of the Soviet cardiologists’ group. But their relationship soon became a bridge between the two hostile nations. In 1980 they, along with a small group of international physicians, founded the IPPNW. By 1982, the IPPNW congress was hosting more than 400 attendees, including the likes of Carl Sagan, and admiral Noel Gayler, the American in charge of targeting nuclear weapons at the Soviets. By the time the group received the Nobel in 1985, it represented 135,000 doctors in more than 60 countries, some of whom met with heads of state, including Mikhail Gorbachev. The group’s first major achievement came in 1982 when six American and Soviet doctors, including Dr. Lown and Dr. Chazov, appeared on Soviet television to discuss the medical effects of a nuclear strike. That discussion was broadcast to over 100 million viewers in the U.S.S.R., unedited—something that had never happened before. It was later shown in the U.S. as well. “The doctors sounded a medical warning to humanity: that nuclear war would be the final epidemic; that there would be no cure and no meaningful medical response,” it said in the IPPNW’s history. “In the words of former New Zealand Prime Minister David Lange, ‘IPPNW made medical reality a part of political reality.’” Though the threat of the Cold War has receded, the group’s advocacy continues. “The nuclear threat not only persists but is in many ways more dangerous than ever before,” the IPPNW warns. More than 15,000 nuclear weapons remain in American and Russian arsenals, and a civilization-ending attack could still be executed at a moment’s notice. More nations are developing nuclear capabilities, and those with existing capabilities are developing new generations of more flexible weaponry. A world in which these weapons are banned remains some distance away, but the fact that there has not been nuclear calamity in the last 75 years is, in part, because these doctors were able to paint a picture of an end we all wish to avoid.

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