Medical Post - December 2024 by ensembleiq

The first and only PDE4i indicated in the topical treatment of plaque psoriasis*

FOR AGES 12+

BOLDLY TAKING ON PLAQUE PSORIASIS

ZORYVE is indicated for topical treatment of plaque psoriasis, including treatment of psoriasis in the intertriginous areas, in patients 12 years of age and older.

Designed for simple administration

• Can be used on all affected areas, including intertriginous areas

• Once-daily topical application

Please consult the Product Monograph at http://arcutis.ca/zoryvepm-hcp for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions, of clinical use. The Product Monograph is also available by calling us at 1-844-692-6729.

PDE4i: phosphodiesterase-4 inhibitor

*Comparative clinical significance has not been established.

†Subject to restrictions. For program terms and conditions go to www.zoryveassist.ca and click Terms and Conditions.

Reference:

1. ZORYVE Product Monograph. Arcutis Biotherapeutics, Inc. April 27, 2023.

The ZORYVE AssistTM Patient Assistance Program is designed to provide financial support to eligible patients receiving a ZORYVE prescription.†

Writer: Dr. Shafiq Qaadri

For this, our Stories-themed issue, Dr. Qaadri, a family physician, has the lead doctor-written true story in this issue (page 12). He’s currently doing an MA in literature at Toronto Metropolitan University (TMU) and is seen above with his youngest son, Salman, 11.

So you’re doing an MA in literature. How is it going?

Lovely, compelling, absorbing. From Oscar Wilde to AI, the wide course offerings are first-rate. My older son was admitted to TMU law school first, and then I started exploring course options myself.

How do you get your ideas for stories?

Generally from my multicultural patients, who come from all over. They frequently share intense stories of homelands in civil strife, war, natural disaster or unpleasant regimes. What is most inspiring is how they are usually able to forge ahead once here in Canada, finding some measure of peace, closure and happiness.

You were a Liberal MPP in Ontario from 2003 to 2018. Would you have liked to have continued in politics?

It was a great honour to serve Ontarians for four consecutive terms in government. But governments, like medicines, all have an expiry/best before date. We reached ours—that’s democracy.

Next Issue

THE ADDICTION ISSUE: Addiction touches every corner of healthcare—and life. In the next issue of the Medical Post (in doctors’ mailboxes in the second half of February), we take a deep dive into the topic of addiction through the physician’s lens. From the opioid crisis to emerging addictions like screen time, vaping and social media, we tackle the challenges physicians face both personally and professionally. We’ll also explore “good addictions” and—addiction to work. Look forward to discussions about addiction’s evolving landscape.

Help your patient get the Viatris original brand EFFEXOR XR

Some insurers limit full-cost coverage for higher-cost interchangeable drugs to patients who meet certain criteria, and in some instances, documentation from the prescriber is required. There is a possibility that the patient may need to contribute out-of-pocket where those conditions are not met.

Write the Viatris original brand name, EFFEXOR XR, and include “no sub,” when appropriate, on your patient’s prescription.

Encourage your patients to visit ViatrisOriginals.ca so they can:

• Download a payment assistance card. This may help patients who have no insurance or whose insurance co-payment amount might be a barrier to obtaining the Viatris original brand medication. This card can help patients obtain the Viatris original brand medication at little or no additional cost compared to the generic version.*

Remind your patient to ask for the Viatris original brand EFFEXOR XR at the pharmacy.

Consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=60600 for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph may also be obtained by calling 1-844-596-9526.

* Subject to change. The Viatris Originals Program is available in all provinces except Quebec. Availability and level of payment assistance vary by brand medication and province.

Reference: 1. EFFEXOR® XR Product Monograph, BGP Pharma ULC. October 31, 2023.

EFFEXOR® is a registered trademark of Viatris Specialty LLC, used under permission by BGP Pharma ULC, a Viatris company. VIATRIS and VIATRIS & Design are registered trademarks of Mylan Inc., used under permission by BGP Pharma ULC, a Viatris company.

EDITORIAL

The Stories Issue

Doctor-written stories and the power of narrative in medicine

A log hisses and cracks in the fireplace. From the ruddy glow you see your cat on the window ledge, staring head tilted at the thick snowflakes drifting down—or perhaps regarding an invisible world only seen by cats. You place your hot cocoa down, pick up a book or a magazine, push back in your armchair and start to read. Instantly, another world appears in your mind’s eye. . . .

Stories are key to the human experience. Perhaps we are story: An orb with neurons in it is at the top of our body and that, swirling in hormonal signals and scanty bits of input, is somehow enough that we tell ourselves a story that makes sense to us: I’m Colin and I rode my bike to work today and I’m writing an editorial right now.

Stories shape how we understand the world, find meaning and make decisions. We’re often more likely to be convinced to give up an unhealthy behaviour by one story about a relative than by

a million websites of peer-reviewed literature.

But you know that: I’m told one of the great blessings of being a physician is hearing patients’ stories. And the narrative medicine movement (see page 8) tells us that strong storytelling skills improve how effective clinicians are. Storytelling is a tool that transforms how one cares for patients, how we learn and how we inspire each other. That’s why we’ve dedicated this issue to the role of story in medicine.

PHYSICIAN-WRITTEN STORIES

Doctors can make wickedly good writers. I’ve seen many doctors who only start writing in mid-life and yet—wow, some compelling, impactful and skillful writing comes out of their keyboard. So I wasn’t surprised that after we called for doctors to send in stories, that we got many good submissions. You can see a few of them on page 12. There

DR. BRIDGET REIDY family medicine

DR. NATHAN RIDER public health & preventive medicine resident

were many more awesome entries, and we’ll be running some of them starting Dec. 18 in our Doctor Daily newsletter, from the Medical Post’s online home: CanadianHealthcareNetwork.ca

Of course, if you write stories it is natural enough to wonder about getting a book published, and on page 35 we have physician authors Drs. Jillian Horton, Brian Goldman and Michael Simon describe how they got their literary agent.

And because this time of year prompts reflection, we asked doctors to share their New Year’s resolutions for 2025. Their goals are featured on page 21.

As you read this issue, we hope all the ways we’ve used “story” as a lens to talk about doctor issues resonate with you, offering inspiration or simply a moment to pause and reflect.

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EDITORIAL

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PHYSICIAN

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COLIN LESLIE EDITOR-IN-CHIEF

For adult patients with insomnia Once-nightly

PrQUVIVIQ® (daridorexant) is indicated for the management of adult patients with insomnia, characterized by difﬁculties with sleep onset and/or sleep maintenance.1

* Some patients may be treated with QUVIVIQ® 25 mg once per night. Please consult the Product Monograph for complete dosing information.

Mechanism of action†

QUVIVIQ® is a dual orexin receptor antagonist (DORA)

QUVIVIQ® antagonizes the activation of orexin receptors by the orexin neuropeptides and consequently decreases the wake drive, allowing sleep to occur.

QUVIVIQ® acts on both orexin 1 and orexin 2 receptors and is equipotent on both.

† Clinical signiﬁcance is unknown.

Connect to a Product Specialist.

Scan the QR code or email at: hcp.ca@idorsia.com.

Consult the Product Monograph at https://pro.idorsia.ca/product-monograph for important information about:

• Contraindications in patients with narcolepsy; using concomitant strong CYP3A4 inhibitor.

• Relevant warnings and precautions regarding concomitant use of CNS depressants, alcohol use, next-day somnolence, sleep paralysis, hallucinations and cataplexy-like symptoms, worsening of depression and suicidal ideation, comorbid diagnosis, complex sleep behaviours, non-medicinal use of sedative drugs, withdrawal symptoms, rebound insomnia, driving or operating heavy machinery, patients with severe obstructive sleep apnea, patients with severe chronic obstructive pulmonary disease, patients with thyroid abnormalities, breast-feeding, geriatric patients, pediatrics.

• Conditions of clinical use, adverse reactions, drug interactions (particularly interactions with CYP3A4), and dosing instructions.

The Product Monograph is also available by calling 1-888-646-1764.

Feedback

Praise for prescribing teams coverage

Getting prescribing teams right (Oct.)

This piece in the last issue of the magazine where a doctor and a pharmacist debated challenges in the relationship and ways to improve things got a huge number of online comments. We were touched by this comment from Dr. Don Gelhorn of Hudson Bay, Sask.: “Excellent discussion! Factual, nonconfrontational, succinct. The best discussion of this topic that I’ve seen in quite awhile.”

$mart strategies for doctors (Oct.)

Dr. Bridget Reidy of Saanich, B.C., just outside Victoria, said: “Unlike any other business, we cannot bill for tasks we delegate. That needs to change, especially in the current environment where everyone thinks teams . . . like it or not (currently

mostly) that low-paying work must be done by a doctor or it’s no pay, no matter the benefit to the public.”

Editorial: The Team Issue (Oct.)

Dr. Garth Kroeker, a psychiatrist in Vancouver, wrote in a letter to the editor that he concedes that work in teams may mean more efficient care for patients and a better lifestyle for individual physicians, “However, in many instances teamwork is not necessary or appropriate. Some patients desire (and in my opinion need) a scrupulously private therapeutic relationship, with minimum ‘team’ involvement. And some physicians have a personality style which favours more solitary work. This is not an educational deficiency, it is a style difference.” He added:

“In my opinion, modern trends in workplace culture, while often endorsing the idea of inclusiveness, can be frankly discriminatory against those who are less gregarious or inclined towards teamwork.” He argued that this “leaves behind many others on an introverted spectrum, including many who would have invaluable skills to contribute to excellent patient care.”

The Immigrants

When present, they are not noticed, and when absent, they are not missed, says Dr. Jabir Jassam, reflecting on feelings of blurred identity.

POLL: Should colleges be prevented from pursuing doctors over any public comments they make?

QUIZ: Doctors in science fiction

3 cool things: membership

Sign up is free and easy for the Medical Post’s online home: CanadianHealthcareNetwork.ca. There are perks to being a member:

1. Write content Lots of physician authors and bloggers got started by writing for our Doctor Daily newsletter. Email Martha Porado at mporado@ensembleiq.com.

2. Debate topics We believe that open debate among physicians, such as the discussions in our online comments, is essential for shaping the best health policies.

3. Test your knowledge Challenge your clinical knowledge with our quizzes and see how you compare to your peers—or simply take a quiz for fun!

VITALS

Slowdown in FP growth: CIHI

BY COLIN LESLIE

A new Canadian Institute for Health Information (CIHI) report Taking the pulse: Measuring shared priorities for Canadian health care, 2024 showed that for 2021-22, there were large variations in provinces’ annual rate of family doctors entering and leaving the workforce (see above).

In 2022, Canada had 48,199 family physicians, CIHI said. Although the number of family physicians is rising, the fiveyear growth rate has slowed from 12.9% between 2012 and 2016 to 7.7% between 2017 and 2021. As well, CIHI noted: Family physicians are on average seeing fewer patients per year, from 1,746 in 2013 to 1,353 in 2021.

The report’s findings for 2023-24 show that 83% of Canadian adults have access to a regular healthcare provider.

Source CIHI

QUEBEC RULES

New

MDs: Serve public system only

The Quebec government plans to require newly trained doctors to work in the province’s public healthcare system for their five initial years of practice. Health Minister Christian Dubé has tabled a bill that will be debated this winter. The move aims to address physician shortages and curb the trend of doctors opting out for private practice or other provinces. Members of the opposition parties in the legislature expressed support for the bill.

“While too many Quebecers are still waiting to be treated, too many doctors decide—from the start of their career—to leave the Quebec public network,” Dubé said. Doctors who enter the private sector or move outside the province within that period would face fines up to $200,000 per day.

Quebec estimates it costs $435,000 to $790,000 to train a doctor. Currently, 775 of the province’s 22,479 physicians work exclusively in the private sector, a 70% increase since 2020.

Data shows just 60% of recent family medicine graduates remain in Quebec, compared to 85% in Ontario. Indeed, a spokesperson for Dubé said that 400 of the 2,536 doctors who completed their studies between 2015 and 2017 have left Quebec for other jurisdictions.

Critics, like the Montreal Economic Institute, argue the policy ignores issues like administrative burdens and inflexible schedules. An institute rep said this adds constraints.

Narrative-based medicine, a well-established field in the United States, has a prominent presence at institutions like Columbia University Irving Medical Center, where its division collaborates across clinical programs and leads interprofessional education initiatives. In Canada, we have the Narrative-Based

“We understand that aspirational language on the website was causing confusion.”

—Mohamed Lachemi, TMU president, clarifying the statement that 75% of admissions to the new med school are to be Indigenous, Black or “equity-deserving” students is not a rigid quota but rather an “aspirational” target.

“The medical association has nothing to do with this. LOST again. Keep trying bag lady.”

—Dr. Jeffrey Steinberg, an Ontario doctor who had rented an apartment to a long-time patient, perhaps forgetting that texts and emails don’t go away wrote after a rent dispute. Here he was trying to intimidate her to withdraw a complaint to the college (which he incorrectly refers to as the association).

Medicine Lab (NBM), housed within Continuing Professional Development at University of Toronto’s Temerty faculty of medicine. “In our workshops and certificate programs, we encourage clinicians to receive a story, not just take a history,” said Dr. Allan Peterkin, co-founder of the NBM Lab.

“Stories of suffering, a patient’s journey, the family’s take—all these can be compelling and instructive. Knowing the whole picture, not just the renal function or cholesterol level, humanizes not only the patient but the doctor’s approach,” said Dr. Shafiq Qaadri, who is currently doing his MA in literature at Toronto Metropolitan University (TMU). He said he’s been invited to be a professor at TMU’s new school of medicine and hopes to introduce a narrative medicine module.

College told:

Don’t touch speech

The College of Physicians and Surgeons of Alberta (CPSA) says it supports balancing free speech and public interest after Alberta Premier Danielle Smith

“To ensure that 100% of people in Ontario have access to a primary-care clinician.”

—Dr. Jane Philpott, saying she’s been asked to work with people across the province to make 100% primary care happen in her role as chair of the province’s new primary care action team.

announced plans to limit professional regulatory bodies’ authority over members’ public comments.

In a video statement, Smith and Alberta Justice Minister Mickey Amery outlined upcoming legislation to ensure regulatory colleges focus solely on professional competence and conduct, leaving members’ personal beliefs and statements outside their purview.

“What a doctor or lawyer believes or says about politics or religion is not a reflection of their competency to practice medicine or law,” Smith stated.

Dr. Scott McLeod, registrar and CEO of the CPSA, expressed support for free expression, adding however, “The public interest requires balance when such views intersect with professional practice in a way that crosses certain boundaries established by the profession’s practice standards.”

Smith and Amery cited cases to illustrate their concerns: an Ontario physician investigated over church-related COVID-19 comments and psychologist Jordan Peterson, who was ordered to undergo social media training by the College of Psychologists of Ontario.

The Alberta government plans to launch consultations and a review of regulated professions before drafting the legislation. CPSA intends to participate in the process.

ALBERTA

What is Awiqli® indicated for?

Awiqli® (insulin icodec injection) is indicated for the once-weekly treatment of adults with diabetes mellitus to improve glycemic control. 2

How is Awiqli® supplied? Awiqli® comes in a 1.5 mL and a 3.0 mL FlexTouch® pen. 2

• Awiqli® should be injected subcutaneously once weekly on any day of the week, but preferably the same day each week. 2

• Awiqli® FlexTouch® pens are co-packaged with the NovoFine® Plus needles.

• A new needle must be used for each injection. 2

How should insulin-naïve patients with T2DM be started on Awiqli®?

The recommended once-weekly starting dose of Awiqli® for insulin-naïve patients with T2DM is 70 Units. 2

What is the starting dose for patients with T2DM already on basal insulin therapy and switching to Awiqli®?

The recommended once-weekly starting dose for patients with T2DM already on basal insulin therapy is the current daily basal insulin dose x7. 2

For patients requiring a one-time additional dose

Depending on the patient’s glycemic control and hypoglycemia history, for the first dose only (week 1), a one-time additional dose of 50% of Awiqli® may be administered. When assessing the need for a onetime additional dose, the risk of hypoglycemic events (due to potential medication errors) should be weighed against temporary worsening of glycemic control (hyperglycemia). 2

The one-time additional dose MUST NOT be added for the second injection onward.

Since patients may forget to remove the one-time additional dose after the first injection, instruct them to check that they inject the correct dose, especially for the first and second injections. 2

Please refer to the Product Monograph for complete dosing information and additional dosing information for patients with type 1 diabetes.

What is the titration schedule for Awiqli®?

Titration should be based on the patient’s metabolic needs, blood glucose monitoring results, and glycemic goal. 2

Example titration schedule

In the ONWARDS clinical trials, the dose of Awiqli® was titrated weekly in ±20 Unit increments.3,4

Weekly dose adjustments were based on three pre-breakfast SMBG values.†

Titrate up

If mean pre-breakfast SMBG value is above target range

No change

If mean pre-breakfast SMBG value is within target range

Titrate down

If lowest pre-breakfast SMBG value is bellow target range

Is there coverage for Awiqli®?

Awiqli® may be covered by private insurance. Instruct your patients to check with their provider.5

Subsequentdoses

* Comparative clinical significance not established.

** For complete dosing and administration information, please refer to the Product Monograph.

† In ONWARDS 1 and 3, dose adjustments were based on three pre-breakfast SMBG readings (on the two days prior to and on the day of titration). Titration was based on the lowest reading value, if any of the three SMBG readings were below the lower limit of the target glucose range. If all three SMBG readings were above this limit, titration was based on the mean of the readings.3,4

‡ Glycemic control was defined as change in A1C from baseline.

SMBG: self-measured blood glucose.

How did Awiqli® compare with Tresiba® and insulin glargine U100 in head-to-head trials in insulin-naïve patients with T2DM?

Awiqli® demonstrated greater glycemic control‡ vs. once-daily basal insulins Tresiba® and insulin glargine U100. 2

ONWARDS 3 study¶: Awiqli® vs. Tresiba®

Patients: Insulin-naïve with T2DM on OAD(s) or GLP-1 RA

At week 26, the estimated mean A1C change from baseline was -1.57% with Awiqli® vs. -1.36% with Tresiba®; non-inferiority and superiority were confirmed. 2,3

ETD (95% CI): -0.21% (-0.34, -0.08). Non-inferiority of Awiqli® vs. Tresiba® confirmed (p<0.001). Superiority in favour of Awiqli® confirmed (p=0.0016). 2,3

(n=294) Tresiba® (n=294)

No statistically significant differences in hypoglycemic events (clinically significant or severe£§) observed with once-weekly Awiqli® vs. Tresiba® at week 26. 2

Incidence per PYE: Awiqli®, 0.31 (n=293); Tresiba®, 0.15 (n=293; p=0.1091)2

ONWARDS 1 study¥: Awiqli® vs. Insulin glargine U100

Patients: Insulin-naïve with T2DM on OAD(s) or GLP-1 RA

At week 52, the estimated mean A1C change from baseline was -1.55% with Awiqli® vs. -1.35% with insulin glargine U100; non-inferiority and superiority were confirmed. 2,4 ETD (95% CI): -0.19% (-0.36, -0.03). Non-inferiority of Awiqli® vs. insulin glargine U100 confirmed (p<0.001). Superiority in favour of Awiqli® confirmed (p=0.021).2,4

(n=492)

No statistically significant differences in hypoglycemic events (clinically significant or severe£§) observed with once-weekly Awiqli® vs. insulin glargine U100 at week 52. 2 Incidence per PYE: Awiqli®, 0.30 (n=492); insulin glargine U100, 0.16 (n=492; p=0.0611)2

Contraindications:

• During episodes of hypoglycemia

• In patients who are hypersensitive to this drug or to any ingredient in the formulation, including any non-medicinal ingredient, or component of the container

Most serious warnings and precautions: Hypoglycemia is the most common adverse effect of insulin products including Awiqli®. As with all insulin products the timing of hypoglycemia may differ.

• Glucose monitoring is required.

• Uncorrected hypoglycemic or hyperglycemic reactions can cause loss of consciousness, coma, and/or death.

• Switching a patient between another type, brand, or manufacturer of insulin and Awiqli® should be done under medical supervision and may result in the need for a change in dosage. Changes in insulin regimen from other insulins to Awiqli® may result in increased risk of hypoglycemia or hyperglycemia. Awiqli® must not be administered more frequently than once a week.

• Medication errors have been reported in which patients accidentally administer shortacting insulin instead of basal (long-acting) insulin. Specific attention should be paid when switching from a daily basal insulin to Awiqli®, which is administered weekly.

• Inspect Awiqli® visually prior to administration and use only if the solution appears clear and colourless.

• Never mix Awiqli® with any other insulin.

• Awiqli® must not be used in combination with other long-acting (basal) insulins (e.g., insulin detemir, insulin glargine, or insulin degludec).

• Never administer Awiqli® by intramuscular (IM) injection, intravenously (IV), or with an insulin infusion pump.

Administration:

• Inspect visually prior to administration and use only if the solution appears clear and colourless

• Do not mix with any other insulin, administer intravenously, administer intramuscularly, or use in insulin infusion pumps

• For patients requiring a one-time additional dose please refer to the Product Monograph Other relevant warnings and precautions:

• Refer to respective product monographs for concomitant oral antidiabetic agents for their warnings and precautions

• Stress or concomitant illness, especially infections and febrile conditions, may change insulin requirements

• Risks associated with sharing insulin delivery devices

• Fluid retention and congestive heart failure with concomitant use of a peroxisome proliferator-activated receptor (PPAR) gamma agonist

• Driving and operating machinery

• Changes in insulin regimen

• Hypokalemia

• Patients with hepatic or renal dysfunction

• Risk of immune responses (e.g., hypersensitivity reactions, lipodystrophy and cutaneous amyloidosis, injection site and local allergic reactions)

• Antibody production

• Diabetic retinopathy

• Pregnant and nursing women or women of childbearing potential

• Pediatrics

• Geriatrics

For more information:

Please consult the Product Monograph at www.AwiqliPM-e.ca for more 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 us at 1-800-465-4334.

Scan to visit Awiqli.ca�

¶ ONWARDS 3: 588 insulin-naïve adult patients with inadequately controlled T2DM on ≥1 oral antidiabetic agents or a GLP-1 RA were randomized to Awiqli® once weekly or Tresiba® U100 once daily in a 26-week, randomized, double-blinded, active-controlled, parallel-group, multicentre, multinational, treat-to-target trial. Pre-trial non-insulin antidiabetic medications were continued as background therapy in both treatment arms throughout the entire trial except for sulfonylureas and glinides, which were reduced at randomization by approximately 50% at the discretion of the investigator. The primary endpoint of the trial was the difference in change from baseline in A1C between insulin Awiqli® and Tresiba® after 26 weeks of treatment to a non-inferiority limit of 0.3%.2

# Missing values were imputed using multiple imputation based on the change from LAOT-WOB value (last available on-treatment without initiation of bolus insulin for more than 2 weeks) for subjects who had an intercurrent event, but have a measurement at the landmark visit. In ONWARDS 3, there were 3.8% of subjects in the Awiqli® arm and 3.1% in the Tresiba® arm for whom A1C data were missing at week 26.

£ Clinically significant hypoglycemia was defined as a plasma glucose <3.0 mmol/L, confirmed with a blood glucose meter.2

§ Severe hypoglycemia was defined as hypoglycemia associated with severe cognitive impairment requiring external assistance for recovery.2

¥ ONWARDS 1: 984 insulin-naïve adult patients with inadequately controlled T2DM on ≥1 oral antidiabetic agents or a GLP-1 RA were randomized to Awiqli® once weekly or insulin glargine U100 once daily in a 52-week, randomized, open-label, active-controlled, parallel-group, multicentre, multinational, treat-to-target trial. Pre-trial non-insulin antidiabetic medications were continued as background therapy in both treatment arms throughout the entire trial except for sulfonylureas and glinides, which were discontinued at randomization. The primary endpoint of the trial was the difference in change from baseline in A1C between insulin Awiqli® and insulin glargine U100 after 52 weeks of treatment to a non-inferiority limit of 0.3%.2

� Awiqli.ca is open to the general public.

A1C, glycated hemoglobin; CI, confidence interval; ETD, estimated treatment difference; GLP-1 RA, glucagon-like peptide-1 receptor agonist; OAD, oral antidiabetic medication; PYE, patient-years exposure; T2DM, type 2 diabetes mellitus.

References:

1. Data on file. 2. Awiqli® Product Monograph. Novo Nordisk Canada Inc. March 12, 2024. 3. Lingvay I, et al. JAMA . 2023;330(3):228–237. 4. Rosenstock J, et al. N Engl J Med 2023;389(4):297–308. 5. Data on file – Coverage.

All trademarks and registered trademarks are the property of their respective owners. Awiqli® 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

Awiqli®

DOCTORS’ STORIES

Where art meets science; a few true stories . . .

The quiet appointment

BY DR. SHAFIQ QAADRI

“You know, doctor, I lost my beautiful angel eight months ago,” the mother said.

That’s what started the conversation in my clinic. Last year the mother and her son had fled to Canada from Ukraine. They had already been through too much. Periodic panic, food shortages, schools destroyed, fractured families. She still looked the part—pale, downcast, thinning hair, underweight. Her husband had to stay behind. “Young men are not allowed to leave,” she said wistfully. “They have to be ready for mobilization any time.”

Then misfortune followed her to Canada.

It was the first time in 25 years of medical practice that I couldn’t speak.

As a family doc, I hope to learn about my patients, engage with them, and explore their lives. This is challenging because of the time constraints that we work under, not to mention all the documentation. But I try not to treat people as just a random collection of diagnoses—as merely sore throats, aching backs, low irons or high sugars. I prefer to see the person, not just the condition that can be billed. Truthfully, I enjoy seeing my patients’ growing realization of medical concepts. They begin to get it—whether we are talking about reducing heart attack risk, managing depression or chronic pain, or avoiding diabetes complications. They will even bring in paperwork from other doctors so I can decode the results for them. I am happy to switch languages and vocab

levels, even Google up an image to illustrate a point.

In medical school, we had been trained to talk tragedy. According to the standard formula, if the patient is tearful, move the tissue box closer to them. That “acknowledges” their pain, “validates” their tears, and gives them “therapeutic space” to mourn. With no emotional cost, we doctors can announce metastatic cancer diagnoses, declare an illness to be terminal, tell families that their loved one is brain dead after a stroke, or that a relative has died of COVID-19. But the advice that I was asked for that day, the scenario that I found myself in, no medical school training had prepared me for.

The mother’s seven-year-old boy, Georgiy, was struck by a drunk driver in a sports car last year. They had been in Canada for less than a month. I don’t know when she will ever find any measure of closure. So far, the hurt to her soul has been wholly unanswerable.

With a deep, solemn stare, she would say things like, “Georgiy will be eight this summer.” Future tense. “He will tell me he wants a bike so he can ride with his friends.”

As the mother reminded me of the accident, I would default to well-rehearsed, board-certified phrases. “I’m sorry for your loss.”

The boy was thrown a distance of 20 feet and killed on the spot. The mother cradled her arms, then re-enacting a fateful gesture: She reminded me that she had to pick up her son from the pavement in parts. As intense and traumatic as that was, that’s not what she was concerned about today.

“You know, I donated his heart.” That was the first shock. My eyes bugged out momentarily. I had no idea. I was startled and impressed. At such a terrible personal moment she had the ultimate courage to donate her young son’s organs. Astonishing. Maybe she got government brochures in the mail, or maybe she saw a banner ad on the internet. Perhaps she wanted some good to come out of the accident. More likely, a member of the transplant team swooped into the emergency department for the harvest and convinced her to sign the consent. However it was accomplished, I hadn’t found out until now. I dared not ask.

“Now there is a young boy with my Georgiy’s heart.”

“I see,” I said, slowly absorbing the information.

“Now the boy’s family wants to meet me to thank me.”

My pen froze. I stopped taking notes.

“What should I do, doctor? Should I meet them?”

I just stared back at her, floored.

“You see, my friends think I should meet them. But I don’t know. I mean, I’m happy for the boy. It’s good he is doing well. But I don’t think I can see him—he has my son’s heart. You understand? So, what should I do?”

Call it empathy, call it putting myself in her shoes,

maybe trying to imagine if I had been in such a situation with my own kids. But I couldn’t speak, couldn’t think. Doctors do not get emotional with patients, at least we’re not supposed to. We “maintain boundaries.” After a few years of training, perhaps most MDs can no longer genuinely feel a patient’s struggle. This ability seems to evaporate out of us. That’s just how the system works—there’s usually no time left over for feeling. The clinical term for this protective shield is “therapeutic distance.” But not that day.

I was silent for several moments, the mother waiting for my reply, waiting for medically approved wisdom to drop. But my boundaries had been breached. Finally, when she saw me tearing up, still quiet, still not offering any guidance, it was as if she were consoling me. As if she were sorry for asking a question of such weight, beyond my capacity to deal with.

“It’s OK, doctor,” she said, in a comforting tone. “I’ll let you know what I decide.” Then she politely pushed the tissue box in my direction, nodded softly, and left.

DR. SHAFIQ QAADRI, a Toronto family physician, CME lecturer and medical writer.

and immediately spit it right back out.

Then they had to do the test as best they could, with whatever small quantity of barium had managed to sneak into my system.

I was a co-operative, compliant child. If they had just told the truth, and said, “This is a disgusting goopy mixture, but we need you to swallow it so we can do the test,” I would have swallowed it down, no matter how disgusting it was.

This life lesson has served me well in my practice: Truth-telling is better than lying—no matter what the age.

DR. ROS SCHWARTZ practises family medicine and psychotherapy in Kingston, Ont. She co-hosts the Doctors Lounge Online, and is also a songwriter and photographer.

Spotting the spots

BY DR. BETTY TANG

This does not taste like strawberries!

BY DR. ROS SCHWARTZ

In the days before echocardiograms, a barium swallow X-ray was the investigation of choice to assess the size and shape of the heart.

As I learned when I was about eight years old, this test involved swallowing semi-liquid barium, a goopy mixture with a disgusting texture and taste.

The X-ray technician lied to me and told me it would be deliciously strawberry-flavoured.

Based on this enthusiastic endorsement, I didn’t start with a tiny taste test—I took in the whole spoonful, all at once!

Mmm mmm mmm… NO, NOT.

NOT TASTY AT ALL.

Did they think I would not notice, when the liquid got into my mouth, that their delectable description was COMPLETELY FALSE?

So—having filled my mouth with this supposedto-be-tasty mixture—I realized it was disgusting,

I am a psychiatrist and receive a LOT of referrals for diagnostic assessment of possible adult ADHD. My mantra is: persistent (symptoms are present since childhood but may be supported by scaffolding and thus not noticeably problematic in earlier years); pervasive (present in at least two, and more likely several, domains of daily functioning); and problematic (causing functional impairment). But here I am going off on a tangent again.

One patient I assessed already had a previous diagnosis of anxiety, which she was being treated for. During our consultation process, she described ongoing symptoms of tachycardia; night sweats with vomiting, dizziness and nausea (which were ascribed to her anxiety disorder); and worsening areas of darker pigmentation, like “café au lait” spots, that she had noticed in the past year.

“Hold on,” I said. “Areas of skin discoloration?”

I looked up these symptoms and noted that many of the symptoms of anxiety overlap with other medical possibilities (of course), but it was the areas of darker pigmentation that tipped me off that it might not all be anxiety. Regardless of whether she also had ADHD or not, she had Addison’s disease. And this is why psychiatrists go to medical school.

DR. BETTY TANG is a psychiatrist with a special interest in adult ADHD working on the Sunshine Coast of British Columbia.

Have you considered

for your patients?

about

More than 156,000 patients in Canada have been prescribed REXULTI across its 3 indications since its launch in 2017.1,2*

What is REXULTI indicated for?

PrREXULTI® (brexpiprazole) is indicated for:5

• Treatment of schizophrenia (SZ) in adults.

• Use as an adjunct to antidepressants for the treatment of major depressive disorder (MDD) in adult patients with an inadequate response to prior antidepressant treatments during the current episode.

• Symptomatic management of agitation associated with Alzheimer’s dementia (AAD) in patients with aggressive behaviour, unresponsive to non-pharmacological approaches.

What is an example of a patient with MDD for which Rexulti may be considered?

Meet Catherine†

• 34-year-old teacher diagnosed with MDD

• Current episode ongoing for 6 months

▶ Treatment: Currently on antidepressant treatment.

▶ Current presentation:

• Has experienced some improvement but expresses frustration that her medication is not providing enough relief.

• Complains of pervasive sad mood and anxious symptoms due to her depression.

• Has not been able to fully engage in routine family activities in the past months.

CANMAT guidelines recommendation

* Clinical significance is unknown.

** See guidelines for complete recommendations.

† Fictional case. May not be representative of the general population.

‡ Results from a phase 3, 6-week, randomized, double-blind, placebo-controlled fixed-dose trial in adult patients who fulfilled the DSM-IV-TR criteria for MDD, with or without symptoms of anxiety, had an inadequate response to 1–3 prior antidepressant treatment(s) in current episode and an inadequate response during 8 weeks of prospective antidepressant treatment. Patients remained on background antidepressant treatment and were randomized to receive adjunct placebo (n=191) or adjunct REXULTI (0.5 mg/day for week 1, 1 mg/day for week 2, 2 mg/day for week 3 onward; n=187).

IN MDD:

What was the efficacy data for REXULTI in the PYXIS clinical trial?

As shown in the pivotal PYXIS trial, REXULTI demonstrated efficacy as an adjunctive treatment for MDD at week 6 for both primary and secondary endpoints.5,6‡

▶ Primary endpoint

When taken with an antidepressant, adding REXULTI improved depression symptoms, as measured by MADRS at week 6 (clinician-rated).5,6‡

Depressive symptoms (MADRS Total score)

Demonstrated improvement as early as week 1

3.12-point greater reduction for patients treated with antidepressant + PrREXULTI® 2 mg/day vs. antidepressant + placebo at week 6 (p=0.0001) 2

Adapted from Product Monograph and Thase et al. (inclu. Supplementary Material)

▶ Key secondary endpoint

REXULTI demonstrated improvement in functioning at week 6, as measured by the SDS Mean score.5,6‡

Functional impairment (SDS Mean score)

Statistically significant greater improvement in SDS Mean score for patients treated with antidepressant + PrREXULTI® 2 mg/day than with antidepressant + placebo at week 6 (p<0.05)

Adapted from Product Monograph and Thase et al. Supplementary Material

Demonstrated SDS domain results at week 6

The social life and family life domains showed statistically significant improvement for patients taking antidepressant + REXULTI 2 mg/day vs. antidepressant + placebo (-1.54 vs. -1.04, p=0.0323; -1.33 vs. -0.73, p=0.0129; respectively), while the work/school domain did not (-1.09 vs. -0.90, p=0.4771).

IN AAD:

What was the efficacy data for PrREXULTI® in the AAD clinical trial Study 11?

In REXULTI’s AAD pivotal trial, REXULTI demonstrated efficacy in improving the frequency of manifestations of agitation symptoms at week 12.5,7§

▶ Primary endpoint

REXULTI demonstrated improvement in the frequency of manifestations of agitation symptoms, observed at week 12 as measured by the CMAI (clinician rated).5,7§

CMAI Total score at week 12

Adapted from Product Monograph and Lee et al. 2023

What is the tolerability profile of REXULTI

in trials of patients with MDD and AAD?

REXULTI was demonstrated to be generally well tolerated. The tables below outline the most commonly reported adverse events in trials of patients with MDD and AAD.

MDD: Treatment-emergent adverse events (TEAEs) with incidence of ≥5% in any antidepressant + REXULTI dose group (1 to 3 mg) and greater than antidepressant + placebo group in short-term Phase 3 clinical trials.5

AAD: TEAEs with incidence of ≥2% in any REXULTI dose group (0.5 to 3 mg) and greater than placebo group in 12-week, placebo-controlled, fixed-dose and flexible dose trials.5

Adapted from Product Monograph

Adverse events reported as reasons for discontinuation of treatment in four phase 3, 6-week, placebo-controlled trials.5

• REXULTI + antidepressant: 2.4% (37/1520)

• placebo + antidepressant: 0.7% (8/1132)

The maximum approved dose of REXULTI for MDD in Canada is 2 mg/day. No additional benefit was demonstrated at doses greater than 2 mg/day.

§ Results from a 12-week, randomized, double-blind, placebo-controlled fixed-dose trial in adult patients with: a probable Alzheimer’s disease diagnosis as per NINCDS-ADRDA Criteria; MMSE ≥5 and ≤22; Total score of ≥4 on the agitation/aggression item of the NPI/NPI-NH; exhibited sufficient agitation behaviours at time of entry to warrant use of pharmacotherapy, after excluding other factors; and met criteria for CMAI Factor 1 Aggressive Behaviours (To meet this criterion, one of the following must be displayed: 1) aggressive behaviours occurring several times per week, or 2) ≥2 aggressive behaviours occurring once or twice per week, or ≥3 aggressive behaviours occurring less than once per week.). Patients received REXULTI 2 mg/day or 3 mg/day (n=225), or placebo (n=116).

Discontinuation rates due to adverse events5

• REXULTI: 6.3% (41/655)

• placebo: 3.4% (13/388)

from Product Monograph

What is the recommended dosing for REXULTI?

REXULTI provides simple once-daily dosing and can be taken with or without food. Dosage should be maintained at the lowest effective level and patients should be periodically reassessed to determine continued need and appropriate dosage for treatment.5

MDD

▶ Recommended dosing

Adapted from Product Monograph ▶

The required length of adjunctive treatment with REXULTI is not known. When prescribed as an adjunct to antidepressants in the treatment of MDD, REXULTI should be used for the shortest period of time that is clinically indicated.

CANMAT: Canadian Network for Mood and Anxiety Treatments; MADRS: Montgomery-Asberg Depression Rating Scale (a 10-item physician-administered questionnaire rating patients’ symptoms of apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts and suicidal thoughts, on a scale from 0 to 6 with higher values reflecting more severe symptoms); LS: least squares; SDS: Sheehan Disability Scale (a 3-item self-rated instrument used to assess functional impairment in three domains, with higher values reflecting greater impairment); DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; CMAI: Cohen-Mansfield Agitation Inventory (a clinicianrated questionnaire consisting of 29 items, which assess the frequency of manifestations of agitated behaviours in elderly patients, based on caregiver input); CGI-S: Clinical Global Impression Severity; NINCDS-ADRDA: National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association; MMSE: Mini-Mental State Examination; NPI/NPI-NH: Neuropsychiatric Inventory/Neuropsychiatric Inventory Nursing Home.

▶ Recommended dosing

from Product Monograph

▶ Recommended dose titration

Recommended dosing

▶ Dose

Adapted from Product Monograph

See the Product Monograph for complete dosing, titration and administration information.

Clinical use:

Consider PrRexulti® for patients like Catherine.

PrREXULTI® is not indicated as an as needed (PRN) treatment for AAD. It may take up to six to eight weeks after REXULTI initiation to demonstrate significant clinical efficacy. The efficacy and safety of REXULTI in the treatment of AAD were demonstrated in two 12-week, randomized, double-blind, placebo-controlled, fixed dose trials in adult patients. When considering the use of REXULTI for the treatment of AAD, clinicians are advised to assess the risks and benefits of the use of REXULTI in elderly patients with AAD keeping in mind the increased risk of mortality in this patient population treated with antipsychotics and the risk predictors for stroke or existing cardiovascular comorbidities.

When considering the use of REXULTI as adjunctive treatment in MDD, clinicians must take into account the safety concerns associated with antipsychotic drugs, a class of drugs to which REXULTI belongs. Safety concerns of this class include: weight gain; hyperlipidemia; hyperglycaemia; tardive dyskinesia; and neuroleptic malignant syndrome. REXULTI should only be prescribed in patients with MDD by clinicians who are aware of the importance and are experienced in the early detection and management of the safety issues associated with this class of drugs. The efficacy and safety of REXULTI in the adjunctive treatment of MDD were demonstrated in 6-week, double-blind, placebo-controlled trials in adult patients. Therefore, the required length of adjunctive treatment with REXULTI is not known. When prescribed as an adjunct to antidepressants in the treatment of MDD, REXULTI should be used for the shortest period of time that is clinically indicated. It

is not known whether efficacy in adjunct treatment is due to REXULTI alone or from combined treatment with an antidepressant.

• The safety and efficacy of REXULTI have not been systematically evaluated in SZ or MDD patients ≥65 years of age, or in AAD patients ≥90 years of age. Use caution when treating geriatric patients.

• REXULTI is not indicated in pediatric patients (<18 years) and its use is not recommended in this population.

Most serious warnings and precautions:

Increased mortality in elderly patients with dementia: Elderly patients with dementia treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of 13 placebo-controlled trials with various atypical antipsychotics (modal duration of 10 weeks) in these patients showed a mean 1.6-fold increase in the death rate in the drug-treated patients. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature.

Other relevant warnings and precautions:

• Body temperature regulation

• Risk of falls and somnolence

• Contains lactose

• Orthostatic hypotension

• Risk of QT prolongation

• Evaluate patients for a history of drug abuse

• Driving and operating machinery

• Reports of hyperglycemia and diabetic ketoacidosis

• Weight gain

• Dyslipidemia

• Hyperprolactinemia

• Priapism

• Risk of leukopenia/neutropenia

• Venous thromboembolism

• Serious hypersensitivity reactions

• Neuroleptic malignant syndrome

• Tardive dyskinesia

• Risk of seizures/convulsions

• Risk of suicide

• Risk of impulse-control disorders/compulsive behaviours

• Severe cutaneous adverse reactions

• Dysphagia

• Should not be used during pregnancy or breast-feeding

• Caution when used in geriatric patient populations due to potential increased risk of cerebrovascular adverse events, including fatalities.

• Monitoring and laboratory tests: blood glucose, fasting lipid profile and body weight, complete blood count (CBC), white blood cell (WBC) and differential counts, prolactin and blood pressure, should be monitored at baseline and periodically throughout treatment.

For more information:

Please consult the Product Monograph at www.rexultimonograph.ca 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 us at 1-877-341-9245

References:

1. Health Canada. Notice of Compliance information, February 2024. 2. Data on File. Lundbeck Canada Inc., February 2024. 3. Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Can J Psychiatry. 2024;1–47. 4. Data on File. Lundbeck Canada Inc., July 2024. 5. REXULTI Product Monograph. Otsuka Pharmaceutical Co., Ltd. 2024. 6. Thase ME, Youakim JM, Skuban A, et al. Efficacy and safety of adjunctive brexpiprazole 2 mg in major depressive disorder: A phase 3, randomized, placebo-controlled study in patients with inadequate response to antidepressants. J Clin Psychiatry. 2015;76(9):1224–1231. (incl. supplementary) 7. Lee D, Slomkowski M, Hefting N, et al. Brexpiprazole for the Treatment of Agitation in Alzheimer Dementia: A Randomized Clinical Trial. JAMA Neurol. 2023;80(12):1307–1316.

All trademarks identified by a ® or a TM are protected trademarks (registered or unregistered) of their owners or licensors.

For more information, please visit www.otsukacanadatm-mc.ca

A

NOT THE BIG BAD WOLF

missive from a medical regulator always inspires a reaction from a doctor, whether it’s a frisson of fear or an eye roll. When the message is about an upcoming peer assessment, the response is usually a mix of alarm and anger.

Drs. Howard Goldstein and Michele Moss know this all too well. As peer assessors, they always start a meeting by reassuring the physician that they’re not out for blood. After all, they both got into the role after going through the process themselves.

Dr. Goldstein received his ominous gray envelope from the College of Physicians and Surgeons of Ontario in 1990. “Everyone I spoke to around that time would tell me that as soon as they

got that envelope, they had an acute gastrocolic reflex,” Dr. Goldstein said.

It was a random peer assessment, although to this day Dr. Goldstein doesn’t believe that the peer assessment selection process is random.

Dr. Henry Wu (now deceased) called, and tried to allay the concerns that the envelope had provoked. When the day came for the assessment, Dr. Wu arrived at Dr. Goldstein’s Toronto family medicine practice, and “was a delightful man.” He was interested in the clinic’s art, a poem Dr. Goldstein wrote for the Medical Post and his hobbies outside of practicing medicine.

Dr. Wu proceeded to review 25 of Dr. Goldstein’s charts, and afterwards they spoke for about an hour on the

Stories from peer assessors sent by the college; they started by calming doctors down, not blowing the house down

BY KYLIE TAGGART

practice of medicine. “I really felt it as a comfort.” Dr. Wu brought humanity into something that could have been strictly an investigative or didactic kind of experience, Dr. Goldstein said.

Another envelope arrived about a year later, but this time it was inviting Dr. Goldstein to be a peer assessor. He accepted and carried out the role for 15 years, visiting more than 100 physicians. Some were first-time assessments, some were re-assessments, but he didn’t know what kind of visit it was until he spoke with the physician.

Dr. Goldstein tried to follow Dr. Wu’s lead. When he made that first call, he tried to soothe physicians’ worries. And when he went to their clinics, he tried to show humanity.

Despite his reassurances, “There were many times when I was not a welcome visitor.” One physician even had a lawyer sit in on the assessment without warning. It was completely within the physician’s rights, but it rattled Dr. Goldstein.

Most of the physicians he visited were good practitioners, but some made him ask, “How can these doctors practice medicine?” One memorable visit was to an office in a walk-up apartment on a busy Toronto street. The doctor was a solo operator, with no administrator and only two chairs in the waiting room. The doctor kept medical samples in a jampacked closet and disposed of decadesold medical records in the bathtub by dousing them with sulfuric acid.

Another kept clinical notes on recipe cards, similar to a tactic used in the 1940s and 1950s to avoid the need for filing cabinets, because recipe cards can be stored in a drawer. Each card had only three lines written about a visit. And yet, when Dr. Goldstein asked the doctor about a patient, he could spout information about the family, the children, their jobs and other details. He didn’t meet the criteria for proper charting, but he knew his patients.

Another time, Dr. Goldstein couldn’t read the doctor’s writing. He spent four hours with the doctor going over the files and concluded they were perfect, except for legibility.

Many of the doctors taught Dr. Goldstein practice management pearls that he quickly adopted into his own practice. One doctor date-stamped and initialled all reports so it was clear they’d seen it. Physicians missing crucial reports was a recurring problem at the time. “I went out and got a date stamp. It was very simple,” Dr. Goldstein said.

Many were excellent physicians and record-keepers and Dr. Goldstein invited some to become peer assessors.

Dr. Michele Moss entered the role of peer assessor after scoring well on a College of Physicians and Surgeons of Alberta peer review. She’s had the role for 25 years. Dr. Moss agrees that the initial letter from the college is, “the most scary thing for a doctor to receive. I go into these things knowing this.”

She’s often confronted with doctors’

anger that the college has picked them. A standard question is, “There are doctors way worse than me, so why do you have to see me?”

Dr. Moss explains that her role is to improve their practice. “Yes, I’m here for the college, but I don’t want to be the big bad wolf that comes in to say you’re a terrible doc,” she said. “My job is to make good practice better.”

“There are doctors way worse than me, so why do you have to see me?”

She reviews about 20 charts with a grading system template, which includes scoring on whether certain elements were included in sufficient depth in the charts, such as patient history, reason for visit, presentation, examination, differential diagnosis and treatment. If it’s a thick chart, she expects them to know details about the patient. Dr. Moss picks an entry in the chart and asks them to explain the appointment to see if it was documented properly, or if there was a disconnect between what was reported and what happened. These days, she gets access to the doctor’s EMR and reviews charts and then meets them on Zoom in a conversation that usually lasts for about two-and-a-half hours.

“I’ve only ever had one where I felt that this person didn’t gain anything. It was always, ‘Yes, but….’”

All the other visits have been positive. She said the best encounter was with a person who had been in practice for about 20 years who confessed he’d gotten into bad habits when it came to charting. He said he didn’t even realize how bad they’d become, but it was for a number of reasons: He knew his patients so well, he kept a lot of information in his head, he got busy and, he confessed, he got lazy. He was happy with the review and understood he wasn’t a bad doctor; he just needed to improve his charting.

Dr. Moss said that many physicians say, “I know this patient really well and so I don’t have to write it down.” But Dr.

Moss asks, what if she was replacing the doctor? Good notes are “so I can carry on the good care that you provided.”

In all her years, only one person has ever requested another assessor for the followup visit. “I must say that 99% of the ones I’ve seen, at the end they say ‘Thank you for making me feel at ease.’”

One physician said they wanted to see if Dr. Moss saw a difference in the followup visit and, “It was like night and day.” The person said they felt so much better, and suggested that everyone should go through the process.

Dr. Moss no longer practices full-time family medicine but works in a multidisciplinary clinic, focusing on contraceptive care and irregular menstruation. When it comes to her charting and patient care, “I’m extremely thorough,” she said. “When I was in family practice, I ran behind a lot,” she confessed.

Dr. Moss has witnessed common mistakes in medical practice as a peer assessor. “What going through all these years of peer review has taught me is there’s no such thing as a routine investigation,” she said. Many “routine investigations” lead patients down rabbit holes of unnecessary testing and create undue angst. She’s also seen cases where doctors have ordered a test because patients requested it. A test or diagnostic imaging is to confirm or refute a diagnosis, she said.

The peer assessor role has also provided some life lessons. Over the years, Dr. Moss has encountered some older physicians who continue to practice for the wrong reasons. The doctors needed the patients more than the patients needed the doctors. “It made me really scared because some of these people didn’t have anything else,” she said.

“The sad thing is, as physicians, if we don’t develop outside friends or interests, you don’t know how to enjoy life outside of the office once it’s time to retire,” Dr. Moss said.

Dr. Goldstein, now retired, has taken that lesson to heart. He shared his stories about being a peer assessor in between time at a cottage and a trip to Spain. He continues to write for the Medical Post, letting all his stories and life lessons flow to those still in practice.

CELEBRATING 10 YEARS OF INVOKANA®1*

Thank you for your continuous support and combined efforts over the past decade. We’re looking forward to many more years of collaboration.

As of 2020: INVOKANA® (canagliflozin) is indicated as an adjunct to diet, exercise, and standard-of-care therapy to reduce the risk of end-stage kidney disease, doubling of serum creatinine, and CV death in adult patients with type 2 diabetes mellitus and diabetic nephropathy with albuminuria (>33.9 mg/mmol).2,3

As of 2018: INVOKANA® is also indicated as an adjunct to diet, exercise, and standard-of-care therapy to reduce the risk of major adverse cardiovascular events (CV death, nonfatal MI, and nonfatal stroke) in adults with type 2 diabetes mellitus and established CVD.2,3

As of 2014: INVOKANA® is also indicated for monotherapy as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.2,3

As of 2017: INVOKANA® is also indicated for use in adult patients with type 2 diabetes mellitus to improve glycemic control in combination with:

• metformin

• sulfonylurea (with or without metformin)

• pioglitazone with metformin

• metformin and sitagliptin

• insulin (with or without metformin)

when the therapy listed above, along with diet and exercise, does not provide adequate glycemic control.2,3

Please consult the Product Monograph available at www.janssen.com/canada/ourmedicines for important information relating to clinical use, contraindications, serious warnings and precautions, adverse reactions, drug interactions, and dosage and administration that has not been discussed in this piece.

The Product Monograph is also available by calling us at 1-800-567-3331.

CV=cardiovascular; CVD=cardiovascular disease.

* Clinical significance has not been established

References: 1. INVOKANA® Notice of Compliance. Janssen Inc. May 23, 2014.

2. INVOKANA® (canagliflozin) Product Monograph. Janssen Inc. March 11, 2024.

3. Data on file, Janssen Inc. March 8, 2022.

The image depicted contains models and is being used for illustrative purposes only. 19 Green Belt Drive | Toronto, Ontario | M3C 1L9 | www.janssen.com/canada

Scan to order INVOKANA® samples or to connect with your INVOKANA® representative.

Choose Relpax for your migraine patients

RELPAX (eletriptan hydrobromide) is indicated for the acute treatment of migraine with or without aura in adults. 1

Consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=74152 for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1-844-596-9526.

Help your patient get the Viatris original brand RELPAX.**

Write the Viatris original brand name, RELPAX, and include “no sub,” when appropriate, on your patient’s prescription.

Encourage your patients to visit ViatrisOriginals.ca so they can:

Remind your patient to ask for the Viatris original brand RELPAX at the pharmacy.

ViatrisOriginals.ca

*Subject to change. The Viatris Originals Program is available in all provinces except Quebec. Availability and level of payment assistance vary by brand medication and province.

**Some insurers limit full-cost coverage for higher-cost interchangeable drugs to patients who meet certain criteria, and in some instances, documentation from the prescriber is required. There is a possibility that the patient may need to contribute out-of-pocket where those conditions are not met.

Reference: 1. RELPAX® Product Monograph, BGP Pharma ULC. August 30, 2023

RELPAX® is a registered trademark of Viatris Specialty LLC, used under permission by BGP Pharma ULC, a Viatris company. VIATRIS and VIATRIS & Design are registered trademarks of Mylan Inc., used under permission by BGP Pharma ULC, a Viatris company.

New Year’s resolutions, anyone?

Doctors

share their reflections and their personal goals for

the year ahead. Plus, some tips for making them stick

BY ABIGAIL CUKIER

It’s that time again—when we start to think of the new year and what we want to achieve professionally and personally. Some people love setting a goal starting Jan. 1, while others may be too disillusioned by past failures to keep their resolutions. But new beginnings, such as a new year, can act as a fresh start to give you the motivation to tackle new goals. For some inspiration, the Medical Post asked a few physicians about their 2025 New Year’s resolutions.

MY HEALTH AND WELL-BEING

As a 52-year-old psychiatrist who has practised medicine for 23 years, I am experiencing the poorly understood life transition of menopause on top of years of being “too busy.” My 2025 resolution is full and complete prioritization of my health and

“SIMPLE IS NOT EASY, KNOWING IS NOT DOING .”

well-being. I hope to embody and role model the foundation of balance for health, vitality and joy. We all need to remember, “Simple is not easy, knowing is not doing” so let’s all get to doing the simple things we all know are important (sleep, exercise, nutrition, social connection and play) to become our very best versions of ourselves!

—DR. SHIMI KANG, Vancouver mental health, addiction and motivation specialist and clinical associate professor, University of British Columbia

AVOID LOW-VALUE RELATIONSHIPS

Do what I can and stop stressing about the outcome, which is not in my control. That applies to work and life in general. Slow down and try to enjoy life. I tend to work way too hard and overcommit and then I semi-crash for a few days thinking I failed. Regarding our healthcare crisis: It looks like it’s going to crash and burn, unless the powers that be come to their senses. I’ll do what I can, but I’m just one individual and I can’t carry the world on my shoulders. Hmm, related to both above: I aim to keep improving my lifestyle and increasing my activity. I walk up to two hours at a time a few times a week, kickbox, kayak and swim. I want to add cross-country skiing and hopefully go back to downhill skiing. The more active I am, the better I feel physically and mentally, and the sharper I feel. I also want to cut down my online presence and return to reading physical books. I’m tired of meaningless relationships. I’ve cut down my circle and aim to spend more time with family and friends without whom my life would be empty. This is harder than it sounds because people do get offended when one starts to protect family time. In the end, time is scarce and I want to spend that precious time nurturing critical relationships.

—DR. FERRUKH FARUQUI, urgent care physician in Ottawa and a fellow in the Dalla Lana Fellowship in Journalism and Health Impact at the University of Toronto

PRACTISE OPTIMISM

Professionally, I resolve to be practically optimistic about healthcare because I know my medical association has heard my pain and is committed to solving solutions. I resolve that I will be part of the solution by working together. Personally, I resolve to share what are my struggles without worrying about stigma. I resolve to make myself a priority (because without my oxygen mask, how can I put on someone else’s?).

—DR. ALYKHAN ABDULLA, medical director, the Kingsway Health Centre, Manotick, Ont., and assistant professor, University of Ottawa Faculty of Medicine

“PERSONALLY, I RESOLVE TO SHARE WHAT ARE MY STRUGGLES WITHOUT WORRYING ABOUT STIGMA”

PLANT TREES

The Canadian Coalition for Green Health Care is crazy about trees! We have seen the benefits of planting trees at hospitals and clinics. My resolution is to encourage more doctors to plant trees at their places of work.

—DR. MYLES SERGEANT, a family doctor in Hamilton and executive director of the Canadian Coalition for Green Health Care

READ THE CLASSICS

Read more classics, fewer British murder mysteries. Watch more documentaries on TV and less CNN.

Start swimming at the Y again after my COVID layoff. Start shooting pool again. I last did it 60 years ago during my misspent youth.

Retired one year and loving it.

Make your resolutions stick

You may be tempted to go after a pile of resolutions as soon as the clock strikes midnight on Jan. 1, but Dr. Aditi Nerurkar says to take it two at a time. In her book, The 5 Resets: Rewire Your Brain and Body for Less Stress and More Resilience, the Harvard medical school doctor says to take it two at a time. Humans have the cognitive processing ability to incorporate only two changes into our lives at any time if we want those changes to be sustainable, she says. Our brains register any

change as a stressor, even if it’s something positive, so our brains have a finite processing ability when it comes to making change. By choosing only two habits at a time, we work with our biology rather than against it, and we’re more likely to follow through.

Be consistent: James Clear, author of Atomic Habits, suggests aiming for smaller steps but doing them consistently, rather than setting large goals that can leave you overwhelmed and less likely to stick to them. He says, “If you get 1% better each day for one

year, you’ll end up 37 times better by the time you’re done. This is why small choices don’t make much of a difference at the time, but add up over the long-term.” For example, if you have a resolution to read more, you don’t need to aim to read for hours. Just pick up your book for a few minutes each night before bed. Instead of aiming to work out for an hour a day, aim for a 20-minute walk. Break a bad habit: If your resolution involves stopping a behaviour, it is important to choose a substitute, Clear says. Plan ahead for how you will

respond when you face the stress or boredom that usually prompts your bad habit. For example, what are you going to do when you get the urge to smoke? Maybe do breathing exercises instead. Also cut out triggers. If you want to stop scrolling your phone late at night, leave it out of your bedroom.

Expect some bumps in the road: If you have a setback, remind yourself it’s not because you are weak, it is actually expected. Our brains and bodies take time to set up new routines, so just start over.

—DR. JOHN CROSBY, retired family doctor, Cambridge, Ont.

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The Medical Post AWARDS

Awards for media engagement, helping marginalized communities, and innovation were presented to Canadian doctors

BY COLIN LESLIE

There is such tremendous work happening in Canada by physicians, and our annual Medical Post Awards are a celebration of these accomplishments.

The Medical Post Awards are selected by peers of physician juries. I travelled to meet some of our winners. Here we have quick quotes from this year’s winners but you can see the full profiles of the winners on our online home: CanadianHealthcareNetwork.ca. Or, scan the QR code with your smartphone camera to watch video interviews with the winners.

Revolutionizing spasticity care with innovative cryoneurolysis treatment

INNOVATIVE PRACTICE AWARD

Dr. Paul Winston, Victoria

As the leader behind the Victoria Peripheral Nerve and Spasticity Clinic, Dr. Paul Winston has revolutionized the treatment of spasticity by introducing a minimally invasive, ultrasoundguided procedure that has become a global model for care.

“We treat people with disabilities who’ve been told there’s nothing more that can be done. One patient, a 45-yearold with cerebral palsy, used a communication board to tell us they had eaten a french fry for the first time—something they’d never been able to do before.”

Innovative team transforms living kidney donation

INTERPROFESSIONAL TEAM

AWARD The Ottawa Hospital’s Living Kidney Donation Program Team, Ottawa

The Living Kidney Donor Team at the Ottawa Hospital, led by Dr. Ann Bugeja, has established the one-day kidney donor evaluation program.

“We instituted a streamlined kidney donor evaluation where potential kidney donors can have their workups completed in a very short period of time. This allows them to at least know that either they can move forward as a kidney donor and try to get that kidney into their loved one faster—or know that if they are not eligible to be a kidney donor, then at least they know that they have that peace of mind and the recipient can look at plan B.”

A

MAKING A DIFFERENCE

AWARD – URBAN

Dr. Jillian Alston, Toronto

Dr. Jillian Alston led the development and implementation of Canada’s first geriatric outreach program tailored for seniors (50 and older) in shelters.

“We consider individuals who are experiencing homelessness as being senior, even starting at the age of 50 as opposed to 65, just because of some of the accelerated aging that they can experience from being marginalized throughout their lives. Now when I’m doing the shelter outreach clinic (I’ll) see people in their 70s and 80s.

The Ottawa Hospital’s Living Kidney Donation Program team.

Photos by Colin Leslie

I’ve actually seen a couple of individuals in their 90s within the shelter.”

A commitment to rural healthcare and vision restoration

MAKING A DIFFERENCE AWARD – RURAL

Dr. Amandeep Rai, Toronto

Ophthalmologist Dr. Amandeep Rai has been key in an annual mission to underserved rural areas to Costa Rica involving faculty members, residents and fellows from the University of Toronto. Each year, this mission performs over 200 surgeries.

“I met a patient who had been waiting six years to get cataract surgery and I think that would be wholly unacceptable anywhere in the world with such advanced cataracts. This patient was legally blind and unable to navigate his environment in a country like Costa Rica that doesn’t really have a social security system. This does also mean that a family member (had to) be a fulltime provider to this patient. So two patients, two people’s lives are impacted by a reversible

cause of blindness. And we went in there and we were able to reverse this patient’s condition completely with an operation that lasted about 30 minutes. This patient has since returned to the workforce.”

Pediatric advocate honoured for social media innovating

MEDIA ENGAGEMENT AWARD – CHANGEMAKER

Dr. Prévost Jantchou, Montreal

Dr. Prévost Jantchou has been a leader in using platforms like TikTok and Instagram to make complex medical topics, such as inflammatory bowel diseases, understandable to the general public.

“One example: A lady wrote to me one day saying, ‘I was ready to straighten the hair of my six-year-old when I saw your video. I just changed my mind because that video was talking about the association between hair-straightening (chemicals) and ovarian, breast and uterine cancer.’ So she said, ‘Thank you, doctor. I was ignorant and I was ready to do it to my sixyear-old.’ This is amazing.”

Stories from the road

These awards are also an opportunity for me to meet doctors in their communities and get a sense of the issues they face (wow, do some hospitals in Canada look rundown compared to others!). All of this year’s recipients are doing amazing work but here are three anecdotes from my plane and road trip across the nation:

• In Victoria, I had interviewed Dr. Paul Winston and was back at my mother’s house reviewing the video as she sat beside me. Dr. Winston said: “The antidote to burnout is joy,” and my mom, 84, gave out a little nod and a “yes!”

• I had struggled through Toronto traffic to reach the Kensington Eye Institute and interview Dr. Amandeep Rai

Combating health misinformation, advancing public health literacy

Dr. Shazma Mithani’s media presence first gained momentum during the COVID-19 pandemic but she continues to combat health misinformation through regular media appearances.

“For me, it’s always about educating people as best I can: Sticking with the facts, keeping things simple and just being as authentic and approachable as possible. I think (that) really helps get that message across and keeps me going day to day to continue that fight against misinformation and disinformation.”

Recognition for learner advocacy and education through social media

MEDIA ENGAGEMENT LEARNER

AWARD Dr. Justina Melkis, Toronto

As the co-founder of “Clerkship Clinical Pearls,” Dr. Justina Melkis has made an impact by creating and sharing educational infographics designed to be easily understood by those at the clerkship level. As well, she has a following of about 60,000 where she connects with medical learners under the handle @mymdmoments for both Instagram and TikTok.

“Sometimes when doctors are online, people have a bit of a stigma about that. They’re like, ‘Why do you have so much time to be on social media?’ But what people don’t understand is that this is also a creative outlet for a lot of physicians. . . . It’s fun for me to do so in my free time.”

Recognition as a top blogger

TOP BLOGGER AWARD

Dr. Howard Goldstein, Toronto

For the blog he’s written for the Medical Post for a decade, Dr. Howard Goldstein received the Top Blogger Award (not selected by the judges but rather based on high reader engagement).

but I hadn’t brought my laptop, which I use to plug in my ring light for video interviews. I asked one of the staffers at the clinic and a few minutes later he came back with exactly the right kind of cord. After I thanked him, he winked. “That’s what nurses do!”

• For the Interprofesional Team Award, I went to the Ottawa Hospital to interview Dr. Ann Bugeja and take pictures of the team—and members just kept on streaming into the boardroom! Some had come from other campuses and not even met each other before. It reminded me what a team sport medicine is.

—Colin Leslie, editor-in-chief, the Medical Post

MEDIA ENGAGEMENT AWARD – TRAILBLAZER Dr. Shazma Mithani, Edmonton

Fee deal innovations

Young FP alert: Who’s offering the best deal? P.E.I. appears to have competitive edge

BY ANN GRAHAM WALKER

For a young physician right now, the massive doctor shortage across Canada translates into a broad range of choices. A new family practice grad with full Canadian credentials would be welcomed just about anywhere in the country, with provinces competing to create the most appealing practice environment that addresses issues in urgent need of reform.

Five issues we keep hearing about: the challenge of time-consuming, not interoperable EMRs; excessive paperwork demands such as sick notes; unpaid hours

providing critical indirect care; crippling business overheads; and the generally unsupported costs of developing healthcare teams that resemble those doctors worked on during medical training.

These issues generally translate into quality-of-life concerns that have been drawing medical students away from family medicine and—for those who do choose family medicine—away from practising longitudinal family medicine (LFM).

We know the situation has reached a crisis that spins off into other areas of

medicine, with the nationwide shortage of FPs creating crushing workloads in specialties and emergency rooms. So how have the provinces been responding?

A MENU OF OPTIONS

As physician agreements expire and parties huddle for negotiations, there have been some meaningful tweaks to established practice models, with an overarching goal to strengthen LMF and recruit and retain a physician population that practises longitudinal care.

B.C.: British Columbia led the way in February 2023 with the launch of its (optional) Longitudinal Family Physician (LFP) payment model. The LFP compensates eligible FPs an hourly rate ($130) for time spent providing service to patients—including time spent in indirect care. These new models are complex and multifaceted, so it’s not easy to generalize, or to compare bottom lines between one provincial plan and another. In B.C., in addition to the hourly rate, there are fees for each patient interaction (calculated in 15-minute units). A third basket of remuneration is calculated according to the number and complexity of patients in a physician’s panel. FPs can choose to remain on the completely separate fee-for-service (FFS) plan, but according to the B.C. Ministry of Health, 80% have signed up for the LFP. Monetarily, the B.C. payment model has been in existence long enough to determine—at least anecdotally—that it has increased FP income by about 30%, according to Doctors of BC past-president Dr. Joshua Greggain. Dr. Greggain was on the 2022 negotiations team that brought the LFP about. A work-in-progress, it has already been expanded to cover inpatient and palliative services, pregnancy/newborn services and longterm care. Envious FFS specialists are wondering if the plan can be adapted to include them in the next round of negotiations.

N.S.: In Nova Scotia a new master agreement that took effect April 1, 2023, ushered in the Longitudinal Family Medicine payment model—a blended plan that, as in B.C., offers eligible FPs an hourly rate for direct and indirect care. The established FFS system remains intact with updated codes, incentives for taking on new patients, compensation for panel size and complexity and support to hire allied healthcare providers to enhance team-based care. Doctors Nova Scotia projects the plan will increase FP remuneration by 20%.

Sask.: Saskatchewan’s new physician contract, announced in February 2024, offers longitudinal-care FPs the option of enrolling in a Transitional Payment Model (TPM) that is intended to provide a bridge as Saskatchewan fully develops a blended capitation system for FPled team-based care. Under the TPM, a physician with a panel of 1,600 will receive $144,000 in annual capitation, in addition to their FFS billing. (This amount is the maximum achievable. It represents a significant increase over established FFS earnings). There is no specific payment for indirect care, as it falls under the blended capitation agreement. New in the Saskatchewan physician agreement is a $10 million annual fund to assist eligible physicians with the costs of developing teambased care, following the Patient’s Medical Home model. According to the Saskatchewan Medical Association, 79% of eligible family physicians joined the TPM within the first six months of its April 1, 2024, launch.

Man.: This province introduced a Family Medicine+ initiative in April 2024 that enables FPs practising longitudinal care to bill up to three hours per week of indirect care. It is not reliant on timeconsuming tracking on the part of physicians. Payments are automatically calculated based on panel size, with the three-hour maximum requiring a panel of 1,500 patients. While maintaining 100% of FFS tariffs, the plan adds quarterly non-volume-based remuneration calculated on panel size and patient complexity.

“P.E.I. physicians will now be above the national average.”

SMALL PROVINCE, BIG PLAN

P.E.I.: Canada’s smallest province has now jumped into the fray with a 249-page, incentive-rich master agreement that addresses just about all of the critical issues noted above. There is something to like for every doctor in this agreement, but once again, the biggest incentives are for FPs choosing to offer LFM.

Over the course of the five-year deal, physician income will be increased by between 8% and 36%, with the 36% going to doctors practising LFM.

For physicians who appreciate a smallscale environment and the challenges of mostly rural practice, P.E.I. was already unique in that it offers physicians the option of working in a salaried model. That comes with a guaranteed income, benefits and no office overheads. If it turns out that you prefer something else, doctors are free to switch back and forth between P.E.I.’s physician payment options, which in addition to salary mode include conventional FFS and contract-for-service.

The new agreement guarantees all salaried doctors support staff, a unified EMR and a benefits package that includes six weeks of paid vacation and 26 weeks of parental leave.

Currently there are 135 FPs practising in P.E.I. (there are about 334 physicians practising there in total). Of course, creating reforms like a single EMR is a lot easier with 334 doctors than in a province like B.C., with around 12,000 doctors who have already invested in about 20 different competing systems.

recognizes all family medicine physicians (whether in LFM or focused practice) as specialists.

“This is more than words,” said a spokesperson from the Medical Society of PEI (MSPEI), in an email to the Medical Post. “(The) way it is presented in this new physician services agreement is through the payment increase to LFM. . . . The gap between family medicine specialties and others has been reduced. Any legacy language that separates specialists from family medicine has been removed. In addition, we provided equal access to continuing medical education for all physicians where historically family physicians received less funding.”

Family physicians who practice LFM and hold a patient panel will be paid at a higher hourly rate than FPs who do focused family medicine.

CASH INCENTIVES

One particularly attractive aspect of the P.E.I. agreement is that it formally

There are additional cash incentives based on a longitudinal family doctor’s panel size with a bonus for increasing the number of patients beyond their previously documented panel size ($10,000 annually per 100 patients).

While those working in the salaried model are expected to provide indirect care as part of their services, the new agreement compensates all P.E.I. FFS physicians for indirect care with a new billing code that enables them to bill (in 15-minute units of up to $57.23 at the contract’s maturity) for up to five hours per week of indirect care.

FFS family physicians will see income increases similar to salaried FPs through increases in fee codes—while the actual number of fee codes is being reduced from 450 to 31 to reduce administrative burden.

“From our analysis, we believe that for most specialties, P.E.I. physicians will now be above the national average, and family physicians will now be among the most competitively paid in Canada,” said the MSPEI spokesperson.

The agreement will fully take effect April 1, 2025, and run until March 31, 2029. In the interim, the previous, expired contract will be extended, while an “Operating Guide” is written to help physicians navigate the new manual.

Protect and relieve your

symptom relief from heartburn associated

favourable safety proﬁle with no reported

patients are required to

discontinue use of PPIs before an H. pylori test3

patients in recurrent use or

EsopH® has been clinically proven to provide fast and e ective symptom relief associated with acid-reﬂux and heartburn1†

In a study of 154 NERD patients, EsopH® was demonstrated to be signiﬁcantly more e ective in providing symptom relief vs. placebo (heartburn, retrosternal pain, regurgitation, and acid taste). The proportion of patients with at least a 3-point reduction in the total symptom score‡ at the end of 2 weeks was: EsopH® 52.6% (40/76); placebo 32.1% (25/78).1†

Adapted from Savarino V., et al. All patients were also on acid suppression with standard dose PPIs

EsopH® liquid gel should be taken orally after each meal and at bedtime up to 4x a day2

EsopH® is conveniently packaged in a single-dose sachet2

% of patients with a Total Symptom Score reduction of at least 3 points

After taking EsopH®, patients should avoid food and liquids for 30 minutes1,2

92% of patients evaluated (n=7230) gave positive feedback on palatability1

Recommended use: Acid reflux therapy. For temporary relief of heartburn and discomfort due to a burning sensation in the esophagus. Helps relieve heartburn associated with excess stomach acid and its backward flow by protecting the esophageal mucosa. Cautions and Warnings: If symptoms worsen, consult a health care practitioner. If you are pregnant or breastfeeding, consult a healthcare practitioner prior to use. Consult a health care practitioner if you are taking any prescription medication. Do not exceed the recommended dose. Do not use the product after expiry date. Store in a cool, dry place, away from sources of heat. Do not freeze. Keep out of reach of children. Contra-Indications: Avoid use in the case of known or suspected hypersensitivity to any of its components. References: 1.Savarino V, et al. Alimentary Pharmacol Ther 2017;45(5):631-642. 2.EsopH Health Canada Product Licence. 2024. https://health-products.canada.ca/lnhpd-bdpsnh/info?licence=80086600. 3.Gąsiorowska A. Otolaryngol Pol 2020;74(4):40-45.

† Multicentre, randomised, placebo-controlled 2-week trial of 154 patients with NERD. Symptoms included heartburn, acid regurgitation, retrosternal pain and acid taste in the mouth. Patients were randomised to receive one standard dose of a PPI (30 min before breakfast) + 10 mL (1 stick) of EsopH® (single dose stick formulation) or placebo (with the same taste and viscosity, packed in identical, sequentially numbered, containers) q.d.s., that is 1 h after each daily meal, and at bedtime for a 14-day treatment period. Patients were also on acid suppression with standard dose PPIs. Any other prescription or OTC therapy was discontinued. The only medications permitted were antacids or alginate-containing formulations in case of symptom occurrence. The primary endpoint was the proportion of patients with at least a 3-point reduction in the total symptom score at the final visit. ‡ Total symptom score: This was calculated by collecting and computing the intensity of each patient’s symptom (on the basis of the RDQ questionnaire at the final visit) and comparing it with the baseline values, obtained at the end of the run in/wash out period (visit 2). Typical symptoms were evaluated according to a 5-degree Likert scale:

reflux disease questionnaire

EsopH® n=76

Placebo n=78

When your patients with major depressive disorder are facing an inadequate response to their antidepressant

Consider adding PrREXULTI®

PrREXULTI® is indicated for use as an adjunct to antidepressants for the treatment of major depressive disorder (MDD) in adult patients with an inadequate response to prior antidepressant treatments during the current episode.3

Clinical use:

The e cacy and safety of REXULTI in the adjunctive treatment of MDD were demonstrated in 6-week, double-blind, placebo-controlled trials in adult patients. Therefore, the required length of adjunctive treatment with REXULTI is not known. When prescribed as an adjunct to antidepressants in the treatment of MDD, REXULTI should be used for the shortest period of time that is clinically indicated. It is not known whether e cacy in adjunct treatment is due to REXULTI alone or from combined treatment with an antidepressant.

• The safety and e cacy of REXULTI have not been systematically evaluated in MDD patients ≥65 years of age. Use caution when treating geriatric patients.

• REXULTI is not indicated in pediatric patients (<18 years) and its use is not recommended in this population.

Most serious warnings and precautions:

Other relevant warnings and precautions:

• Body temperature regulation

• Risk of falls and somnolence

• Contains lactose

• Orthostatic hypotension

• Risk of QT prolongation

• Evaluate patients for a history of drug abuse

• Driving and operating machinery

• Reports of hyperglycemia and diabetic ketoacidosis

• Weight gain

• Dyslipidemia

• Hyperprolactinemia

• Priapism

• Risk of leukopenia/neutropenia

• Venous thromboembolism

• Serious hypersensitivity reactions

• Neuroleptic malignant syndrome

CANMAT: Canadian Network for Mood and Anxiety Treatments.

* See guidelines for complete recommendations.

• Tardive dyskinesia

• Risk of seizures/convulsions

• Risk of suicide

• Risk of impulse-control disorders/compulsive behaviours

• Severe cutaneous adverse reactions

• Dysphagia

• Should not be used during pregnancy or breast-feeding

• Caution when used in geriatric patient populations due to potential increased risk of cerebrovascular adverse events, including fatalities

• Monitoring and laboratory tests: blood glucose, fasting lipid proﬁle and body weight, complete blood count (CBC), white blood cell (WBC) and di erential counts, prolactin and blood pressure, should be monitored at baseline and periodically throughout treatment

For more information:

Please consult the Product Monograph at www.rexultimonograph.ca for important information relating to clinical use, warnings, and precautions, adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-877-341-9245

References: 1. Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Can J Psychiatry. 2024;1–47. 2. CANMAT. Data on File. CANMAT Letter to PAAB. 3. REXULTI Product Monograph. Otsuka Pharmaceutical Co., Ltd. All trademarks identiﬁed by a ® or a ™ are protected trademarks (registered or unregistered) of their owners or licensors. For more information, please visit www.otsukacanadatm-mc.ca © Otsuka Canada Pharmaceutical Inc. and Lundbeck Canada Inc. All

Back Pages

Slow decline

How one patient’s mystery symptoms led to a life-saving discovery in the ER

‘So many things are perfectly clear in retrospect,’ writes Dr. Raj Waghmare after untangling an interesting, uncommon case

As I enter the room, chart in hand, Emily O’Connor (name changed) sighs with relief and says, “I’m back.” It’s been three weeks since I’d first met her, here in the ER, and if I hadn’t looked at her record beforehand, I wouldn’t have remembered.

“Is this the doctor who saw you before?” her husband says. She nods yes. “Good, then. He knows the story.”

Of course, I only know the story

because I read my notes from the first visit, reviewed her test results from that day and read today’s triage note. I’ve seen a few hundred patients in the preceding weeks and without her chart, I wouldn’t even know her name. But I’m glad she seems relieved it’s me, and I use my familiarity to make her comfortable. “I’m glad you came back,” I say. “You don’t look so good.”

At her first visit, in late February, she reported a three-week history of a decreased appetite. Solids were intolerable, making her nauseated and even liquids turned her stomach. Along

BY DR. RAJ WAGHMARE

with this, she had urinary frequency, constipation and fatigue. In the two days prior to her initial visit, she had a couple of episodes of vomiting as well. Along with this, she had pain in her upper abdomen, just below her sternum. Because of her abdominal pain and anorexia, she’d lost three to four pounds since symptom onset.

Other than these past few weeks, Emily had been healthy. She denied any previous medical issues, had never had surgery and neither smoked nor drank. She’s married, has two teenaged children and works in sales.

That first visit

On exam that first visit, she was afebrile, had a heart rate of 80 beats per minute, blood pressure slightly high at 150/90 and a normal oxygen saturation. Her colour was good, no pallor, nor jaundice, and other than mild epigastric tenderness, her physical exam was normal. Because she’s in her early 40s, Caucasian and slightly overweight, gallstones were at the top of my differential diagnosis. Along with an ultrasound, I ordered a one-litre saline bolus and requested a CBC, electrolytes, creatinine and liver enzymes.

Two hours later, the results were back. The ultrasound was normal and, for the most part, so was her blood work. Her creatinine and white blood cell count were slightly elevated, at 115 and 12 respectively. Her alkaline was also elevated at 160. On reassessment, she felt about the same, perhaps slightly better after the bolus of saline.

COLUMN

I told her I wasn’t exactly sure what was going on, but with her epigastric pain, anorexia and recent vomiting, the next step would be a gastroscopy. She agreed with this and I set up an urgent outpatient appointment with a gastroenterologist.

Back in the ER

Now, three weeks later, she’s back. She’s now had six weeks of nausea and her episodes of vomiting are increasing in frequency. She’s seen the gastroenterologist, and there were several findings on her scope to explain her symptoms: gastritis, an ulcer, as well as a hiatus hernia. Although the specialist started her on a proton-pump inhibitor, her symptoms have not settled. They’ve worsened. She’s vomiting daily, now up to six times in 24 hours. She’s also taking laxatives and fibre for constipation, but they aren’t helping. Most concerning, however, is that she’s lost almost 20 pounds. She’s weak, and has generalized body aches.

She tells me that although the ulcer explained most of her symptoms, medication hasn’t helped. She’s changed her diet and is trying to “eat clean,” but this is only contributing to her weight loss and, in turn, her weakness. And although her abdominal pain has improved (she has virtually none), she can’t eat without vomiting now. “The body aches are terrible,” she says. “My muscles ache non-stop. My bones ache.”

Again, her vital signs are normal, as is her physical exam. I can’t even elicit abdominal tenderness this time around.

“I’m going to repeat your blood work,” I say, “hydrate you, and order a CT scan of your abdomen.”

“Thank you,” she says.

“Regardless of the results,” I say, “you’ll likely need admission so we can sort out what’s going on. A 20-pound weight loss over six weeks is no good.”

“I figured the same,” she says. With such profound weight loss, my first worry is cancer, specifically pancreatic cancer. I’ve diagnosed a few new cases of pancreatic cancer in the ER in the past 12 months, and I’m hoping this isn’t yet another.

The next five hours are the epitome of

an ER shift: cellulitis, a concussion, two lacerations, a knee injury, a fractured wrist, balanitis, a corneal abrasion, a mental health crisis, otitis media, vomiting, back pain, an abscess, a kidney stone, benign chest pain and a cold. There was one case of congestive heart failure, but he was stable and well, and would go home that night. It’s like this every night, and over the years I’ve had dozens of observers, many of them high school or university students contemplating medicine. At the end of many of these shifts, if nothing exciting has happened, I tell them that although the ER isn’t exactly as depicted on TV, it’s still pretty cool.

I’m near the end of my shift when Emily’s tests are back. Her CT scan is completely normal, but her blood work isn’t. Her white count is higher now, at 16, and her hemoglobin, which was 160 three weeks ago, is now 130. It’s not that low, but it’s a definite drop in a short period. I ask if she’s experienced any black stool, suggesting that the ulcer may be bleeding periodically, but she denies it. “Like I said, I have barely pooped at all.” Her sodium is a little low, at 131, her potassium has dropped to 2.8 and her creatinine is now about three times normal at 320.

“You’re going to have to be admitted,” I tell her. “Not just for the weight loss, but now, your kidneys are showing signs of injury.” I tell her that it’s most likely because of dehydration, as she can barely tolerate oral intake, but once admitted, we’ll explore other potential causes.

An hour later

An hour later, a general internist sees Emily, orders more hydration, a repeat consultation with a gastroenterologist, as well as a nephrology consultation, and admits her to hospital.

Despite two litres of I.V. fluid, her creatinine is unchanged the following morning. The gastroenterologist sees her and suggests a repeat upper endoscopy, as well as a colonoscopy this time around, as well as a CT scan of her head and chest (as the abdominal scan was normal). The nephrologist sees her shortly after, orders more blood work and suggests a renal biopsy if

her creatinine fails to improve and lab investigations are non-conclusive. Fortunately, that evening, her blood tests shed some light. Her serum calcium is grossly elevated at 4.6. She is given a dose of pamidronate, and a new CT requisition is completed, this time requesting a scan from her head to her pelvis.

On her third day of admission, she is started on prednisone, as well as calcitonin, twice a day, for two days, and her CT scan is completed. It shows a golf-ball sized lesion abutting the posterior aspect of her thyroid gland.

If it had been on the anterior aspect of her thyroid, it would have likely been grossly visible for quite some time. It wasn’t. Of course, on the posterior aspect of the thyroid are the parathyroid glands, and hyperparathyroidism is suspected— either due to a parathyroid adenoma or carcinoma. Emily’s parathyroid hormone comes back 20 times higher than normal. Emily’s admission lasts 10 days, over which treatment with I.V. fluids, prednisone and pamidronate correct her hypercalcemia. Her creatinine improves, and so do her symptoms, and a followup consultation is made at a tertiary care hospital for parathyroidectomy.

So many things are perfectly clear in retrospect. All of Emily’s symptoms were explicable by her severe hypercalcemia: her anorexia, her nausea, her vomiting, her weakness, her aches and even her ulcer. Even the urinary frequency she mentioned at her first visit could have been attributed to her hypercalcemia (and in turn, her hyperparathyroidism). In fact, the only systems her high calcium didn’t seem to affect were her cardiovascular and neurologic. And in our ER, abnormalities of these two systems would likely have prompted ordering of extended electrolytes. Nonetheless, it was a great case, and interesting, uncommon cases like this are also part of the epitome of life in the ER. And although it isn’t always exciting, it’s never boring.

DR. RAJ WAGHMARE is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 20 years of medical practice all over Ontario.

FINANCE

The most expensive stories for investors

Dr. Mark Soth outlines how some stories we hear make successful investing harder

People love stories. They grab our attention and we relate to them on an emotional level. Companies that sell stories, and get paid for attracting eyeballs or clicks, are wise to use them. Investing is challenging because we are constantly bombarded by narratives about when to invest and what to invest in. Unfortunately, these stories often lead investors astray. Find out how, so that you can recognize and enjoy the most common and expensive stories, without buying them.

The efficient market hypothesis: False. But, true enough: The efficient markets hypothesis argues that markets are efficient, leaving no room to make excess profits by investing since

everything is already fairly and accurately priced. Markets are information processing machines. Each day millions of investors bring their bits of knowledge about a company and its future prospects to the table. They compete on both sides of a trade to get the best price given their outlook. That price-finding contains information about the future cash flow of a company and the probability of that unfolding as expected.

At the market level, the larger a player is, the more weight their information is given to the market price. If you have read it, heard it or considered it—it is likely that those larger players have too. They also have resources to uncover information that you don’t. To make a

BY DR. MARK SOTH

profit from a story, your narrative must be more accurate than theirs. Otherwise, the story is already priced in. However, the future is uncertain and even though information is more accessible than ever, markets are not perfectly efficient at determining price. Humans and our biases are involved.

But, the inefficiencies are small, fleeting and their timing is unpredictable. It is like walking on a busy sidewalk looking for money. Every once in a while, someone will drop a dollar. However, there are millions of other walkers, many of whom have super-human reflexes. And you may get your hand stepped on if you reach for the dollar.

Even if you have access to the best story, the market environment has so many skilled players that the winner is a matter of chance. This is called the paradox of skill. It does not mean that there are not skilled managers. They are just so uniformly skilled and resourced that the deciding factor is usually chance. They can have lucky streaks. Unfortunately, that does not predict their future performance.

The most valuable phrase for investors: Understanding that markets are efficient enough at processing information that you cannot consistently beat them (outside of luck) is valuable. If you accept that and hear a compelling story, you can save yourself by recalling, “It is all priced in.” Unless it is insider information (illegal), it is known, and the probability of it coming to pass is factored into the current price.

Repeating “It is all priced in” can stop you from acting when you hear some of the common, but expensive stories. They sound great. Media gets paid to sell them. Your buddy in the doctor’s lounge sounds smart telling them. I like to tell them too—Here are a few common ones below.

The next big thing

People love exciting stories and feeling like they are on the vanguard of a disruptive revolution. For example, Nvidia may profit greatly from artificial intelligence. However, that is known, and the probability of that happening is why it is as expensive as it is. That narrative may be correct. However, to profit further from buying Nvidia now, the future must look even better than the current narrative. The exciting stories you hear are all priced in.

Even if you are correct about a disruptive technology, you need to know who the winners will be before they win. For example, the thesis that the internet

would change our lives and dominate was correct. Did you choose Google? Or Nortel? Or a bunch of the other losers of the dotcom bust?

The doomsday prophets

The only thing that sells better than an exciting story is a scary one. There are constant stories in the media about the next financial calamity. When it does not happen, they move onto the next story. If it does, they focus on it—in hindsight. Unexpected bad things do happen. So, if you constantly predict them, eventually you will be right. A broken watch is right twice per day.

The problem is that fear is powerful and markets generally move up over time. Missing just the best 10 market days from 2003 to 2022 because you moved to cash (expecting a crisis) would cut your returns in half. That period included the 2008 financial crisis and the COVID-19 pandemic—plus various politicians, trade wars, ground wars and band break-ups. Lots of calamity. Making it even more difficult is that the best days cluster around the worst days. You don’t need to look further than the recent U.S. election to see this phenomenon. The world may be scary, but it is all priced in.

The expensive self-talk

Financial media channels can be very expensive if you believe that they are giving your actionable information. You should heed their disclaimers about only being for entertainment value. The only more expensive storyteller is the one in the mirror. We are wired to tell ourselves all sorts of expensive stories.

With the efficient market and paradox of skill, luck plays a major role in the outcome of an individual investment. We can attenuate that by diversifying among as much of the market as possible and maximizing our time exposed to it. That is a bet on the overall progress of the capital markets. If that doesn’t play out, then there are probably no safe places to hide.

Anyone can have a lucky streak. Great! Just don’t confuse outcomes with skill and process. It is human nature to attribute success to our genius and failures to external factors. We are also wired to focus on rare massive payouts

and forget our grinding losses. This makes casinos successful. Don’t gamble in the stock markets by stock-picking or market-timing. It is all priced in. Instead, invest in the whole market to be compensated for risk exposure while avoiding the uncompensated specific risks of placing bets.

The markets are too high

As mentioned, the fear generated by bad stories unfolding around us can cost us money by missing a rising market. However, we are afraid of heights too. When markets have risen, then people expect there to be a fall. That is how gravity works in the world around us. We can relate to that story. Markets do fall. However, they rise more than they fall. It is not symmetrical. Markets get too far ahead of themselves when the aggregate narrative is more positive than what will likely happen. They fall when that becomes apparent. However, no one can predict when or how that will happen. Anything currently knowable is priced in. Even knowing that markets pull back, we cannot predict movements with enough precision to time an exit and re-entry well. Waiting for a 10% pullback while the markets advance 20% still leaves you in the dust. Historically, strategies to build cash and “buy the dip” rather than being fully invested underperformed by 1% to 3% per year depending on the strategy and data set you look at. The longest one I have seen is 90 years of U.S. market history. What seems like a big move up or down in the past year is just a blip on that chart. Statistically, all-time-highs are most likely to be followed by more all-time highs. Investing should be easy, but stories make it difficult: Being compensated for risking money in a market should be easy. Accepting that “It is all priced in” makes buying and holding the whole market logical. Broad index tracking funds have made that easy to do at a low cost. Despite that product innovation, investing is still hard for us to do in real life. We are humans and we love stories.

DR. MARK SOTH, a practising academic intensivist in Hamilton, writes the Loonie Doctor blog.

HOW TO Doctors: how to get a literary agent

Three doctor-authors with book deals talk getting published

BY COLIN LESLIE

“Can you introduce me to your agent?”

Doctor-authors say they get asked this pretty regularly by colleagues. They often find themselves explaining that anyone can pitch a literary agent but there is a structure to query letters—and usually more pre-pitch work than expected to be done.

Dr. Jillian Horton, whose book We Are All Perfectly Fine was published by HarperCollins in 2022, said she hears from lots of doctors who say they want to be a writer and ask how to get started.

“The first thing I always say to people is: It’s not a contemplative act. You have to get it out of your brain and onto a page,” Dr. Horton said. Key is first figuring out what you want to accomplish, she said. Writing for an external goal—“I want to be a famous bestselling author”—usually won’t sustain you, because the likelihood of that happening is so small, Dr. Horton said.

But, she said, “If you figure out what your internal goal is—maybe it is to make people feel less alone, to encourage, to inspire—then it becomes separate from this (big goal) ‘climb Mount Everest.’ You’ve got a bite-sized piece.”

Dr. Horton said a column she did for CMAJ blogs, “was probably the most important thing I ever wrote. Why? Because when I wrote that column, it gave me a ‘play space,’ and I found my voice.” For years she also wrote drafts of a fiction book that ultimately was never published.

But all that work meant that when she got ready to send a query letter for We Are All Perfectly Fine, she quickly got representation (her agent is Jackie Kaiser

at Westwood Creative Artists, who also represents Yann Martel). She said people often say to her: “‘Oh, you must have had an in,’ (but) no, I never met my agent (before pitching).”

After that, it all went quickly. “From the time I pitched her, signed with her and the book got sold (after an exclusive submission), I don’t even think that was eight weeks. . . . but what people don’t see is the 10 years before that.”

Value of an agent

Host of the CBC radio show White Coat, Black Art, Dr. Brian Goldman, who is currently writing the first draft to his fifth book, credits much of his success to his agent, Rick Broadhead, who has represented him for nearly two decades.

Dr. Goldman emphasizes that agents are more than just middlemen—they are navigators in the ever-changing publishing landscape. “A successful agent knows the market and can evaluate your

book (proposal) as to how in tune it is with the market. That includes knowing what similarly-themed books have been sold, written, green-lit, are about to be published, etc.,” Dr. Goldman explained in an email interview. As well as negotiating your contract, “An agent is your confidant. Writers tend to be a bit introverted and reflective. Writing a book is a long and often lonely process. Having an agent you get along with helps with that.”

Query letters

Dr. Michael Simon, an FP in Saint John, N.B., said he’d been attending writing conferences and occasionally getting his short science fiction published in magazines and anthologies for years. He also wrote a couple of novels and thought he was ready to get an agent. So he researched agents who represent the kind of sci-fi books he writes and pitched a few of them.

“There’s a very specific structure to a query letter, telling the agent who you are,” Dr. Simon said: “A little (hook) paragraph, a blurb about the book, what credit you have, if any, and you may compare it to other books in the same genre. For example, I compared mine to The Martian and The Expanse.”

His persistence paid off. “Three years ago, I received an offer from an American agent to represent my work, and last year, she sold two of my books!”

That agent had asked to see the full manuscript (you have to have the finished product done before pitching for fiction) after reading his initial query. Getting signed is a big deal: Agents generally don’t have huge numbers of authors. “My agent has 20 clients,” Dr. Simon said. He noted that agents want to represent authors for more than just one book.

Now he has two science fiction series, a total of five books, coming out next year. First Command, published by Aethon Books, will be launched in February. Extinction, by Podium Entertainment, will be released in April.

Finding a literary agent may seem daunting, but as these physician-authors demonstrate, doctors make great writers and with some persistence, it is achievable.

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British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, PEI & Newfoundland CONTEST

Caption the cartoon

WHAT WOULD BE A FUNNY LINE FOR A CHARACTER TO SAY HERE?

Use your smartphone to scan the QR code above—or go online to www. canadianhealthcarenetwork.ca/ caption-decembers-cartoon-plant and you can enter your answer on the Medical Post’s online home. If your answer is selected, you’ll receive a $75 Amazon gift card and this cartoon will re-run in the next issue of the Medical Post magazine with your caption! So you get money—and doubtless esteem and accolades from your colleagues!

Caption contest winner

‘So that’s what you meant when you said you have a textbook migraine.’

We had a lot of great entries for the captionthe-cartoon contest in the October issue of the magazine, but we thought Dr. Terrence Creatchman’s entry above was the funniest. Dr. Creatchman, a family doctor in Hamilton, will receive a $75 Amazon gift card as a prize.

SOLVE MY PROBLEM

How do you track adult vaccination?

Engage patients

The problem is now we have others outside the primary care office vaccinating, including public health and very commonly pharmacists. I have no issue with whoever gives the vaccine, but I need to be told that it was given, so I can update the chart. I feel that it is mandatory (but not happening) for a fax to be sent by the pharmacy to the primary care provider when a vaccine is given so we can do so. Just giving the patient a slip of paper is fraught with hazard as most do not make it to the clinic. It’s the responsibility of the family doc to be the keeper of the patient record, so all parts of the system need to help us do so! Having said that, here are a few possible ways:

1. Have the patient enter them as they get them (as well as putting in their old ones) in an app called CANImmunize. It is far from perfect but is a potential digital repository for patients that then can be shared with the clinician.

2. In Ontario, give patients a yellow immunization card and have them keep track of their record. (Other provinces have similar.)

3. Keep track of vaccines in a section of your chart (if paper), or if EMR, in a prevention section.

—DR. ALAN KAPLAN

Annual physicals

I use annual physicals as an opportunity to ask patients about their vaccination status and update any vaccines they

“I have no issue with whoever gives the vaccine, but I need to be told that it was given, so I can update the chart.”

to be aware of those given at pharmacies and elsewhere. A central vaccine registry could be helpful, but I fear it could become an additional administrative burden for family docs also.

—DR. ANNE SORENSEN

Get patients to track

have gotten from pharmacies. This is also a good time to talk to patients if they have any hesitations about vaccinations and address their concerns. Our clinic also has nurses that run flu vaccine days, and we send out an email blast to patients reminding them to get the flu shot. Some patients will inform us that they have already gotten their vaccine and we will update their records accordingly.

—DR. STEPHANIE ZHOU

Central registry?

I do my best to address the patient in front of me to review the vaccines they require and offer prescriptions for those not covered. But I also realize that for me to adequately and comprehensively address all medical issues, including vaccines for all my patients, I would need to work at least 27 hours per day. My EMR shows the vaccines given when I look up each patient, but it can be difficult

As an ER doctor, I usually am most concerned about tetanus status—I’m quite religious about making sure patients’ tetanus is up to date (within the past 10 years) and, if not, to update it. If they don’t know, I just give it to them and let them know it’s good for 10 years. Normally I’m giving the Tdap now to cover pertussis, too, since it seems to be making a comeback. I encourage patients to make their own vaccine records to help keep track of vaccinations from pharmacies, doctors’ offices, etc. For guidance in what immunizations patients should get, I recommend the official Canadian government site. Though not perfect, it’s a good start.

—DR. RYAN CHUANG

Problem

I’m setting up practice. How can I make it as environmentally friendly as possible?

Send solutions (and new questions!) to lleger@ensembleIQ.com by Jan. 12. Get a $25 gift card if your answer is chosen.

DR. ALAN KAPLAN

A family physician in Markham, Ont.

DR. STEPHANIE ZHOU

An FP and addictions physician in Toronto

DR. ANNE SORENSEN A family physician in Oshawa, Ont.

DR. RYAN CHUANG

An emergency physician in Calgary

OVER 300,000 CANADIANS AND OVER 8 MILLION PATIENTS GLOBALLY HAVE RECEIVED AREXVY. 1*

AREXVY is a vaccine indicated for the prevention of lower respiratory tract disease (LRTD) caused by respiratory syncytial virus (RSV) in adults 60 years of age and older.2

Please consult the Product Monograph at gsk.ca/AREXVY/PM for important information relating to warnings, precautions, adverse reactions, drug interactions, and dosing. To request a Product Monograph or to report an adverse event, please call 1-800-387-7374.

* Clinical signiﬁcance unknown.

† Comparative clinical signiﬁcance unknown.

References: 1. Data on ﬁle. GSK. 2. AREXVY Product Monograph. GlaxoSmithKline Inc.

NEWS FOR YOUR TRINTELLIX PATIENTS

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Get your patients to visit trintellix-support.ca to download their TRINTELLIX Patient Choice Card

Tell them to present their TRINTELLIX Patient Choice Card at the pharmacy along with their TRINTELLIX prescription

Consult the Product Monograph at www.trintellixmonograph.ca for important information about contraindications, serious warnings and precautions, other warnings and precautions, adverse reactions, interactions, dosing instructions and conditions of clinical use not discussed in this piece. The Product Monograph is also available by calling 1-800-586-2325.

* The TRINTELLIX Patient Choice Card Program is available in all provinces except Quebec.

Reference: 1.