Medical Post - December 2019

The RVU solution 12

The ‘Big 5’ bank faceoff 24

Quality assurance made easy 53

A guide to practice insurance 63

THE

MONEY ISSUE DECEMBER 2019

Introducing the MD Physician Council Fulfilling our commitment of understanding your needs

Christian Finley MD, MPH, FRCSC

Stephanie Perry MD, FRCPC

Janet Tootoosis B.Sc., MD, CCFP, FCFP

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Jean-Michel Guay MD

Erika Mehl MD, CCFP

Hortense Nsoh Tabien MD, MPH, PhD

Darcy Johnson B.Sc., MD, CCFP, FCFP

Frank Papanikolaou MD, FRCSC

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Contents UPFRONT

5

33

66

Three self-taught financial writers and physicians share their stories and advice

On Adrian Owen’s ‘Into the Gray Zone’

The money docs

Editorial

The benefits of a national healthcare system

7

Feedback

Doctors respond to our recent coverage on regulators

8

Rounds

Ontario’s new audit regime and considerations before retirement

FEATURES

12

The RVU solution

Could an American tool help Canadian associations in their approach to relativity?

24

The ‘Big 5’ bank faceoff

A look at what Canadian banks have on offer for doctors

VOLUME 55 NO. 6

BACK PAGES

48

How long does grief last?

Books: Being and somethingness

67

Classifieds

70

PMHx: The FLQ crisis and the FMSQ

A terrorist cell, international press, and a specialist strike

Dr. Mary Fernando reflects on the death of her dear friend one year later

50

Dogtor Daisy

A cartoon series by Dr. Joanna Li

53

Quality assurance made easy-ish

Dr. Mario Elia explains how to use your EMR to improve patient outcomes

57

A language deeper than words

Dr. Gretchen Roedde on writing the first Cree-English medical dictionary

61

Artist bio WITH MONEY AS THE THEME of this issue, we asked Pete

Ryan, our cover illustrator this year, how much he earns annually? “HA! Well, without giving a number, I’ve been able to pay off my student loans, and buy a house over the last few years, and that’s more than enough compensation for my efforts!” He said he used to teach and that was about 20% of his income but now his work is strictly editorial. He does save for retirement. “RRSPs mostly, but my partner and I also invest, with an eye on the long term.”

Solve my problem

How do you build rapport with less privileged patients?

63

A beginner’s guide to practice insurance What you need to know starting out

Next Issue: February

PRACTICE MANAGEMENT: That’s the theme of the next issue

of the magazine (hitting mailboxes the week of Feb. 19). We’re aiming to look at retention of staff when some doctors feel like they have a revolving door of MOAs and receptionists. Also: how to get the lowest possible overhead.

THE MEDICAL POST DECEMBER 2019 3

NO MATTER HOW YOU SEE IT, THE NUMBERS ARE ALWAYS RIGHT.

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2

And for the 5th consecutive year, ALG named Subaru as the Top Mainstream Brand for Residual Value.

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Visit us at subarufleet.ca 1. ALG named Subaru the Top Mainstream Brand for Residual Value in the 2019 Canadian Residual Value Awards. ALG is the benchmark for residual value projections in North America, publishing residual values for all vehicles in the United States and Canada. For more information, visit www.alg.com. 2. Based on IHS Markit Vehicles in Operation as of June 30, 2018 for Model Years 2009 to 2018 vs Total New Registrations of those vehicles.

EDITORIAL

Let’s not be afraid of bold ideas The case for nationalizing Canadian healthcare delivery Have you thought about what problems

would go away or be easier to manage if it was Ottawa that delivered healthcare instead of the provinces?

• Toronto’s Dr. Nav Persaud argued in the CMAJ last year that if we had a national EMR, many aspects of our health IT would be easier to manage.

• Physician supply could be improved if we had national licences for doctors. Getting medical school sizes and residency spot allocation right would surely be easier.

• A national pharmacare program.

• Better health data. As the Globe & Mail recently reported: “Provincial responsibility for health and education keeps important information stuck in silos and provides little incentive for provinces to keep easily comparable numbers about themselves.” For instance, we simply have no data on wait times

THE MEDICAL POST GROUP BRAND DIRECTOR, HEALTHCARE Donna Kerry dkerry@ensembleiq.com VICE PRESIDENT/ GENERAL MANAGER EVENTS Michael Cronin mcronin@ensembleiq.com SENIOR DIRECTOR AUDIENCE STRATEGY Lina Trunina ltrunina@ensembleiq.com

EDITOR-IN-CHIEF Colin Leslie cleslie@ensembleiq.com SENIOR EDITOR Tristan Bronca tbronca@ensembleiq.com WEB OPERATIONS MANAGER Valerie White vwhite@ensembleiq.com VICE PRESIDENT, PRODUCTION Derek Estey destey@ensembleiq.com PRODUCTION MANAGER Lisette Pronovost lpronovost@ensembleiq.com

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

for mental-health services, which cities have the lowest vaccination rates and many other important healthcare benchmarks.

• Nationwide issues such as rural health and opioids warrant national discussions. Even finding solutions to how we cover high-cost orphan drugs and how we think about the value of various treatments would be easier.

Yes, a century-and-a-half ago Canada’s founding fathers set healthcare delivery in the Constitution Act as a provincial responsibility. They did that because at the time we were a nation barely connected by a railway and that made the most sense then. Does that mean it’s the right framework for us today?

Pixar, the animation studio, has something called their 22 rules of storytelling. Number nine is: “When you’re stuck, make a list of what wouldn’t

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

DR. COURTNEY HOWARD emergency medicine DR. ALAN KAPLAN family medicine DR. JORDYN LERNER resident, public health DR. BRIDGET REIDY family medicine

ACCOUNT MANAGER Ted Georgaros tgeorgaros@ensembleiq.com CLASSIFIEDS Nancy Dumont ndumont@ensembleiq.com CORPORATE OFFICERS CHIEF EXECUTIVE OFFICER Jennifer Litterick CHIEF FINANCIAL OFFICER Jane Volland

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

COLIN LESLIE EDITOR-IN-CHIEF

happen next. Lots of times the material to get you unstuck will show up.”

As we go into the year 2020, we should be bold about seeking solutions.

Obviously if we wanted the federal government to take over delivery of healthcare that would require significant constitutional reform. But there’s a difference between things Canada’s founding fathers put in the constitution because of core values— free speech—and choices they made that were basically administrative. Sure, maybe it’s crazy to say, “Let’s change the constitution and nationalize healthcare delivery” but maybe it isn’t?

Canadian doctors are amazing people.

You’re going to be able to solve the problems you face. Happy New Year.

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Contents copyright © 2019 by Stagnito Partners Canada Inc., may not be reprinted without permission. The Medical Post receives unsolicited features and materials (including letters to the editor) from time to time. The Medical Post, its affiliates and assignees may use, reproduce, publish, re-publish, distribute, store and archive such submissions in whole or in part in any form or medium whatsoever, without compensation of any sort. The Medical Post, ISSN-0025-7435, PM Agreement No. PM42940023, established 1965, is published 6 times per year except for occasional combined, expanded or premium issues, which count as two subscription issues by EnsembleIQ, 20 Eglinton Avenue West, Suite 1800, Toronto, Ontario, M4R 1K8.

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THE MEDICAL POST DECEMBER 2019 5

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Feedback Is there really a doctor shortage? Are colleges getting better? and other questions

Why we don’t have enough doctors (Oct.) “I will be the devil’s advocate,” wrote Dr. Robert Yufe, a neurologist in Toronto. “I submit that Canada has enough family doctors. The reason that Canadians do not have a family doctor is because family doctors graduating today choose not to assume the burden of comprehensive care and start a practice. They choose walk-in clinics, emergency rooms, pain clinics or parttime work and the reasons are well-known: no overhead and no responsibility.

Government can ensure that graduating doctors assume the burden of comprehensive care by making it attractive to do so and every Canadian will have a family doctor.”

“Maybe it’s because the personal cost (mental and physical) of having

a comprehensive family practice is too much and these young graduating doctors see it in us older folks,” wrote Dr. Judy Price, a family doctor in Hantsport, N.S. “If we were compensated better, we might be able to hire assistants (much like a lawyer) to help with the administration and tasks that make practising medicine so dehumanizing and so demoralizing. I, for one, am just over 60 years of age, have only been practising for 15 years and am putting in my notice for retirement. I’d rather have my health.”

Too much information (Oct.) “We should all be accorded the presumption of innocence,” wrote Dr. Ernest Hajcsar of Burlington, Ont. “It is a basic tenet of law and it is flagrantly violated by the CPSO every time it publishes a complaint before any finding of guilt. I feel the only publication of a complaint should be when the doctor is found to be a public safety risk. No warnings or advice should be published.”

Why do women doctors get sued less? (Oct.) “I would offer one other possible explanation to this data,” wrote Dr. Bridget Reidy of Victoria. “When someone is angry at a man,

“Most of these comments are like blaming the new owner of a house, left filthy by the last owner, before giving them time to clean up the mess.”

probably particularly a fast man, they often don’t express it in the exam room. (Medical office administrators) tell me they hear about it instead, so it’s hardly a stretch to think the lawyer or college might also suffice. So maybe slower speed and/or lower social rank and/or superior communication skills give women, on average, an opportunity to hear it directly and do something about it. More studies, both to verify MOA impression and to figure out which factors make it, can only help.”

Against fear (Oct.) The Q&A with Ontario college registrar Dr. Nancy Whitmore generated a lot of online comments, particularly related to how she’d never experienced a college complaint herself.

“Perhaps the core qualifications for a college registrar should include personal experience of being dragged through the complaints process,” wrote Dr. John Macintyre. “That would be far more bracing to a registrar’s empathy than a few ‘touch points’,” he added in reference to Dr. Whitmore’s comments about how she’s seen colleagues go through the process.

“No college complaints doesn’t equate with good doctoring, let’s be clear,” wrote Dr. Julie Connolly, a family doctor in Sudbury, Ont. “It can equate with no doctoring though, or a career with a very cursory doctor-patient interface, or one spent in the judge’s seat more than on the front lines.”

“Most of these comments are like blaming the new owner of a house, left filthy by the last owner, before giving them time to clean up the mess. I see significant changes and a willingness for input,” wrote Dr. George Riley of Oakville, Ont.

THE MEDICAL POST DECEMBER 2019 7

Rounds DISPATCH VITALS

Balance between FFS and APP stabilizes

BY COLIN LESLIE

Alternative payment plans (APP), as opposed to feefor-service (FFS), grew rapidly between the mid-1990s and 2010. Since then, the ratio has stabilized. In the last 10 years, FFS payments as a percentage of total clinical payments to physicians in Canada have been between 70% and 73%, according to the latest physician numbers from the Canadian Institute for Health Information. APP payments accounted for the balance.

APPs for doctors include those that operate on salaries, sessional and hourly rates, capitation models and contract-based payments. Many physicians are compensated through multiple models, which could include both FFS and APPs. However, funding through the different payment models varies significantly across jurisdictions.

CLINICAL APP BY PROVINCE Percentage of physicians who received any…

Jurisdiction

APP clinical payments

FFS payments

APP payments

N.L.

35%

85%

57%

P.E.I.

36%

89%

74%

N.S.

55%

63%

96%

N.B.

34%

95%

63%

QUE.

20%

99%

88%

ONT.

36%

99%

56%

MAN.

29%

90%

72%

SASK.

37%

64%

47%

ALTA.

13%

91%

17%

B.C.

20%

95%

67%

CANADA

27%

96%

69%

The new OHIP audit regime Doctors at the Ontario Medical Association are

nervous about a new set of legislation that proposes a new auditing framework for OHIP billings.

According to the OMA, the legislation, Bill 138, an omnibus bill that spans legislation from gaming to snowmobiles to stocks, will not only increase the administrative burden and the red tape with which physicians must contend, but also place the burden on physicians to prove their own innocence when an auditor finds a problem with their billings.

“It raises issues of fundamental fairness,” said OMA president Dr. Sohail Gandhi in a public statement. “Even people who receive a parking ticket have the right of appeal and more access to fair and due process than this legislation gives to physicians.”

It is the association’s position that “the province already has all the powers it needs to identify issues around inappropriate billing.”

But it appears that even if the province has those powers, they haven’t been properly exercised. OHIP billings work basically on an honour system and auditor general reports from previous years have found that, in many cases, the government didn’t investigate cases of anomalous billing and did not follow-up on cases of possible inappropriate billing.

Despite these shortcomings, OMA leaders believe the proposed auditing framework goes far beyond addressing it. They’ve drawn direct comparisons between the proposed system and the Medical Review Committee (MRC), an initiative in the early 2000s that was struck down after a judge found it was too hard on doctors.

Consultations between the OMA and government on this topic are ongoing. Despite the public communications, several OMA leaders have clarified that they do support some changes to the OHIP audit system but would like those changes to be the ones proposed by Justice Peter Cory—recommendations that were crafted back in 2005 in direct response to the MRC but never adopted. Whether the current government is open to amending its legislation to fit those recommendations has yet to be seen.

—TRISTAN BRONCA

8 DECEMBER 2019 THE MEDICAL POST

ROUNDS

AUSCULTATIONS

“This is a violation of the sanctity of contracts.”

—Dr. Christine Molnar, president of the Alberta Medical Association, after Jason Kenney’s United Conservative Party adopted two omnibus bills that will allow government to rip up the contract with Alberta’s doctors and—for doctors who begin work after 2022— determine where they can practise.

“Clinicians are not going to use systems that are in silos.”

—Dr. Mohamed Alarakhia, an FP in Waterloo, Ont., during a panel in which Canada Health Infoway announced that PrescribeIT is now in 250 Canadian communities.

Dr. Alarakhia praised the e-prescribing system because it is integrated into EMRs.

“The legislation should put a chill in the spine of every physician in Ontario.”

—Dr. Sohail Gandhi, president of the Ontario Medical Association, after the province introduced Bill 138, which will allow for stricter auditing of physician billings.

Dr. Gandhi argues the new system requires physicians to prove their own innocence.

Sources: Canadian Press • Infoway Partnership conference • CanadianHealthcareNetwork.ca

DISPATCH

Boomers wrestle with retirement question Wandering the halls of the Family Medicine Forum

in October in a wing of the Vancouver Convention Centre stuck out toward the sun-splashed harbour, one could start to feel like the world is filled with millennial doctors.

But a surprisingly large number of folks with grey hair slid into a session on planning for retirement as it was about to start. Ostensibly it was a presentation

by Dr. Louise Nasmith, 67, formerly an academic, and Dr. Cal Gutkin, 74, formerly the CEO of the College of Family Physicians of Canada, but it started to feel like a rap session for the audience.

“I started to feel myself, I’m going to say, getting cranky,” Dr. Nasmith said of her feelings prior to her decision to retire. “When I started to feel that, it unnerved me. I didn’t want people to say ‘when will she go?’ I wanted to leave when people would

actually miss me.”

Listening to the questions and discussion from the audience, it became clear what a deeply emotional decision this is for boomer doctors.

“You’re not supposed to treat family but, whoa, some patients feel as close as family over the years,” one family doctor said.

Many in the audience talked about concern there wouldn’t be someone to replace them. “You have to be hard-nosed,” one doctor said, by which he meant, once you make a plan you have to stick to it, even in less-than-ideal circumstances.

Many in the audience expressed concerns about announcing their plans to retire, uncomfortable with the prospect that they might be treated differently by patients because of it.

One Quebec doctor who is 63 but looks 50 said his patients just started asking him regularly about his retirement plans in the last year. (Dr. Nasmith said questions from patients are common since most are anxious about having a doctor.)

The mood got lighter as the session approached its end. “Don’t retire in November,” one doctor quipped. “Canadian winters are dark and cold.”

Another noted many older doctors don’t have a family doctor themselves. “First, find a young family doctor yourself.”—COLIN LESLIE

THE MEDICAL POST DECEMBER 2019 9

COVERED BY MOST PRIVATE AND PUBLIC FORMULARIES ACROSS CANADA (GENERAL BENEFIT OR SPECIAL AUTHORIZATION)*

1†

A NEW MDD ADJUNCT TREATMENT OPTION

REXULTI

Pr

®

Stepping into the picture in major depressive disorder (MDD)1 When the MDD journey leads to an adjunct treatment, choose REXULTI‡ ‡ Clinicians must take into account the safety concerns associated with such antipsychotic drugs.

In trial 4 (PYXIS), the mean SDS (Sheehan Disability Scale) score showed statistically significant greater improvement with antidepressant + REXULTI (2 mg/day) at week 6 than with antidepressant + placebo (-1.35 vs. -0.91; p<0.05; key secondary endpoint).2§ REXULTI 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.2

Clinical use: 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.

• Not indicated in geriatric patients >65 years of age with dementia and caution should be used when treating geriatric patients • Not indicated in pediatric patients <18 years of age and its use is not recommended in this population Most serious warnings and precautions: Elderly patients: 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.

Other relevant warnings and precautions: • Body temperature regulation • For patients with diseases, conditions, or medications that could exacerbate somnolence, postural hypotension, motor and sensory instability, complete fall risk assessments when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic therapy.

• Orthostatic hypotension; generally at highest risk at the beginning of treatment and during dose escalation • Risk of QT interval prolongation; exercise particular care when administering REXULTI to patients who are suspected to be at an increased risk of experiencing torsade de pointes.

• Patients should be evaluated carefully for a history of drug abuse.

• Patients should have baseline and periodic monitoring of blood glucose and body weight. Any patient treated with atypical antipsychotics should also be monitored for symptoms of hyperglycemia. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing.

• Patients with risk factors for diabetes mellitus who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control.

• Antipsychotic drugs have been associated with metabolic changes, including weight gain.

• Clinical monitoring of weight is recommended.

• Undesirable alterations in lipids have been observed in subjects treated with atypical antipsychotics. Patients should have baseline and periodic monitoring of fasting lipid profile.

• Like other antipsychotics, REXULTI can elevate prolactin levels. Elevations associated with REXULTI treatment are generally mild and may decline during administration, however, in some infrequent cases the effect may persist during chronic administration.

• Rare cases of priapism have been reported with antipsychotic use.

• Events of leukopenia/neutropenia have been reported temporally related to antipsychotic agents. Agranulocytosis has also been reported. Therefore, it is recommended that patients have their complete blood count (CBC) tested prior to starting REXULTI and then periodically throughout treatment. Patients with a history of a clinically significant low white blood cell count (WBC) or drug-induced leukopenia/neutropenia should have their CBC monitored frequently during the first few months of therapy and discontinuation of REXULTI should be considered at the first sign of a clinically significant decline in WBC in the absence of other causative factors.

• Venous thromboembolism • Serious hypersensitivity reactions, such as anaphylaxis, angioedema and facial swelling, rash and urticaria • Neuroleptic malignant syndrome is a potentially fatal symptom complex that has been reported in association with antipsychotic drugs.

• Tardive dyskinesia may develop in patients with antipsychotic drugs.

• Use cautiously in patients with a history of seizures or with conditions that lower the seizure threshold.

• Potential to impair judgment, thinking, or motor skills; may cause somnolence.

• Completed suicide, attempted suicide, suicidal behavior and suicidal ideation have been reported during post-market use of REXULTI. • Patients with a prior history of impulse-control disorder may be at increased risk and should be monitored carefully.

• Consider dose reduction or stopping REXULTI in patients who develop compulsive behaviors that may result in self-harm and harm to others.

• REXULTI should not be used during pregnancy unless the expected benefits to the mother markedly outweigh the potential risks to the fetus. It is recommended that women receiving REXULTI should not breast-feed.

• Geriatrics (>65 years of age): Dose selection should be cautious, usually starting at the low end of the dosing range.

In placebo-controlled trials with some atypical antipsychotics, there was a higher incidence of cerebrovascular adverse events including fatalities compared to placebo-treated subjects. Esophageal dysmotility and aspiration have been associated with antipsychotic drug use, including REXULTI. • Patients with hepatic impairment: For patients with MDD and moderate to severe hepatic impairment (Child-Pugh score ≥7), the maximum recommended dosage is 1.25 mg once daily.

• Patients with renal impairment: For patients with MDD and moderate, severe or end-stage renal impairment (creatinine clearance [CLcr] <60 mL/minute), the maximum recommended dosage is 1.25 mg once daily.

• CYP2D6 poor metabolizers: Dosage adjustments are recommended.

• REXULTI tablets contain lactose.

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. * REXULTI is eligible by Non-Insured Health Benefits and Correctional Service Canada as a general benefit, and for formulary coverage in the following provinces: Alberta (regular benefit); Manitoba (open benefit); Ontario (general benefit); New Brunswick, Newfoundland and Labrador, PEI and Saskatchewan (special authorization benefit). † Comparative clinical significance is unknown. § 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, 1 or 2 mg/day for week 3 onwards; n=187).

References: 1. Health Canada. Rexulti MDD. Notice of Compliance information.

2. REXULTI Product Monograph. Otsuka Pharmaceutical Co., Ltd.

REXULTI is a registered trademark of Otsuka Pharmaceutical Co., Ltd., used under licence by Otsuka Canada Pharmaceutical Inc.

LUN-REX-00004E

Getty Images

FEATURE

The RVU solution The Medical Post 2019 Relatively Ranking shows big variations between top-billing specialties and bottom-billing specialties. Could an element in the U.S. system have an answer?

BY COLIN LESLIE

T

he Medical Post has done comparison rankings of provincial relativity before.

But those were based only on fee-for-service (FFS) billings. Alternative payment programs (APP) make up almost one third of Canadian doctors’ clinical income today, even though APPs barely existed in the mid-1990s. It was only last year that the Canadian Institute for Health Information (CIHI) started releasing data from its new full-timeequivalent metric, which combines both FFS and APP remuneration.

The Medical Post 2019 Relativity Ranking used this new FTE metric to compare the ratio between the

average billings of the top three earning specialties and the bottom three in each province. We then ranked the provinces.

Our 2019 Relativity Ranking shows that Quebec doctors have the least variation between top billers and bottom, and Alberta doctors have the greatest. In fact, in Alberta, the top three specialties’ average billings are almost three times those of the bottom three.

Billings don’t equal income, of course.

Overhead is not included here. But outside of getting access to doctors’ tax returns, calculating accurate overhead costs for different specialties and different practice situations is difficult.

In Canada, overhead estimates by

specialty mostly come from surveying doctors. However, some provinces are working on more robust measurement, developing metrics for “model offices,” for example. In such cases, all the various practice costs are identified so that data can be fit into the model. The cost per square foot of medical office space in a town, for instance, is plugged into the model, along with the average cost of equipment, clinic supplies, and a range of other expenses. As factors change—or different communities use the model— you simply adjust the relevant metrics, and you’re left with a good sense of what overhead should be for various specialties in various practice situations.

THE MEDICAL POST DECEMBER 2019 13

FEATURE MEDICAL RANKING POST RELATIVITY

Provincial relativity ranking Last year, for the first time, the Canadian Institute for Health Information released a new and more complete way of examining Canadian doctors’ clinical incomes: The FTE metric.

This FTE (full-time-equivalent) metric tracks gross clinical payments to doctors, including both fee-for-service (FFS) and alternative payment program (APP) payments.

In the charts at right, we used the 2017/18 FTE metric numbers to examine which provinces had the greatest income relativity variations and which had the least. We did this by taking the top three specialties’ average clinical payments and comparing them with the bottom three. For instance, Alberta had the most variation, with the three highestearning specialties receiving 2.84 times what the three lowest received. Of course, overhead variations mean take-home pay will be different.

—COLIN LESLIE

QUEBEC

NEW BRUNSWICK

2017-2018

2017-2018

Ophthalmology

$805,200

Ophthalmology

$771,040

Thoracic/cardiovascular surgery

$630,015

Urology

$648,012

General surgery

$619,813

Plastic surgery

$600,906

Plastic surgery

$547,718

Dermatology

$577,403 $541,085

Urology

$531,872

Thoracic/cardiovascular surgery

Neurosurgery

$525,489

General surgery

$536,094

$525,210

Obstetrics/gynecology

$531,945

Otolaryngology

$478,015

Otolaryngology

$518,725

Internal medicine

$476,508

Orthopedic surgery

$442,775

Obstetrics/gynecology

$462,792

Internal medicine

$431,098

Dermatology

$453,089

Neurosurgery

$418,050

Pediatrics

$393,440

Pediatrics

$401,390

Psychiatry

$365,154

Psychiatry

$371,463

Family medicine

$362,969

Physical medicine

$354,393

Neurology

$336,062

Family medicine

Physical medicine

$319,907

$333,105

Neurology

$306,710

Orthopedic surgery

2017-2018 relativity score

2.02

6

2016-2017 relativity score

2.07

3

2015-2016 relativity score

2.12

2

2014-2015 relativity score

2.13

2

1

2017-2018 relativity score

6

2016-2017 relativity score

2.07

2

2015-2016 relativity score

2.08

1

2014-2015 relativity score

2.08

1

SASKATCHEWAN

MANITOBA

2017-2018

Ophthalmology Thoracic/cardiovascular surgery

2

2.03

2017-2018

$1,021,390

Ophthalmology

$1,156,563

$773,925

Thoracic/cardiovascular surgery

$757,297

Neurosurgery

$657,503

Urology

$690,829

Urology

$642,895

Plastic surgery

$646,083

General surgery

$584,659

Dermatology

$640,095

Plastic surgery

$568,500

General surgery

$610,692

Orthopedic surgery

$560,509

Neurosurgery

$576,084

Obstetrics/gynecology

$555,692

Orthopedic surgery

$555,795

Otolaryngology

$550,072

Otolaryngology

$533,616

Why not pathology and radiology?

For these specialties, the proportion of funding that comes from the medical care plan versus hospital budgets is not consistent across the country so CIHI does not think it appropriate to include these specialties in the FTE metric.

Internal medicine

$478,951

Obstetrics/gynecology

$506,656

Dermatology

$466,130

Internal medicine

$467,028

Pediatrics

$381,150

Physical medicine

$392,271

Physical medicine

$374,388

Neurology

$359,307

Psychiatry

$353,586

Family medicine

$351,811

Neurology

$348,872

Psychiatry

$340,736

Family medicine

$319,974

Pediatrics

$330,382

2017-2018 relativity score

2.40

6

2017-2018 relativity score

2.55

6

n/a No doctors *D ata was suppressed because there were only between 1 and 4 doctors.

2016-2017 relativity score

2.36

6

2016-2017 relativity score

2.55

9

2015-2016 relativity score

2.53

8

2015-2016 relativity score

2.52

7

2014-2015 relativity score

2.51

7

2014-2015 relativity score

2.58

9

Ratio of top three earning specialties to bottom three HIGH LOW

Source: CIHI

14 DECEMBER 2019 THE MEDICAL POST

6

Note: Saskatchewan’s and Alberta’s full-time equivalent figures are calculated using only fee-for-service payments in the numerator.

7

FEATURE

BRITISH COLUMBIA

ONTARIO

2017-2018

N.L.

2017-2018

2017-2018

Ophthalmology

$936,854

Ophthalmology

$724,734

Ophthalmology

$983,302

Thoracic/cardiovascular surgery

$654,144

Neurosurgery

$680,149

Orthopedic surgery

$748,421

Neurosurgery

$618,281

Thoracic/cardiovascular surgery

$668,701

Urology

$570,418

Urology

$589,836

Urology

$525,149

Thoracic/cardiovascular surgery

$568,063

Obstetrics/gynecology

$533,264

Otolaryngology

$512,212

Neurosurgery

$553,058

General surgery

$513,130

General surgery

$470,543

Plastic surgery

$548,800

Plastic surgery

$501,699

Orthopedic surgery

$466,172

Physical medicine

Orthopedic surgery

$500,667

Internal medicine

$433,244

Dermatology

$536,933

Otolaryngology

$492,509

Obstetrics/gynecology

$430,573

Otolaryngology

$486,159

Internal medicine

$486,885

Plastic surgery

$421,013

General surgery

$467,744

Dermatology

$470,390

Dermatology

$355,028

Internal medicine

$418,348

Neurology

$429,845

Neurology

$334,329

Neurology

$417,324

Pediatrics

$399,201

Physical medicine

$316,393

Obstetrics/gynecology

$387,033

Physical medicine

$383,414

Pediatrics

$312,198

Pediatrics

$374,289

Family medicine

$301,398

Family medicine

$298,078

Psychiatry

$304,689

Psychiatry

$297,581

Psychiatry

$277,284

Family medicine

$287,626

3

4

*

5

2017-2018 relativity score

2.25

6

2017-2018 relativity score

2.34

6

2017-2018 relativity score

2.38

2016-2017 relativity score

2.29

4

2016-2017 relativity score

2.29

5

2016-2017 relativity score

2.39

7

2015-2016 relativity score

2.30

4

2015-2016 relativity score

2.32

5

2015-2016 relativity score

2.35

6

2014-2015 relativity score

2.20

4

2014-2015 relativity score

2.27

5

2014-2015 relativity score

2.28

6

NOVA SCOTIA

P.E.I.

2017-2018

ALBERTA

2017-2018

2017-2018

Ophthalmology

$875,956

Ophthalmology

Thoracic/cardiovascular surgery

$610,361

Urology

$647,729

Urology

$584,033

General surgery

$539,337

Plastic surgery

$552,476

Orthopedic surgery

$513,348

Dermatology

$535,518

Obstetrics/gynecology

$499,120

Otolaryngology

$504,272

Thoracic/cardiovascular surgery

n/a

$487,900

Neurosurgery

n/a

Orthopedic surgery

$440,509

Dermatology

*

Orthopedic surgery

$591,427

Obstetrics/gynecology

$435,983

Physical medicine

*

Internal medicine

$541,850

Neurosurgery

$374,760

Plastic surgery

*

Obstetrics/gynecology

$534,111

Internal medicine

$366,049

Otolaryngology

Pediatrics

$346,562

Internal medicine

Psychiatry

$300,026

Neurology

$290,198

Family medicine

$288,019

Physical medicine

$233,526

General surgery

2017-2018 relativity score

2.55

8

0

$1,146,643

Ophthalmology Thoracic/cardiovascular surgery

$1,254,402 $897,087

Urology

$715,853

Otolaryngology

$676,864

Plastic surgery

$670,895

General surgery

$637,748

Dermatology

$618,799

*

Pediatrics

$413,892

$427,215

Neurology

$400,528

Psychiatry

$377,743

Family medicine

$389,429

Pediatrics

$314,656

Physical medicine

$377,948

Family medicine

$310,562

Neurosurgery

$333,579

Neurology

$280,202

Psychiatry

$328,719

9

10

0

2017-2018 relativity score

2.58

0

2017-2018 relativity score

2.76

0

2016-2017 relativity score

n/a

-

2016-2017 relativity score

2.48

8

2016-2017 relativity score

2.84

10

2015-2016 relativity score

2.55

9

2015-2016 relativity score

2.22

3

2015-2016 relativity score

2.87

10

2014-2015 relativity score

2.55

8

2014-2015 relativity score

2.15

3

2014-2015 relativity score

2.87

10

THE MEDICAL POST DECEMBER 2019 15

FEATURE

The question then becomes what will the association do about it? Dr. Molnar conceded it is always hard for member organizations to say to anyone that they don’t deserve what they are earning and that it should be reduced. “What we have to focus on at this point is fairness and transparency,” she said. “People have to be able to say: ‘I don’t like the outcome.

But it would appear that it was a fair and just process and I’m going to go along with it for now.’”

The results of the initiative and what to do about it must be ratified by the AMA general membership, Dr. Molnar said. Currently the AMA does not have the necessary approval from Alberta Health to reallocate money from one specialty to another, even if the membership approved such a change.

OTHER PROVINCES

In provinces where the top three specialties are billing, on average, twoand-a-half to three times as much as the bottom three, the demand for these kinds of measures is going to grow. Medical associations are examining relativity in different ways but the Alberta Medical Association (AMA), with its Income Equity Initiative, has taken the lead over the last few years in its efforts to get a clear-eyed look at the problem.

ALBERTA’S PROGRESS

It has not been easy work for the AMA. The association decided last year that an overhead study it had conducted with Alberta Health was not good enough.

“We looked at early results of the study,” said AMA president Dr. Christine Molnar, “and we talked with our joint partner, Alberta Health. We decided it was flawed.

The data coming out of it was so flawed it was not useful to us.”

Since then a small group at the AMA has been working on how to better determine expenses. It is looking to repurpose some of the data from the old overhead study and thinking broadly about how to fairly represent overhead

16 DECEMBER 2019 THE MEDICAL POST

which is, in some cases, common across certain groups of doctors, and in others completely unique to a particular specialty.

“I think we’re tending towards a more current business cost model that will be more like a model office,” said Dr. Molnar, a diagnostic radiologist and nuclear medicine specialist. One advantage is that it will help physicians understand what an efficient office should look like.

Of course, overhead is just one component of the Income Equity Initiative. To determine if there is income inequity among Alberta physicians, the AMA is also studying hours of work, length of training and competitiveness. These other components can be more complex to evaluate than overhead. But the AMA is expecting the overhead study and the other three studies all to be done by December 2020.

At that point, the Income Equity Initiative should be able to say something about whether there is income inequity—and if there is, the extent of it—between specialties.

The challenges the AMA faces mirror those in other provinces. Looking at relativity is tough but important work. Ontario has used a number of models—OMA RVS, RBRVS, RVIC and CANDI—to try and deal with relativity.

British Columbia had the Relative Value Guide effort in the mid-1990s. Other associations have proposed their own methods for examining and ultimately addressing the issues.

But even when these models are developed, they either aren’t applied or are applied only minimally. Highbilling specialties often take legal action against the measures, or threaten to split off from the medical associations.

Some specialty sections question the data. All these pressures have made fixing relativity the third rail for medical leaders: It won’t go well for you if you touch it.

Still, the perception of income inequality grates many members of specialties at the lower end of the billing spectrum. Some even argue continued income inequity undermines professional collegiality.

One has to wonder: Is there a better way?

There is—kind of. Relative value units (RVUs) are the backbone of how the U.S. Medicare/Medicaid and most American private insurers determine physician

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FEATURE

There’s a myth that the RUC actually uses stopwatches to time doctors as they complete tasks.

It doesn’t.

productivity and compensation. Doctors Nova Scotia is aiming to use RVUs as part of the massive effort to update its fee schedule.

One can see the advantages. The RVU system evaluates relativity on a more granular level. Let’s walk through how it does that.

THE CASE FOR RVUs

First, all American doctors use the same language to describe their clinical work: the current procedural terminology or CPT. “The CPT system is a nomenclature system so you can describe the services, and it’s a system that is clinically relevant. There’re lots of instructions built in so people know how to pick the right procedure code.”

That’s Dr. Peter Hollmann, a Rhode Island physician who I was connected with when I asked the American Medical Association for an expert on RVUs. He’s a past chair of the CPT Editorial Panel and is currently on the American Medical Association’s specialty society resource-based relative value scale update committee, known as the RUC. Someone had to take each CPT code and assign it a relative value unit when the system was set up in the early 1990s

18 DECEMBER 2019 THE MEDICAL POST

but even if those initial decisions were off, RVUs are periodically adjusted based on regular comparisons of similar procedures. “You might say this procedure takes me a half an hour and it’s pretty easy, and this procedure takes me half an hour but, my goodness, it’s very difficult, so I think the latter ought to be 30% higher in value. Or this procedure is 20 minutes and this other procedure is 50 minutes and it’s pretty much the same intensity, so I think the latter ought to be two-and-a-half times its value because it takes me two-and-a-half times as long,” Dr. Hollmann explained.

There’s a myth that the RUC actually uses stopwatches to time doctors as they complete tasks. It doesn’t. The valuations are mostly done from surveys of doctors who are familiar with the procedure, though sometimes databases and operating room logs are used supplementally.

But if survey results are relied on to determine RVUs and these are used to determine fees, is there not a risk some would want to skew the results?

“Let’s go over this attempt to game the system, even if it’s unconscious,” Dr. Hollmann said. “If I’m comparing something I do to another thing that I

do commonly, I think you’re going to get pretty accurate (results),” he said.

In other words, it is likely comparisons of procedures within a specialty are accurate. But what about when you compare, say, ophthalmology and urology?

“Your society presents this to (the multispecialty RUC). These are people who have been listening to these explanations and surveys before,” said Dr. Hollmann. It’s a technical expert panel, he noted, that can spot flaws in the information. Ultimately, it requires a two-thirds majority vote to approve a value. “If somebody takes the information and sort of spins it, you’re not going to have a very easy time getting away with that.”

All of these factors—from the time required, to the intensity to the requisite expertise—comprise the “work” component of a RVU. The panel also evaluates a “practice expense” component, which varies depending on the cost of equipment, supplies and support staff, as well as a small “malpractice” component, which accounts for the risk associated with a procedure. Those three elements determine the final RVU.

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FEATURE

Changes in government administration and contract negotiations has resulted in inertia.

Trust is

earned Then you just multiply the RVU by the “conversion factor” (currently 36.0391) to produce the dollar value.

This measure allows U.S. Congress (which determines the conversion factor) to control the annual expenditure on Medicare. For example, the CPT code 99213 is used all the time by American doctors. It’s for a followup office visit for an established patient. The current RVU for 99213 is 2.09. (So 2.09 X 36.0391 = $75.32 USD). RVUs also go through a geographic price cost modifier to adjust for regional cost variations.

RVUs are primarily tools for allocating expenses and cost benchmarking for Medicare. The fact that they work to measure productivity and to calculate physician compensation is actually secondary. But this method is so effective that nearly every healthcare system in the U.S. uses it. “I have always been in practice but I also worked parttime at Blue Cross Blue Shield in Rhode Island, an insurance company,” noted Dr. Hollmann. “Once this system came along, I said, ‘We’re crazy not to use it the way Medicare does, because you’ve got people investing millions of dollars of volunteer time and work … and it’s about as accurate as you’re going to get.”

DOCTORS NOVA SCOTIA

The only province that has looked

seriously at using RVUs is Nova Scotia and it is currently on hold in that province for a couple of reasons, according to Kevin Chapman, director of partnerships and finance for Doctors Nova Scotia.

One, the EMR landscape in the province is in transition. In 2016 Nightingale, formerly one of the leading EMRs in the province, sold its Canadian assets to Telus Health. So all Nightingale users have to migrate to either Telus’ Med Access EMR or the QHR Accuro EMR. “Essentially every doctor has to migrate and that’s supposed to be done by the end of December,” said Chapman.

Two, Nova Scotia doctors recently completed their fee deal negotiations and while the provincial government had originally been keen on developing a new fee schedule, in Chapman’s view, it seems not to be so keen anymore.

Changes in government administration and contract negotiations has resulted in inertia. (He noted that setting up a new schedule via RVUs involves a lot of “nitty gritty” discussion, and that both sides should be in agreement that doing so be treated as an information management project rather than a cost-savings project.

Currently, Chapman argued that the old manual is out of date, and doctors are having to use lookalike codes that don’t match the operative record and thus can become a problem during audits.)

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THE MEDICAL POST DECEMBER 2019 21

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1

Anne-Marie Martin BACKGROUND: Anne-Marie is a wife, mother and grandmother. She is experiencing vaginal dryness as well as painful intercourse.

TREATMENT GOALS: To alleviate the atrophic vaginitis and dyspareunia she has been experiencing.

TREATMENT: Anne-Marie’s doctor prescribed Premarin Vaginal Cream at the lowest effective dose. A three-month follow-up was suggested to evaluate treatment response.

TREATMENT OF DYSPAREUNIA, ATROPHIC VAGINITIS AND KRAUROSIS VULVAE.1

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• Each 30 g tube of PREMARIN cream is accompanied with two calibrated plastic applicators • PREMARIN Vaginal Cream is supplied in a soft cream.† *Comparative clinical significance is unknown.

CE=Conjugated Estrogen †Clinical significance is unknown.

Indications and clinical use: Premarin Vaginal Cream (conjugated estrogens, CSD) is indicated for the treatment of atrophic vaginitis, dyspareunia, and kraurosis vulvae.

It has not been shown to be effective for any purpose during pregnancy and its use may cause severe harm to the fetus.

It should be prescribed with an appropriate doseof a progestin for women with intact uteri in order to prevent endometrial hyperplasia/carcinoma.

Not indicated for use in pediatric patients (<16 years of age).

Contraindications: • Liver dysfunction or disease • Known or suspected estrogen-dependent malignant neoplasia • Endometrial hyperplasia • Known, suspected, or past history of breast cancer • Undiagnosed abnormal genital bleeding • Known or suspected pregnancy • Active or past history of confirmed venous thromboembolism or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Partial or complete loss of vision due to ophthalmic vascular disease • Known thrombophilic disorders • Migraine with or without aura Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years).

Risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis: estrogen plus progestin therapy (mean age 63.3 years).

Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication Other relevant warnings and precautions: • Estrogen administration to nursing mothers has been shown to decrease the quantity and quality of breast milk. Detectable amounts of estrogens have been identifi ed in the milk of mothers receiving the drug.

Where an assessment of the risk to benefi t ratio suggests the use of this product in nursing women is unfavourable, formula feeding should be substituted for breast feeding.

• Possible increased risk of endometrial hyperplasia/ carcinoma • Particular caution is indicated in women with hepatic hemangiomas, as HRT may cause an exacerbation of this condition • Caution is advised in patients with a history of liver and/ or biliary disorders • Cerebrovascular insufficiency. Patients who develop visual disturbances, classical migraine, transient aphasia, paralysis or loss of consciousness should discontinue medication • Patients who have a history of depression should be observed

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• Possible risk of ovarian cancer • May weaken and contribute to the failure of condoms, diaphragms, or cervical caps • Monitor blood pressure with hormone replacement therapy use • Caution in women with pre-existing endocrine and metabolic disorders • Symptoms and physical findings associated with a previous diagnosis of endometriosis may reappear or become aggravated with estrogen use • May increase pre-existing uterine leiomyomata • Abnormal vaginal bleeding • Risk of gallbladder diseases • May exacerbate systemic lupus erythematosus • May induce or exacerbate angioedema symptoms • Risk of developing probable dementia (women >65 years) • May exacerbate epilepsy • Caution in patients with otosclerosis • May cause fluid retention For more information: Please consult the product monograph at https://www. pfizer.ca/pm/en/PremarinPI.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

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Reference: 1. Premarin Vaginal Cream Product Monograph, Pfi zer Canada ULC, June 07, 2018.

FEATURE

That said, Doctors Nova Scotia plans to start pressing the government to move on this again in the new year.

Doing something like this for a larger province such as Ontario would be a massive enterprise.

TWEAKS AND CRITICISMS

Even though the RVU system can be used as a clinical productivity-based compensation system, Americans often tweak it to adjust for other important parts of physician work besides CPT coded services. “At some practices, we would say, ‘We’re going to say Dr. Peter Hollmann’s teaching is worth X number of RVUs or his consulting with the hospital is worth X number of RVUs,’” said Dr. Hollmann.

He also said the system has gotten more nuanced in recent years. “For a long time the Medicare payment rules didn’t recognize a lot of the extra work that went into things that occurred between office visits, such as coordinating care and phone calls and stuff like that. Obviously, some specialties have more of it than others,” he said. “Finally, in the last several years, there’s been more of a recognition of that and that’s improving the payment for specialties that did a lot of this work.”

Tough choices got Quebec to #1, argues Dr. Gaétan Barrette

Quebec is the province where the relativity score between the richest and poorest specialties is smallest, according to data from the Canadian Institute for Health Information.

Dr. Gaétan Barrette, who from 2006 to 2014 was president of the Fédération des médecins spécialistes du Québec (FMSQ), which negotiates fees for the provinces’ specialists, attributes these results to the model put in

As well, while private insurers and hospitals that are competing with one another may pay doctors more than 100% of the RVU that Medicare pays, they generally still use the RVUs as their marker for relativity between services.

(Medicaid rates can be as low as 50% of what Medicare pays, for example, and private insurance companies often pay more than Medicare.)

The RVU system is fairly new. It was developed by William Hsiao, an economist at Harvard School of Public Health, and his colleagues in the 1980s. There are, of course, American doctors who complain about it but Dr. Hollmann’s retort is twofold: What system would you use instead, and do you remember what Medicare was like before it began to rely on RVUs?

CANADIANIZATION

The basic units of work for Canadian doctors are much the same as for American doctors. So if there’s concern that somehow using an American RVU system doesn’t match with Canadian values about healthcare and equity, it is easy enough to use modifiers while maintaining RVUs as core markers for clinical productivity.

Another concern for Canadian

place by the federation.

Dr. Barrette told the Medical Post that when he started at the FMSQ he had a mandate to negotiate remuneration increases for specialists in Quebec, which at the time was lower than the rest of the country.

“It worked so well that today Quebec medical specialists are on average better paid than Ontario doctors,” said Dr. Barrette, who went on to be Quebec’s Minister of Health from 2014 to 2018.

Dr. Barrette said the specialists’ federation also

doctors is that because the RVUs are not directly linked to pay, the power of the U.S. Congress to adjust the conversion factor gives government absolute control over the size of the Medicare budget.

Congress adjusted the conversion factor up last year but when they adjust it down that forces American doctors who bill Medicare to eat the cost. This is a concern of American doctors, but most have the option to avoid doing Medicare work and instead provide care for patients with health insurance.

Such is not true for Canadian doctors.

Giving a Canadian province complete control to set a provincial conversion factor is plainly unworkable. There would have to be arbitrators or tribunals involved or some acknowledgement that provinces can’t reduce conversion factors when health system utilization is rising.

There are some elements of the RVU system, such as practice expense tracking, that are evident in the “model office” work being done by some medical associations. There are definitely challenges with using RVUs in Canada, but as medical associations struggle with ways to address relativity, they should not be afraid to piggy-back off this clinical relative value work already being done.

tackled the disparity in remuneration between specialties. “I chose to do it because there was a lot of dis­satisfaction among our members. The rich did not want to lose money and the poorest wanted more,” he said.

They used a workload and full-time equivalent model and allocated new money asymmetrically. “The goal was to give less to the richest— but still an increase—give reasonably to those in the middle, and give more to the poorest,” he said.

Other provinces should take inspiration from what has been done in Quebec, he said, but he admits it’s not easy.

“Negotiating externally with the government is the easy part of the job. Negotiating internally with members is where it’s difficult. We must not be afraid to make this kind of change happen,” Dr. Barrette said. “The problem with the gaps in the specialties is that if we are not aggressive in our approach, the gaps will never change. I was aggressive and it worked.”

—JUSTINE MONTMINY

THE MEDICAL POST DECEMBER 2019 23

FEATURE

The ‘Big 5’ bank faceoff

Canadian banks have revamped their efforts to attract physician clients—so, we compared their offerings

24 DECEMBER 2019 THE MEDICAL POST

last decade, the renewed push likely has much to do with the fact that the wealth management needs of this demographic is no longer owned (for all intents and purposes) by a single player. For the last 50 years, MD Financial Management had really cornered the physician market, and the fact that it was owned by the Canadian Medical Association, a not-for-profit organization, gave them a significant advantage over other financial institutions. But when the CMA sold MD to Scotiabank in 2018 in what quickly became a very controversial deal, that advantage seemed to disappear.

Hence all the action in the marketplace. Recognizing the unique situations physicians are in, each of the five banks have launched programs that come with a range of personalized products and services to satisfy physicians’ practice and personal needs: from lines of credit and mortgages, to a suite of wealth management and financial advice packages, to a variety of bells, whistles and perks that have been designed specifically for physicians. We took a closer look at the offerings to help you evaluate which, if any, may appeal to you.

Getty Images

O

ver the last year or so, all of the big Canadian banks have launched renewed efforts to attract one of the most sought-after professional clientele demographics in finance: doctors. It’s easy to see why. As physicians you have (or, for the younger doctors, will have) a high net worth, your income is virtually guaranteed, and because so many of you manage your own practices, your financial needs can be complex.

While all of the big five banks we spoke to for this piece say they have been catering to this client base for at least the

BY TRISTAN BRONCA

FEATURE

CIBC

BMO

BMO launched its holistic healthcare banking program last June, but the bank has been offering tailored services to healthcare professionals, including doctors, for the past 10 years. According to a spokesperson, this has given the dedicated teams at the bank unique insight into the demographic. “They enter the workforce at a later age, carrying significant personal debt,” the spokesperson wrote in an email to the Medical Post, “and once practising, they also have to adapt to changing regulatory and healthcare business landscapes.” On the business banking side, BMO’s business has grown at a rate of 30% annually.

For young doctors, BMO offers assistance with mortgages and financing for large purchases (like a practice), as well as help with cash-flow management for operational expenses. Their SelfEmployed New Professional Program is

26 DECEMBER 2019 THE MEDICAL POST

designed to help new doctors buy a house.

For established doctors, BMO offers capital financing and other specialized financing options to cover up to 100% of the cost of large practicerelated expenses. The bank also offers amortization periods of 25 years at competitive rates. Other options, such as a personal line of credit, are available to practising doctors. For medical students, BMO offers Medical Student Line of Credit with a limit of $325,000 at a rate of prime minus 0.25%.

Tailored retirement planning is also part of BMO’s offering, as with most other personalized offerings from the banks. The bank will also help with business succession strategy for physicians looking to retire, either facilitating the hand-off of the practice to another practitioner or providing “practical, tax-efficient solutions to continue its operation and enhance its financial value.”

CIBC launched its Full Service Physician Package in March 2019, offering, among many other things, one-on-one financial planning for students and practising physicians, lending to cover up to 100% of practice start-up and expansion costs for new physicians, and $350,000 lines of credit for medical students, both available at rates of prime minus 0.25%. But according to Andrew Turnbull, the senior vice-president of business banking at CIBC, the primary differentiating factor in CIBC’s offering is the way their products and services are designed with both the business and personal needs of physicians in mind.

“The advice we provide is truly integrated,” he told the Medical Post. For instance, the line-of-credit offering is available on both business and personal borrowing and on both secured and unsecured lending. “We’re the leading institution on that front.”

On the wealth management side, Turnbull said CIBC offers personal portfolio services with bank employee pricing available to both physician clients and their spouses. For do-ityourself investors, CIBC also has a specialized desk at their DIY investing platform, CIBC Investors Edge, called “Premium Edge.” The bank’s most experienced relationship managers work on this desk where, he said, doctors have direct one-on-one access without needing to hold for assistance.

Doctors who are part of their physician package can access this with $500,000 in investments, which is typically only available to clients with more than $1 million.

RBC

When RBC launched its RBC Healthcare Advantage program, it was building on 15 years of experience catering to this group of professionals. “RBC Healthcare was built on a core foundation to address their evolving personal and professional needs,” said RBC Healthcare vicepresident Niranjan Vivekanandan in a release.

Like the other banks, RBC also offers a number of personalized financial planning and tailored tools and advice

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FEATURE

to doctors. What seems to distinguish RBC’s offering are the perks available to physicians who belong to its program.

“We’ve been providing traditional banking services to doctors in a specialized way,” Vivekanandan told the Medical Post. “What we did last year is launch a new business that complements those financial services with new services.”

For example, through a partnership with WestJet, fourth-year medical students who sign on to the program are offered Gold Status with the airline for their residency matching period. This gives them access to a priority support number and entitles them to perks like discounts on flights, priority boarding (with first access to carry-on space), and lounge access. As Vivekanandan explained it, the rationale is to give students a bit of a break while they are flying all over the country—sometimes up to a dozen times—during the matching process for their residency.

“We wanted to help them focus on preparing for their interview rather than having to focus on getting there,” Vivekanandan said.

For practising doctors, RBC has also partnered with three organizations that offer non-financial solutions to doctors within their practice that might eventually affect their finances: Chime, an AI-enabled application that optimizes clinic workflow; Mikata Health, a tool that helps clinics manage appointments and reduce no-shows; and CoHealth, a tool that helps patients navigate their own care and educate themselves during the process.

As part of their offerings, RBC also has something called an “On-Call” program. “Doctors don’t have a standard work schedule so we can’t either,” Vivekanandan told the Medical Post of the program’s advisers, who “go where the physician are.” For quick queries or those that don’t otherwise require a visit from an adviser, there’s also a dedicated wait-free helpline open to all doctors in the program.

SCOTIABANK

When the CMA put MD Financial up for sale, there were reportedly offers

28 DECEMBER 2019 THE MEDICAL POST

from all the big Canadian banks.

While it’s not clear how the ultimately successful offer from Scotiabank differed in terms of dollars and cents (the price tag for MD was nearly $2.7 billion), the CMA leadership said that the bank distinguished itself in terms of “cultural fit and alignment” with the CMA. Now, the private banking team at Scotiabank co-locates with the team at MD and the bank has launched the Scotiabank Healthcare+ program complete with a dedicated national team to address the business banking needs of doctors.

“It was a key acquisition for the bank,” said Roxana Tavana, the vice-president of business banking for Scotiabank. “For many decades we’ve been focused on healthcare professionals . . . MD allowed us to further enhance our offering.”

As with CIBC and some of the other banks, qualifying physicians and even students in the program are eligible for a personal line of credit at a rate of prime minus 0.25%. On the business banking side, the $35 monthly fee associated with the account is waived as part of the physician program, a perk usually restricted to those with a minimum of $30,000 in their account. But Tavana said that, as a guiding principle, their key program benefits go beyond waiving fees and competitive rates—rather it’s the perks that make the most sense to doctors at different stages in their careers.

For instance, Scotia offers a mobile mortgage assessment program to accommodate doctors’ off-hours work schedules, and works with projected income for young doctors who are often contending with substantial debt. Scotia also offers a wide variety of business and personal credit cards that come with a wide variety of “bells and whistles,” like airport lounge access and cash-back programs.

MD’s offerings have also improved as a result of their new partnership with Scotiabank, according to Jean-François Bordeleau, a senior practice manager at the firm. This year MD reduced their fees for physicians and their families acrossthe-board and many of the offerings have stayed the same or improved.

Under MD’s discretionary investment

model, MD Platinum pools—which are a part of MD Private Investment Council solutions—allow entry for doctors with only $30,000 to invest (the minimum threshold, according to Bordeleau, is typically $1 million). In the nondiscretionary investment model, MDPlus, mutual funds are on average 49% less expensive than the market, taking into account both account-level fees and expense ratios, something Bordeleau said “can’t be beat by our competitors.”

TD

TD conducted market research in 2017 which, according to Lee Odlin, the associate vice-president of TD Wealth, identified a gap in services offered to the medical professional community. “The fragmented service model by financial institutions did not meet the unique needs of busy healthcare practitioners,” Odlin wrote in an email to the Medical Post.

When the bank launched its TD Wealth Management for Healthcare Practitioners plan in Dec. 2018, it was to address those needs. Like CIBC and the other banks, TD also offers integrated services across a physician’s personal and business life, and also offers something they call “an acceleration of services” which allows doctors at the beginning of their career to qualify for products, services and relationships typically only accessible to high net-worth clients. “This is due to the complexity of advice needed and the career trajectory we see these professionals on,” Odlin wrote.

According to Odlin, what makes TD’s offer unique is that everything done on behalf of the client is quarterbacked by a dedicated senior private banker, “a personal relationship manager” who works solely with medical professionals.

After evaluating the doctor’s needs across banking, credit, business and investment management, they work with them to design a plan to build net worth and manage their taxes.

“The private banker will support the client with their chequing and credit needs and will introduce them to investment managers to support with investment management and business bankers to support on the non-personal side.”

What if it’s

PAH?

Pulmonary Arterial Hypertension and Connective Tissue Diseases Unexplained dyspnea in scleroderma could signal PAH; screening patients and initiating treatment as early as possible is critical for optimizing outcomes

John Granton, MD, FRCPC Head, Division of Respirology University Health Network and Sinai Health System Professor, University of Toronto Toronto, ON

P

Janet Pope, MD, FRCPC Division Head, Rheumatology St. Joseph’s Health Centre Professor, Schulich School of Medicine London, ON

occur in lupus is associated with a better prognosis than fibrosis of arteries. PAH with scleroderma may cause pulmonary veno-occlusive disease and fibrosis of the right ventricle, giving it a worse prognosis than idiopathic PAH. Dr. John Granton: Although it is

ulmonary arterial hypertension (PAH) is a life-threatening complication of connective tissue diseases (CTDs) primarily seen in systemic scleroderma and mixed CTD, but also in systemic lupus erythematosus, rheumatoid arthritis and others. Approximately 15% of scleroderma patients develop PAH, accounting for 30% of sclerodermarelated deaths. In Western countries, PAH related to CTD is the second most common form of PAH after idiopathic PAH.1 Three-year survival for patients with untreated scleroderma-related PAH is approximately 56%, compared with 91% for individuals with scleroderma who do not develop PAH.2 While most medical care for PAH will be provided by specialists in regional pulmonary hypertension centres, rheumatologists, cardiologists, respirologists and family physicians

all have roles to play in providing collaborative care for patients with CTD-related PAH. Because PAH is a progressive disease that is often advanced before symptoms become evident, the value of early detection and aggressive treatment cannot be overstated.

WHAT IS THE ROLE OF AUTOIMMUNITY AND INFLAMMATION IN THE PATHOGENESIS OF PAH? Dr. Janet Pope: Although scleroderma and other CTDs are autoimmune in nature, the role of autoimmunity in the destruction of the pulmonary vasculature in PAH is unknown. The pathophysiology of PAH in CTDs is the obliteration of the pulmonary arterioles with fibrosis throughout the interstitium, and muscular proliferation of the media and intima of the blood vessels. Plexiform lesions are also characteristic. The vasculitis that may

unclear how autoimmunity causes the vasculopathy in PAH, it is interesting that aggressive, targeted therapy using immune-modulating therapies can result in better control of PAH related to lupus — but only in some patients.

Additionally, basic and translational research suggest that inflammation plays a role in PAH. However, treatment of inflammation has not been successful in modifying progression of most forms of PAH — it’s not a steroid-responsive disease, nor has the use of therapies targeting components of the inflammatory cascade borne fruit as treatment.

HOW DOES THE ETIOLOGY OF PAH DIFFER ACROSS CTDS AND SUBSETS? DO WE KNOW WHICH PATIENTS ARE MOST AT RISK FOR PAH? Dr. Pope: PAH occurs in approximately one in six patients with scleroderma.

However, some PAH cases are seen primarily as a vasculopathy (Group 1

This educational supplement is designed to provide Canadian physicians with the latest in clinical thinking and therapeutic practice.

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The information and opinions contained herein do not necessarily reflect those of the sponsor.

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[1]

PAH), while others are secondary to interstitial lung diseases (Group 3 or hypoxia-related PAH). PAH with lupus has a better prognosis than PAH with scleroderma which may be due to vasculitis in the pulmonary arteries in lupus.

PAH also occurs in mixed CTD that is scleroderma-like (i.e., featuring puffy fingers, significant telangiectasia, Raynaud’s phenomenon, and anticentromere-positive antibodies) so these patients should also be screened. In the other CTDs and rheumatoid arthritis, PAH is very rare and is only detected when there is unexplained dyspnea.

WHY IS SCREENING CTD PATIENTS FOR PAH SO IMPORTANT? WHEN AND HOW SHOULD THEY BE SCREENED? Dr. Granton: When someone is diagnosed with scleroderma or another CTD we cannot predict which patient is

Unexplained dyspnea… what if it’s

PAH?

likely to develop PAH, based on their autoimmune profile or a cluster of immunological and clinical risk factors.

This has led to the practice of screening for PAH in these populations with the hope that earlier disease identification and intervention will have greater impact on long-term outcomes. Although the benefit of early screening in high-risk populations has not been conclusively demonstrated, screening for PAH is currently recommended for patients with the scleroderma spectrum of diseases by several scientific societies.

Various guidelines, such as the 2015 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension,1 and the algorithm derived from the DETECT study,3 propose PAH screening protocols for patients with scleroderma but none of these are perfect. I think the key to

screening is to maintain a questioning mind with all CTD patients, asking them if they are experiencing dyspnea and noting if there have been any changes in exercise capacity.

Objectively, pulmonary function tests can be used to look for an isolated low diffusing capacity for carbon monoxide (DLCO) or a ratio of forced vital capacity percent predicted to DLCO >2, both of which are suggestive of PAH,4 at which point we would move to an echocardiogram. Formal walk test assessments can be useful as well to quantify the degree of disability and follow patients over time.

Dr. Pope: Screening for PAH in scleroderma is so important because it is common and earlier diagnosis and treatment prevents worsening to some degree and may prolong survival.

Anna, 62, was diagnosed with limited cutaneous scleroderma eight years ago. Treatment includes a calcium channel blocker for mild Raynaud’s phenomenon and a proton pump inhibitor to treat GERD. She presents to her rheumatologist for the first time in more than two years because her Raynaud’s “has been acting up more often.”

During the interview, Anna notes she has been feeling “a little out of breath” after mild exertion over the past few months, which she had attributed to not getting enough exercise.

On examination, nose, throat and upper airway are normal, and blood pressure is 132/86 mmHg. Breath sounds are normal with no adventitious sounds; heart sounds are normal with no additional sounds or murmurs. She has sclerodactyly and telangiactasias.

There are no signs of skin calcification and no peripheral edema. Being aware of Anna’s risk for PAH, her rheumatologist orders a series of tests.

X-ray to rule out interstitial lung disease

Chest X-ray is clear

PFTs with spirometry to rule out asthma and COPD and to assess CO diffusing capacity

FEV1 at 97%, FVC at 99%, DLCO at 58% of predicted

Echocardiogram specifying assessment of right AND left atrial size and right and left ventricular size/function, right systolic ventricular pressure and valvular function. It may be helpful to write “R/O PAH in patient with known scleroderma” to help guide the echocardiographer.

* Moderate elevation in tricuspid regurgitant velocity; right ventricle systolic pressure estimated 48mmHg * Mild enlargement of the right atrium * No significant abnormalities of left ventricle, mitral/aortic valves * No evidence of congenital heart disease/shunt

Refer to nearest PH/PAH treatment centre (http://www.phacanada.ca/)

[2]

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Only those patients with shortness of breath and confirmed PAH are eligible for treatment, but all programs have demonstrated that PAH is detected earlier by screening. The WHO suggests annual screening for all scleroderma patients but in my opinion individuals who are very active without reporting dyspnea may only require screening every two to three years. Patients who are older and who have a longer history of scleroderma — and possibly anticentromere antibodies — are at higher risk for PAH and should be screened. For other CTDs, think of investigating patients who are symptomatic.

Screening may also include an echocardiogram to estimate pulmonary arterial pressure and assess the right side of the heart for signs of dilation, ventricular hypertrophy, right heart strain and right axis deviation. The echo can also measure right ventricular ejection fraction using the TAPSE (tricuspid annular plane systolic excursion) score.

WHO SHOULD INITIATE AN ECHOCARDIOGRAM AND WHAT SHOULD THEY BE ASKING FOR? HOW CAN CLINICIANS ENSURE PATIENTS ARE PROPERLY SCREENED? Dr. Pope: It is often the specialist (usually a rheumatologist) following the CTD patient who orders the echocardiogram and pulmonary function tests. Most echocardiograms provide an excellent report for the left heart so it is helpful to specify that the report should also include the right heart as there may be indirect evidence of pulmonary hypertension even if there is no tricuspid regurgitation. It can be useful to clearly specify that you are seeking to rule out PAH. Dr. Granton: The key is to know your

echocardiographer and only refer patients to centres that accurately and thoroughly interrogate the right ventricle in particular to assess direct and indirect features of pulmonary hypertension. Making explicit instructions to them can be helpful.

Technicians familiar with PAH will know to assess right ventricular size and function as well as left ventricular systolic and diastolic function, valvular

function, and to look for congenital abnormalities such as septal defects.

We’re starting to standardize the approach to conducting echocardiograms for PAH inquiries in order to develop some local expertise. In the meantime, clinicians can contact their nearest pulmonary hypertension (PH) treatment centre for referrals to echocardiographers who do a thorough assessment.

WHEN SHOULD PATIENTS BE REFERRED TO A PH CENTRE? Dr. Granton: All patients in whom PAH is suspected — based on elevation in estimated right ventricular systolic pressure or signs of right ventricular dilation or dysfunction — should be referred to a PH treatment centre.

Currently, there are 16 adult centres across Canada that diagnose and treat PAH. Staff at all centres would be happy to review cases if there are any doubts as to whether or not a patient should be referred. A full listing can be found on the Pulmonary Hypertension Association of Canada website (http:// www.phacanada.ca/).

The University Health Network Pulmonary Hypertension Program has started to offer telehealth services so we can see patients who live in more remote locations. I think we can expect to see more of this kind of service which will be beneficial to people with PAH and to referring clinicians who don’t live and work near major centres.

Dr. Pope: All patients with PAH should be referred to a PH centre for access to specialized and excellent care. In fact, many jurisdictions do not allow for reimbursement of PAH medications if the patient is not attending an expert PH centre. Any patients who present with unexplained dyspnea and those who are at high risk of PAH, such as those with a long history of scleroderma, can be referred to determine if a right heart catheterization is needed, even if their echocardiogram is relatively normal. It’s important to remember that echocardiograms can return both false positives and false negatives for PAH.

WHAT ARE THE KEY PRINCIPLES OF PAH MANAGEMENT IN CTD PATIENTS? Dr. Pope: The accepted hemodynamic

WHO Functional Classifications of Pulmonary Hypertension Class I: patients with PH but without resulting limitation of physical activity. Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain, or near syncope.

Class II: patients with PH resulting in slight limitation of physical activity. They are comfortable at rest.

Ordinary physical activity causes undue dyspnea or fatigue, chest pain, or near syncope.

Class III: patients with PH resulting in marked limitation of physical activity. They are comfortable at rest.

Less than ordinary activity causes undue dyspnea or fatigue, chest pain, or near syncope.

Class IV: patients with PH with inability to carry out any physical activity without symptoms. These patients manifest signs of rightsided heart failure. Dyspnea and/ or fatigue may even be present at rest. Discomfort is increased by any physical activity.

definition of PAH is a mean resting pulmonary pressure of ≥ 25mmHg with a pulmonary capillary wedge pressure of <15mmHG on right heart catheterization.1 A newer definition has recently been considered; with a mean pressure of > 20 mmHg and elevation in pulmonary vascular resistance. It is unclear how this definition will translate into clinical practice and treatment. If these parameters are met and pulmonary emboli and high-wedge pressure PH (which indicates left heart failure) have been ruled out, patients are diagnosed with PAH and treated to targets with PAH-specific therapies if they are considered WHO functional class II or higher (see WHO sidebar above).

Dr. Granton: PAH is a life-altering

diagnosis so the goals of treatment are to get patients into the lowerrisk categories — the WHO or New York Heart Association classification stages I or II — and keep them there.

MADE MADE POSSIBLE POSSIBLE THROUGH THROUGH THE THE FINANCIAL FINANCIAL SUPPORT SUPPORT OFOF JANSSEN JANSSEN INC. INC.

[3]

We want them to feel better and have a better quality of life. We set targets such as being able to walk 450 metres or more without dyspnea, no episodes of syncope, no progression of PAH symptoms and no signs of right heart involvement or failure on echocardiogram. Looking for reductions in markers such as brain natriuretic peptide, as we do in heart failure, and uric acid can also be helpful.

If patients meet all of the set targets or endpoints, we consider them to have a good risk profile. If they don’t, then they have an intermediate- to high-risk profile and we adjust their regimen accordingly.

Sadly, many patients will require a lung transplant if their disease advances.

Dr. Pope: PAH is treated with agents that target three established pathways: the endothelin pathway (endothelin receptor blockers), the nitric oxide pathway (PDE5 inhibitors and soluble guanylate cyclase stimulators), and the prostacyclin pathway (prostanoids and IP receptor agonists). Drugs from each of these classes can be used in combination, except PDE5 inhibitors with the soluble guanylate cyclase stimulator. If targets are not achieved, we typically add an agent from another class instead of switching. The use of endothelin receptor antagonists (ERAs) requires ongoing transaminase monitoring as per each specific product monograph. Unlike idiopathic PAH, CTD-related PAH is not anticoagulated.

Dr. Granton: A 2016 meta-analysis looked

at 17 studies that compared initial, sequential, and add-on combination therapy with monotherapy in PAH and found significant risk reduction for clinical worsening, including death, with combined approaches.5 Those of

us who manage a large number of PAH patients certainly see an impressive response to combined therapies in many patients when used early on.

WHAT PHYSICAL, EMOTIONAL, AND PSYCHOSOCIAL ISSUES DO THESE PATIENTS DEAL WITH AND HOW CAN THEY BE SUPPORTED? Dr. Granton: We know that the impact of PAH on anxiety, depression and existential distress in patients and their families is under-recognized.

They quickly learn that PAH is a progressive and lethal diagnosis and they do struggle with a sense of loss and uncertainty. We also know that patients can find it difficult to cope with daily physical activities required at home and in the workplace, and that they can experience relationship challenges and fewer opportunities to engage socially.6 Our approach is to openly discuss these matters and make referrals to psychologists and psychiatrists and other community supports, as needed. The Pulmonary Hypertension Association of Canada offers useful resources for people living with PAH and their caregivers.

Dr. Pope: Supportive care — which

may involve exercise interventions, oxygen if a patient is hypoxic and treatment of right heart failure — can prolong survival. Multiple drugs are usually combined in PAH treatment so expert centres often have nurses and reimbursement specialists to help patients navigate the system.

WHAT ROLES DO REFERRING PHYSICIANS (RHEUMATOLOGY, PRIMARY CARE) PLAY IN PATIENT MANAGEMENT, FOLLOW UP AND SUPPORT? Dr. Pope: Rheumatologists are key for screening patients with scleroderma

REFERENCES 1. Galiè N, Humbert M, Vachiery JL et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European Heart Journal. 2016; 37(1): 67–119.

2. Coghlan JG, Wolf M, Distler O et al. Incidence of pulmonary hypertension and determining factors in patients with systemic sclerosis. Eur Respir J 2018; 51:1197–2017.

3. Coghlan JG, Denton CP, Grünig E et al. Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study Ann Rheum Dis 2014;73:1340–1349.

4. Steen VD, Lucas M, Fertig N et al. Pulmonary arterial hypertension and severe pulmonary fibrosis in systemic sclerosis patients with a nucleolar antibody. J Rheumatol 2007;34(11):2230–2235.

5. Lajoie AC, Lauzière G, Lega JC et al. Combination therapy versus monotherapy for pulmonary arterial hypertension: a meta-analysis. Lancet Respir Med. 2016 4(4):291–305.

6. Guillevin L, Armstrong I, Aldrighetti R et al. Understanding the impact of pulmonary arterial hypertension on patients’ and carers’ lives. Eur Respir Rev 2013;22: 535–542.

[4]

and those with mixed CTD with scleroderma features.

Dr. Granton: Our program operates on a shared care model. We do have a cardiologist and rheumatologist on staff, but we also maintain relationships with referring specialists in the community.

Family practitioners are important because they will follow these patients closely and therefore are in a good position to manage fluid balance by ensuring patients are adhering to sodium- and fluid- restricted diet and taking their medications properly. They can also catch developing signs of right heart failure, such as peripheral edema, and screen for worsening PAH symptoms.

PAH Resources PULMONARY HYPERTENSION ASSOCIATION OF CANADA: Resources for health professionals, patients and caregivers, including a directory of PH treatment centres across the country. www.phacanada.ca US PULMONARY HYPERTENSION ASSOCIATION: U.S.-based source of PAH resources including professional and patient education, consensus statements and more. https://phassociation.org SCLERODERMA SOCIETY OF CANADA: www.scleroderma.ca

Further Reading Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel Report. Chest 2019; 155(3):565–586.

2015 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension.

European Heart Journal 2016;37(1):67–119.

Available at: https://doi.org/10.1093/eurheartj/ ehv317 The importance of patient perspectives in pulmonary hypertension.

Eur Respir J 2018;53:1801919. Available at https://erj.ersjournals.com/content/erj/ early/2018/10/11/13993003.01919-2018.full.pdf

Group Brand Director/Healthcare: DONNA KERRY Senior Account Manager: NORM COOK Editor: DEIRDRE MACLEAN Project Editor: BRAD HUSSEY Creative Director: NANCY PETERMAN This supplement is published by EnsembleIQ, 20 Eglinton Ave. W., Suite 1800, Toronto, ON M4R 1K8.

No part of this publication may be reproduced, in whole or in part, without the written permission of the publisher. ©2019.

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FEATURE

THE Y E N O M DOCS

nd cians a rts i s y h p Three ce expe n a n fi t gh self-tau some advice offer

Getty Images

We’re going to level with you: A lot people want your money. They want to manage it, to sell you things, to make you believe that they’re going to give you the best returns. Some of them deserve a shot, we’re sure, but determining who’s a good fit for you and what you need to do yourself takes some work.

We approached three physicians—two of whom write about finances online and one of whom oversees a forum on financial independence for physicians— for some insight. We asked them to share a few pieces of advice about managing

finances they’ve gleaned from learning to manage their own: from their first forays into financial literacy, to the wide world of personal insurance, to managing one’s own investments. Regardless of the stage in your career, this is advice you can trust.

THE MEDICAL POST DECEMBER 2019 33

FEATURE

I have this dream. In it, I see a country brimming with people—which, of course, includes physicians—who are debt free. Each one has a lovely retirement nest egg that is shaping up to be almost excessive. They never go to bed worried about finances, or wake up thinking about how to balance the upcoming bills.

That sounds pretty good, no? How do we get from here to there?

THE Y MONE DOCS

FIND YOUR REASON

Looking out for your own best interests starts with education—here is what mine looked like BY DR. FIREFLY Becoming financially literate was my

first self-directed learning project.

Sorry medicine, even though you’re the primary learning focus in my life now, you came second at the start. It began with a good textbook, some good online resources, and lots of curiosity.

There are now more books and online resources than ever. As for curiosity? If you’re reading this article, I bet you’re curious too!

We don’t all need to become financial planners and accountants—we have professionals in those fields for very good reasons. But we do need to know how to protect our own interests and that starts with a better understanding of what is happening.

I admit I raised my eyebrows when I read the statement from Bruno Lévesque of the Financial Consumer Agency of Canada that our country “is a world leader in financial literacy research.” I don’t think we’re feeling the effects of this research on the ground, with my

34 DECEMBER 2019 THE MEDICAL POST

patients, colleagues, friends, or even with my family.

In the first rotation of my clerkship in medical school, I remember listening to a young-ish surgeon and an older anesthesiologist chat during an operation. The surgeon was discussing how, despite his high income, he was in a really tight financial spot due to alimony payments he was making to two previous spouses, and how his marriages suffered (at least in part) due to terrible work hours in residency and afterward. The anesthesiologist expressed sympathy. For his part, the anesthesiologist was technically in the retirement age bracket but did not have sufficient retirement funds and would have to work at least another 10 years despite being ready to transition out of medicine. I remember my mind whirling. Was this for real? Variants on this conversation played out more than once during my brief two years of clerkship. These issues are for real.

LOCATE YOURSELF IN TERMS OF NET WORTH

Much like navigating your way towards a beautiful hidden waterfall on a hike, or to a recommended local gem in a foreign city, we need to know where we are so that we figure out how to get to where we want to go.

In financial terms, this means finding out your current net worth. For me, I add up my assets (because I actually have some for the first time in my life!) and subtract my debts. Then I track this on the first of every month to see if I’m moving in the right direction and at a reasonable pace.

COME UP WITH A DEBT DISPERSION STRATEGY

You got debt? You are far from alone.

The average Canadian reportedly owes $1.70 for every $1.00 of income! What’s your debt like? Now, imagine this debt dissolving into the ether.

Getty Images

Financial literacy night school

Why do you care about money? Why should you make understanding money (a.k.a. financial literacy) a priority? Why is now a reasonable time to step into learning more about your money?

My “why” centered around priorities.

In terms of work priorities, I aim to be a good physician for my patients, and this includes looking at aspects that may be outside of the clinical, ground-level one-on-one work. I have no idea how non-clinical work such as advocacy or systems change is compensated— which leads me to think it might not be compensated at all, in some cases.

In that case, I’m going to need to build a good financial base upon which I can turn my focus on different areas of need.

ADOLESCENTS AND YOUNG ADULTS MAY BE AT RISK FOR

MenB

Because they share

1

In Canada between 2011 and 2015:2 • Individuals 10-24 years of age accounted for 1 out of 4 cases of invasive meningococcal disease (IMD) • MenB caused the majority (63%) of IMD cases

Serogroup B %

63

37%

All other Serogroups

MenB = serogroup B IMD

Help protect your adolescent and young adult patients from MenB with TRUMENBA® 1 TRUMENBA is indicated for active immunization to help prevent invasive meningococcal disease (IMD) caused

by Neisseria meningitidis serogroup B in individuals 10 through 25 years of age.

Please consult the Product Monograph at www.pfizer.ca/ pm/en/Trumenba.pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available upon request by calling 1-800-463-6001.

References: 1. TRUMENBA® Product Monograph. Pfizer Canada ULC. 2. Public Health Agency of Canada. Vaccine Preventable Disease Surveillance Report to December 31, 2015. Available at: https://www.canada.ca/ content/dam/phac-aspc/documents/services/publications/healthy-living/vaccine-preventable-disease-surveillance-report-december-31-2015/vaccine-preventable-disease-eng.pdf. Accessed on June 20, 2019.

TRUMENBA® is a registered trademark of Wyeth LLC, Pfizer Canada ULC, Licensee © 2019 Pfizer Canada ULC, Kirkland, Quebec H9J 2M5

PP-TRU-CAN-0047-EN

Advertising

October 2019 – “Getting it right for physicians” – sponsored by CIBC

By Pippa Wysong When Dr. Christine Tang graduated from medical school in 1998, she had a debt of 40,000 dollars which, back then, was substantial. Like any new doctor in Canada she was faced with trying to pay it off while finding additional resources for starting up her practice.

She had to set up an office, hire staff and buy equipment. As a plastic surgeon the costs of devices and equipment were, and continue to be, substantial. Then, as time went on, there were personal expenses such as getting a mortgage for a house and costs associated with starting a family.

“There was a CIBC branch at the hospital I worked at, and because it was so convenient I turned to them to help manage my finances,” she said. Dr. Tang works at William Osler Health Centre - Etobicoke General Hospital.

Luckily, she met Marcello Aquilina, a senior financial advisor at CIBC in Etobicoke, who became her advisor.

“Marcello wasn’t a typical advisor. He worked with a lot of doctors and knew what sorts of services I needed probably before I did,” she said. A big part of her experience has been about building a relationship and trust.

As an advisor, Aquilina was ahead of the curve in terms of how he worked with physicians.

At the time, banks didn’t have specialized services for physicians. There was nothing like the newly launched CIBC Full Service Physician Package, a comprehensive suite of services designed to address the diverse needs of a physician’s overall portfolio. It was launched in April of this year, and with lower and fewer fees, has caught the attention of physicians But back in 1998 Aquilina adjusted how he conducted business with physician-clients on his own, a move that foreshadowed the Full Service Physician Package. He made sure they didn’t need appointments with multiple advisors, met on their terms – where and when they needed, and ensured that service was fast and efficient.

“The doctors at the hospital were always rushed and needed to get things done quickly. So, I got things done quickly,” he said. In addition, doctors had a diverse range of needs when it came to their portfolios and he took extra steps to make things easier for them.

Aquilina took on a wider variety of tasks than typical advisors. He helped with everything from mortgages, lines of credit, personal and corporate investments, personal and corporate credit cards, and more. He became a one-stop nexus for physicians Indeed, these are the services he provides for Dr. Tang. Aquilina helped her set-up and maintain her savings accounts, a US dollar account, five lines of credit, personal and business credit cards, professional portfolio management for her corporate investments, and corporate accounts for the rental properties she owns.

The CIBC logo is a trademark of CIBC.

Over the years he’s been around to help Dr. Tang achieve her ambitions as a plastic surgeon and owner of a growing practice, even helping her with financing $400,000 worth of equipment for her practice, and is present when she meets with a Financial Planning Consultant during RRSP season.

“I consider Marcello a friend. We’ve known each other for 25 years. In fact, we are both involved with various hospital committees, meetings and events. I was lucky I started with an advisor who could help me with the diverse things in my portfolio, I don’t have time to deal with it all myself. I’m not sure I appreciated it at the time,” Dr. Tang said.

Advisors who support the CIBC Full Service Physician Package undergo specialized training to learn about the different payment schemes for physicians (not all are fee-for-service), the types of incorporation structures doctors use, and the fact the legislative environment physicians operate under can change affecting taxation and remuneration.

“Since 1998 CIBC tried other service packages for professionals, but they weren’t as good as the Full Service Physician Package,” Aquilina said. In fact, because of his 20-plus years of experience working with physicians he had substantial input in the development of the package.

Doctors had a lot of input too. The early stages of developing the package involved full-day shadowing with doctors. This provided deeper insight into the day-to-day activities of doctors – the corporate structures they used, what their schedules were like, how their offices worked, whether they worked at multiple sites, financial needs in the office environment, how they needed money to flow, and how they got paid.

Now, advisors have the knowledge-base to work with physicians at any stage of their career be they recent grads, growing their practice, or those who are transitioning or retiring.

For physicians growing their practice, successfully managing their finances means reducing their tax burden, having a financial plan in place for retirement and having well-performing investments . The goal is to help doctors maintain their lifestyle as they age.

“We knew doctors wanted an advisor and institution who understand the unique challenges physicians face,” Aquilina said. Physicians have to think like individuals as well as like corporations. It helps if the financial institution does the same .

While the CIBC Full Service Physician Package has simplified services from the front-end for clients, for Aquilina who helped create the model, it’s still business as usual.

Rx

Aimovig®—the 1st and only anti-CGRP receptor in migraine prevention1,2*

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Migraine is a common and complex disease.3,4 In 2010/2011, an estimated 2.7 million Canadians reported that they have been diagnosed with a migraine.5

What is Aimovig®?

Aimovig® is an anti-calcitonin gene-related peptide receptor (anti-CGRPR). CGRP has been found to play a role in migraine pathophysiology. Aimovig® competes with CGRP for binding to the CGRP receptor and antagonizes CGRP receptor function.1

Indication

Aimovig® (erenumab) is indicated for prevention of migraine in adults who have at least 4 migraine days per month. Aimovig® should be initiated by physicians experienced in the diagnosis and treatment of migraine.1

How effective was Aimovig® in reducing monthly migraine days in clinical trials?

In two clinical trials, a significantly greater percentage of patients achieved a ≥50% reduction in mean MMD vs. placebo (secondary endpoint).1

Study 1: Episodic migraine† Baseline to months 4-6 of the 24-week study

of Aimovig 70 mg patients (n=312) ®

of Aimovig 140 mg patients (n=318) ®

placebo (n=281), p<0.001

Was Aimovig® generally well tolerated?

Aimovig® was generally well tolerated with an established safety profile. The adverse reactions reported with Aimovig® 70 mg and 140 mg (at a greater frequency than placebo) were: injection site reactions (5.6%, 4.5% vs.

3.2%), constipation (1.3%, 3.2% vs. 1.1%), muscle spasm (0.1%, 2.0% vs. 0.4%) and pruritus¶ (0.7%, 1.8% vs. 0.5%), respectively.1§

What is the dosing and administration for Aimovig®?

Aimovig offers once-monthly dosing from the start. ®

• Aimovig® is administered subcutaneously through single-dose pre-filled autoinjector.

• Aimovig® is intended for patient selfadministration. Administration should be performed by an individual who has been trained to administer the product.1 Two dosing options are available for patients to self-administer using the SureClick® autoinjector.1 The recommended dose of Aimovig® is 70 mg administered once monthly. Some patients may benefit from a dose of 140 mg administered as two consecutive subcutaneous injections of 70 mg or one subcutaneous injection of 140 mg.

• Needle of the SureClick® autoinjector is hidden.

• Injection should take ~15 seconds.

See Product Monograph for complete administration instructions.

What is the GO Program®? placebo (n=316), p<0.001

Aimovig® is backed by the GO Program®, a program

This Q&A is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908.

No part of this Q&A may be reproduced, in whole or in part, without the written permission of the publisher. © 2019

go.program@novartis.com

Clinical use: Safety and efficacy have not been studied in patients aged 65 or older.

Relevant warnings & precautions: • Aimovig® crosses the placenta. Avoid use during pregnancy as a cautionary measure.

• In nursing women, a decision should be made whether to discontinue nursing or discontinue Aimovig®, weighing the potential benefit of Aimovig® to the mother and breastfeeding to the infant.

For more information: Please consult the product monograph at www.novartis.ca/aimovigmonograph 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 1-800-363-8883.

CGRP=calcitonin gene-related peptide MMD=monthly migraine days * Comparative clinical significance has not been established. † Randomized, multi-centre, 24-week, placebo-controlled, double-blind study to evaluate the prevention of episodic migraines. Patients had a history of migraine with or without aura for a duration of ≥12 months and 4-14 migraine days per month. Patients received monthly subcutaneous injections of either Aimovig® 70 mg, Aimovig® 140 mg or placebo for 6 months.1 ‡ Randomized, multi-centre, 12-week, placebo-controlled, double-blind study to evaluate the prevention of chronic migraines. Patients had a history of migraine with or without aura (≥15 headache days per month with ≥8 migraine days per month). Patients received monthly subcutaneous injections of either Aimovig® 70 mg, Aimovig® 140 mg or placebo for 3 months.1 ¶ Pruritus includes generalized pruritus, pruritus, and pruritic rash.1 § A total of over 2,500 patients (>2,600 patient years) have been treated with Aimovig® in registration studies. Of these, >1,300 patients were exposed for at least 12 months.1

References

1. Aimovig® Product Monograph, May 23, 2019. Distributed by Novartis Pharmaceuticals Canada Inc. 2. Data on file, Novartis Pharmaceuticals Canada Inc. 3. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version); 2013 Cephalalgia 33(9)629–808. 4. Pringsheim T, et al. Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S159. 5. Ramage-Morin P and Gilmour H. Prevalence of migraine in the Canadian household population. Available at: https:// www.statcan.gc.ca/pub/82-003-x/2014006/article/14033-eng. htm. Accessed July 13, 2018. ® Aimovig and SureClick are registered trademarks of Amgen Inc. used under license by Novartis Pharmaceuticals Canada Inc. ® Go Program is a registered trademark of Novartis AG. November/2019 – PRO/AMV/0018E

FEATURE

Is this the most optimal route?

Not necessarily for everyone—it just happens to be the one that works for me.

There is a multitude of debt meltaway strategies. A quick Google search returned 7.5 million hits. I’ve even written about a couple. Pick any one.

You don’t even have to stick with the one you picked! The key is to get started and keep going, and keep going till the debt is squeezed out of existence.

I decided to funnel over 90% of my disposable income into paying down my line-of-credit debt. I left my provincial student loan debt for the time being, given that it was not accumulating interest.

GET YOUR WEALTH-BUILDING GUIDE

I found Millionaire Teacher by Andrew Hallam by serendipitous accident in my undergraduate days. That book became my launchpad into the world of personal finance, but there are many good books (or audiobooks for you commuters out there), podcasts, and blogs to get into! I have listed some of the ones that I found useful on my website, drfirefly.com. Feel free to start with those, or find the ones that speak to you.

Another essential part of wealth building is to understand tax-sheltering.

Learn the differences between a Tax Free Savings Account (TFSA) and a Registered Retirement Savings Plan (RRSP). Once my line of credit was paid down, I shifted gears and began

to put money into my TFSA to buy low management expense ratio exchangetraded funds. I decided to invest through a TFSA first instead of an RRSP because I wanted to save the RRSP contribution room for when I am a staff physician, to help decrease the income tax in the first year or so.

TAKE ACTION ON WEALTH BUILDING

After a period of learning—whatever time period feels reasonable to you—I would say the next step is to act. Open your investment account. Buy your first rental property. Start your first side business. Plant the seeds of your money tree, start watering it, and keep nurturing it.

As soon as I started making a resident salary, I set up a Questrade account for self-directed investing with low trading fees. I put a couple hundred here and there into my TFSA in Questrade until I paid off my line of credit, and then really started shoveling every spare dollar into that account.

A question that pops up often at this juncture is, “Should I pay down debt first or build wealth first?” Everyone’s answer is going to be different. One way to find your answer is to look at the interest on the debt and the potential interest on the investment and decide if a) the math

works in favour of one or the other and b) if your psyche prefers one or the other.

I decided to primarily focus on my debt first, even though the math would have technically worked out over the long term to weigh in favour of first starting to invest in low management expense ratio exchange-traded funds.

After the line of credit was paid down, I switched to investing through my TFSA. After I maxed out my TFSA, I began to put money in a high-interest savings account (HISA) in order to build up the sum needed to pay down my provincial student loan debt in one go at the end of my training. I used an HISA to harness some minimal interest generation while not exposing that money to the risks of a market downturn at the wrong time.

Is this the most optimal route?

Not necessarily for everyone—it just happens to be the one that works for me.

Hopefully this is helpful in some way for you to decide on your route! Now you too can go to your own self-directed, adultlearning financial literacy night school. is a Canadian resident physician with an interest in personal finance and philosophy of life. She hopes to help with spreading financial literacy as one possible bulwark against professional burnout in the healthcare fields and beyond.

DR. FIREFLY

THE MEDICAL POST DECEMBER 2019 39

FEATURE

THE Y MONE DOCS

BY DR. MARK SOTH

As doctors, there aren’t too many people we can trust for advice on this—except, perhaps, Kenny Rogers Most doctors know that they need

some insurance. However, they also usually follow what is suggested to them by colleagues, financial advisors or insurance brokers. These sources may have different levels of knowledge, motivations and biases. Our usual Vulcan-like logic also gets mired in the very powerful emotions of greed and fear that are intertwined with the events we insure against and large potential pay-outs. That makes it important to understand what we need, and why, before we engage with insurance providers.

Here is how I think about insurance: It’s like gambling in the casino of life.

Insurance is about odds, losses, and winnings. Not enough is gambling that the bad event either won’t happen or that you can handle it. Too much

40 DECEMBER 2019 THE MEDICAL POST

insurance is betting against the house that you are going to get lucky (mind you, when something bad happens) and get a windfall pay-out. Just like a casino, insurance companies know the odds very well and set the rules of the game.

The premiums and fine print make sure that they are stacked in their favour. You won’t outsmart them.

So, I evaluate how much insurance I need before discussing with an advisor/ broker. I also re-evaluate it when my needs change. Here’s how I have applied that.

CAR & HOUSE INSURANCE

Everybody needs these. However, most doctors don’t need to pay the big premium that comes with a low deductible. If I have something go wrong, I can absorb $1K. No problem.

The other benefit of these types of

UMBRELLA LIABILITY INSURANCE

This can be tacked onto a car/house policy for a small premium. It covers for being sued beyond the basic policies.

One of the pitfalls of having a high-status career, or if you display your wealth, is that people (and their lawyers) can see you as a lawsuit cash-cow. Mo(ooo) tivating to sue.

OWN-OCCUPATION DISABILITY INSURANCE

This is vital for early career physicians.

It covers income for disability from a 90-day wait-period until age 65. People will try to sell you the maximum amount of insurance that your income allows.

However, you should ask yourself: How much income do I need to provide for myself (and family) plus some incremental care costs? That could be much lower, if you live well below your means. It also changes over your career span.

In my early career, I had a huge mortgage, little kids and not very much in savings. I needed a truck-load of disability insurance. Currently, I have enough invested to more than cover our living expenses and obligations. If I

Getty Images

How I handle my personal insurance

insurance is that if you have a claim, they have skin in the game. That helps with getting things fixed properly. A bigger claim will follow if they don’t.

For example, we had some shingles blow off our roof last year. After multiple calls and being stood-up by roofers, we called the insurance company. Someone was there to fix the roof within days.

We had to pay (since it was within our deductible) but it actually got done.

Plus, if something further happens, the roofers are on the record with the insurance company.

The Medical Post wins at the Eddie & Ozzie Awards The Medical Post was recognized at the 2019 Folio: Eddie & Ozzie Awards in New York on October 30, 2019.

9

9

RABLE HONOTION MEN

ER

WINN

Fighting the MD suicide epidemic 12

The undying burden of paperwork 16

BURN

9

Phone fee codes by province 23

RABLE HONOTION MEN

Tips on reducing no-shows 30

THE BEST

OUT.

PROVINCES TO PRACTISE IN

BY TRISTAN BRONCA AND COLIN LESLIE

MEDICAL POST RANKS:

WE GATHERED a lot of data to create

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

Welcome to your NE Medical W Post

metrics. The letter grades for each of the six metrics come from the data we collected in each area.

It is important to note these metrics look at the balance of only certain professional factors, so things such as “good weather” are not tracked but then, it is always 21°C inside a hospital.

For cases where provinces have the same letter grade, the provinces are ranked according to the percentages we used to come up with the letter grades (for example, B.C.'s overall score was 68% versus Nova Scotia which scored 66%).

AB B BBC+ C+ C+ C+ C

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

Getty Images

BEST PROVINCES TO PRACTISE IN

APRIL 2018 12 SEPTEMBER 2018 THE MEDICAL POST

OZZIE WINNER

OZZIE HONORABLE MENTION

EDDIE HONORABLE MENTION

Redesign 2018 (B2B) creative director, Nancy Peterman, graphic design, Erin McPhee and cover artist Justin Poulsen

Cover Design (B2B) Allies. June 2018 creative director, Nancy Peterman, graphic design, Erin McPhee and cover artist Justin Poulsen

Series of Articles (B2B) “Best Provinces to Practise In” by senior editor Tristan Bronca and editor-in-chief Colin Leslie

We are thrilled that all the hard work our staff do serving Canada’s doctors is being recognized internationally!

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Rx

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17%

19%

improvement with Viibryd® 20 mg/day

improvement with Viibryd® 40 mg/day

(p=0.0073)

(p=0.003)

60

MADRS total score

50

What is Viibryd® indicated for?

Viibryd® (vilazodone hydrochloride) is indicated for the symptomatic relief of major depressive disorder (MDD) in adults.1

What is the mechanism of action of Viibryd®?

Viibryd® is both a selective serotonin reuptake inhibitor and a partial agonist of the 5-HT1A receptors. The precise mechanism of the antidepressant effect of Viibryd® is not fully understood, but it is presumed to be related to enhancement of serotonergic activity in the central nervous system.1* 5-HT1A: 5-hydroxytryptamine receptor subtype 1A

How effective was Viibryd® in clinical trials? ®

The efficacy of Viibryd was studied in 4 MDD trials in adult patients who met DSM-IV-TR criteria for MDD.1 MADRS total score In a 10-week study, Viibryd® significantly improved MDD symptoms as measured by the MADRS total score.1,2†

31.3

31.8

31.0

30 20

16.1 13.8

10

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‡

-6.6‡

n=198

13.2

-6.6‡

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0 BASELINE 10 WEEK

placebo

BASELINE 10 WEEK

BASELINE 10 WEEK

Viibryd® 20 mg

Viibryd® 40 mg

p=0.037 vs. placebo

Viibryd® (n=231)

Adapted from Product Monograph and Mathews et al.

placebo (n=232)

DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders MADRS: Montgomery–Åsberg Depression Rating Scale LSMD: Least Square Mean Difference

Adapted from Khan et al.

CGI-S Total Score Results of the secondary efficacy parameter CGI-S Score from the 10-week study were supportive of the primary efficacy results.1†

What are the common adverse events of Viibryd®?

CGI-S: Clinical Global Impressions Severity

HAM-A Total Score In 2 studies, Viibryd® demonstrated statistically significantly improvement in depression-related anxiety vs. placebo as measured by the HAM-A scale at week 8 (secondary endpoint).3,4‡§

HAM-A: Hamilton Rating Scale for Anxiety LS: Least Squares

Viibryd® has an established safety profile.1 Adverse reactions occurring in ≥ 2% of Viibryd®-treated patients and at a greater rate than placebo-treated patients in pooled MDD placebo-controlled studies System Organ Class Preferred Term

placebo n=967 (%)

Viibryd® 20 mg/ day n=288 (%)

Viibryd® 40 mg/ day n=978 (%)

Gastrointestinal disorders

HAM-A total score change from baseline LS mean HAM-A change from baseline

A new antidepressant option for your patients with MDD

40

HAM-A total score change from baseline LS mean HAM-A change from baseline

MADRS total score change from baseline

p=0.045 vs. placebo

Diarrhea

10

26

29

Nausea

7

22

24

Dry mouth

5

8

7

Vomiting

2

4

5

Abdominal pain1

3

7

4

Dyspepsia

2

2

3

Flatulence

1

3

3

Gastroenteritis

1

1

2

Abdominal distention

1

2

1

Nervous system disorders Headache2

14

15

14

Dizziness

5

6

8

Somnolence

2

4

5

Paresthesia

1

1

2

2

7

6

2

2

3

1

2

3

3

4

3

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1

2

1

1

3

Psychiatric disorders Viibryd® (n=198)

placebo (n=199)

Adapted from Rickles et al.

Insomnia Abnormal dreams Restlessness

3

General disorders Fatigue Cardiac disorders Palpitations

* Clinical significance is unknown. † Double-blind, 10-week, placebo- and active-controlled, fixed-dose study. Patients were treated with Viibryd® 20 mg/day, Viibryd® 40 mg/day, citalopram 40 mg/day or placebo. The study was not designed to evaluate statistical differences with Viibryd® vs. citalopram. Analysis based on observed cases at the end of treatment. ‡§ Randomized, double-blind, placebo-controlled, multicenter, 8-week study. Viibryd® treatment was initiated once daily at 10 mg for 7 days, followed by 20 mg for the next 7 days, and then 40 mg for the duration of the study. Last observation carried forward (LOCF) analysis shown.

Metabolism and nutrition disorders Increased appetite

Musculosketal and connective tissue disorders Arthralgia

1

2

1

1

1

2

Investigations Increased weight

• The onset of diarrhea and nausea occurred mostly during the initial 2-week titration period and median duration was 5 days for nausea and 8 days for diarrhea (mean duration of 15 days for nausea and 19 days for diarrhea). Approximately half of the vomiting occurred in the initial 2 weeks of treatment and the median duration was 1 day.1 • In the 52-week open label study, the most frequently occurring adverse events were diarrhea (35.7%), nausea (31.6%), dry mouth (11.0%) and vomiting (7.3%). The majority of events were either mild or moderate in intensity. Adverse events related to gastrointestinal disorders led to discontinuation in 4.0% of vilazodone-treated patients in this 52-week study.1

What was the effect of Viibryd® on weight?

• In the 4 placebo-controlled 8- to 10-week studies, slight mean changes in body weight were observed in the vilazodone 20-mg and 40-mg groups compared with placebo.1

8-10 weeks

1 Includes abdominal discomfort, abdominal pain upper and abdominal pain 2 Includes headache and tension headache 3 Includes restlessness, akathisia and restless legs syndrome

Information on select adverse events£

• In the 52 week open-label study, mean weight increased mildly over time.1

What was the effect of Viibryd® on sexual function?

The incidence of self-reported adverse sexual reactions was low and similar to placebo in clinical studies, as measured by the total score on either the ASEX or the CSFQ.1

52 weeks

®

Sexual adverse reactions occurring in ≥2% Viibryd patients and greater than the rate of placebo-treated patients Males (n=955)

10

Females (n=1278)

% of patients

8

What is the dosing for Viibryd®?

Viibryd® offers simple once-daily dosing. The recommended dose range is 20-40 mg once daily with food.1

6 4%

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3%

2% 2%

2%

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1%

<1%

0%

0 Abnormal orgasm

Erectile dysfunction

Libido decreased

Viibryd® 40 mg/day (n=978)

1% 0%

1% 1% 0%

Ejaculation disorder

Abnormal orgasm

Viibryd® 20 mg/day (n=288)

2% 2% <1% Libido decreased placebo (n=967)

• Physicians should routinely inquire about possible sexual side effects.

ASEX=Arizona Sexual Experiences Scale CSFQ=Changes in Sexual Function Questionnaire £ See the Product Monograph for additional adverse event information.

Includes abnormal orgasm and anorgasmia.

10 mg (x7 days)

INITIATE

20 mg (x7 days)

40 mg

TITRATE

Dose may be increased from 20 mg to 40 mg after 7 days based on individual patient efficacy and tolerability.

• Therapeutic response is usually seen after 1–2 weeks of treatment.1 • Viibryd® should be taken with food. Viibryd® bioavavailability can decrease to ~50% in the fasted state compared to fed state, and may result in diminished effectiveness in some patients.1 Please see the Product Monograph for complete dosing and administration information.

Clinical use: • The short-term efficacy of Viibryd® was demonstrated in randomized, double-blind, placebo-controlled studies of 8 to 10 weeks. Long-term maintenance efficacy has not been established.

Physicians should periodically re-evaluate the usefulness of the drug for individuals.

• Viibryd® is not indicated for use in patients under the age of 18.

Contraindications: • Patients who are currently taking, or within two weeks of terminating, MAOIs including linezolid or methylene blue due to risk of serotonin syndrome.

Most serious warnings and precautions: Behavioural and emotional changes, incuding self-harm: The use of SSRIs and other newer antidepressants in patients under the age of 18 may be associated with behavioural and emotional changes, including increased risk of suicidal ideation and behaviour. The use of SSRIs and other newer antidepressants in both pediatrics and adults may be associated with severe agitation-type adverse events coupled with self-harm and harm to others. The agitation-type events include: akathisia, agitation, disinhibition, emotional lability, hostility, aggression, depersonalization. Rigorous clinical monitoring for suicidal ideation or other indicators of potential for suicidal behaviour is advised in patients of all ages. Patients, their families, and their caregivers should be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, other unusual changes in behaviour, worsening of depression, and suicidal ideation, especially when initiating therapy or changing dose or dosage regimen.

Discontinuation symptoms: Patients should not discontinue Viibryd® abruptly, due to risk of discontinuation symptoms such as dysphoric mood, irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. When discontinuing Viibryd®, reduce the dose gradually whenever possible.

Other relevant warnings and precautions: • Caution in patients with severe hepatic impairment.

• Cognitive and motor disturbances • Electroconvulsive therapy (ECT) • Bone fracture risk • Hyponatremia • Glaucoma • Pregnant or nursing women • Blood pressure • Seizures • Suicide • Dependence • Serotonin syndrome • Activation of mania/hypomania • Abnormal bleeding For more information: Consult the Product Monograph at https://allergan-web-cdn-prod.azureedge.net/allergancanadaspecialty/allergancanadaspecialty/media/actavis-canada-specialty/en/products/pms/viibrydpm-eng_11apr2019.pdf for important information regarding adverse reactions, drug interactions, and dosing information not discussed in this piece. The Product Monograph is also available by calling Allergan Inc. at 1-800-668-6424.

References 1. Viibryd® Product Monograph. Allergan Inc., April 11, 2019. 2. Mathews M, et al. Efficacy and safety of vilazodone 20 an 40 mg in major depressive disorder: a randomized, double-blind, placebo-controlled trial. Int Clin Psychopharmacol 2015;30:67-74. 3. Rickels K, et al. Evidence for Efficacy and Tolerability of Vilazodone in the Treatment of Major Depressive Disorder: A Randomized, Double-Blind, PlaceboControlled Trial. J Clin Psychiatry. 2009;70:326-33. 4. Khan A, et al. A Randomized, Double-Blind, Placebo-Controlled, 8-Week Study of Vilazodone, a Serotonergic Agent for the Treatment of Major Depressive Disorder. J Clin Psychiatry. 2011;72:441-7.

VIIBRYD® and its design are registered trademarks of Allergan Sales, LLC, used under license by Allergan Inc. Allergan® and its design are trademarks of Allergan Inc.

This Q&A is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908.

No part of this Q&A may be reproduced, in whole or in part, without the written permission of the publisher. © 2019

FEATURE

A doctor who lives within their means and invests should be able to be their own life insurance provider within 20 years.

became disabled, that would suck, but financially we’d be OK. So, I recently called our broker. He was eager to reevaluate our insurance needs (it had been a while and surely my income had increased along with how much I could insure). He was surprised when I then cancelled a disability policy.

His only responses to my financial independence and the lack of a logical need for insurance were: 1) All doctors should insure their full income because there could be lost income. That argument is valid if the purpose of money is to have as much as you can when you die. It is not valid if you feel that the purpose of money is to buy time, security, comfort, and to help causes important to you. You can only experience that while alive. Excess money is nice, but not vital.

2) He could get me some docs to talk to who became disabled and were glad that they had insurance. That tactic would leverage my fear (appropriate if I were underinsured) or greed (if I wanted to be the richest man in the graveyard).

An effective sales tactic, but it loses its teeth if you have deliberately thought about your insurance needs using my gambling/need framework.

CRITICAL ILLNESS INSURANCE This is a bet that you will get one of a

44 DECEMBER 2019 THE MEDICAL POST

list of horrible diseases or injuries (all doctors have a list of those). It bridges the financial gap between when permanent disability insurance kicks in or you kick the bucket and life insurance pays out.

This is valuable if you don’t have enough financial reserve to bridge yourself to one of those outcomes. Again, early on this is the case for many of us. However, if we develop an emergency fund or have access to an unused line of credit, then those may be better approaches. They are much more flexible.

LIFE INSURANCE

Adequate life insurance ensures that our loved ones are not saddled with our debts, or suffer from our lost income, if we die. Early on, when our obligations are higher than our financial resources, life insurance is vital. As those obligations decrease and our investment income grows to cover our expenses, we need less. Those without dependents probably don’t need it.

A doctor who lives within their means and invests should be able to be their own life insurance provider within 20 years. That makes 20-year term life insurance a logical choice, followed by ditching it. For those who spend beyond their means and don’t save. Well, ongoing life insurance is another cost you’ll need to add to the spending treadmill.

Whole life insurance is complex and heavily marketed. By its nature, it is insuring you for life. Even after you don’t really need life insurance.

Remember, regardless of your age and how they spin the benefits, the insurance company knows the odds. They win.

There can be some uses for whole life insurance if you are likely to die with a large estate or as a way to hold a fixed-income-like asset in a corporation.

However, there are alternatives that may be simpler, more flexible, and with fewer hidden fees. Usually, the good uses of whole life are not readily apparent until mid-career. They are also like marriage: a long-term commitment and expensive to exit from. Better to date when you are young and figure things out.

We have a small, joint last-to-die whole-life policy held by our corporation that we started after 10 years into practice for the above reasons.

Think of your insurance like “The Gambler”: “You gotta know when to hold’em, Know when to fold’em, Know when to walk away, Know when to run.” is a practising academic intensivist in Ontario. He also speaks and blogs about personal finance and investing for physicians and other highincome professionals.

DR. MARK SOTH

Your patient’s journey starts with you

© 2019 Pfizer Canada ULC Kirkland, Quebec H9J 2M5

1

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

2

Remind your patient to ask for the Pfizer original brand medication at the pharmacy.

3

Encourage your patient to visit the Pfizer Originals Program website at PfizerOriginals.ca for tips on how to ask for their Pfizer original brand medication.

TM and ® are trademarks of Pfizer Inc. or its affiliates and are used under licence by Pfizer Canada ULC. ® Pfizer Inc., used under license.

PfizerOriginals.ca

PP-PFO-CAN-0096-EN

When you purposely prescribe the Pfizer original brand medication, help make sure your patient gets it.

FEATURE

Self-directed investing, simplified

Now in the middle of our career in medicine, my husband and I manage our own investments. Here’s why If I had to describe my approach to

independence. We disengaged the money and investing in one word, it autopilot, moved our money away and would be “simplicity.” As my husband decided to keep looking. and I have moved from exhausted Simplicity in investing was residents with debt to mid-career, harder to achieve and we made THE aging but financially secure many financial mistakes in Y MONE physicians, we value an approach the beginning—an investment DOCS to finances that doesn’t eat up our condo rented to university time. Life is complicated enough, students, a dalliance investing in so keeping our money management gold, and a physician stock picking as easy and low-maintenance as possible investment club. The stock picking club affords more time to spend together, presented glowing narratives about more time to spend with our kids and market-dominating companies like more time to pursue interests outside of Nokia, a company that in 2006 was medicine. poised to monopolize the global cell Simplicity starts with spending. We phone business. Surely, Nokia was going are both from humble backgrounds. My to experience massive growth in its stock husband is the first in his family to go to price. In 2019, the phone in your pocket university and I immigrated to Canada at is not a Nokia and the narrative of global age 11. All of my family’s possessions fit growth shrank along with its stock price. into a couple of suitcases that we lugged Examining Nokia’s financial statements off the transatlantic flight. Saving and would not have told us about a struggling being happy with less was a necessity for computer company named Apple that us growing up. Although we indulge in would release a product in 2007 that our fair share of gadgets and luxuries, we would destroy Nokia in less than five want to teach our children that owning years. We realized that it’s impossible to too much stuff can become a burden. predict which way individual stocks will With any significant purchase I always go and that active management of your ask myself “Will this increase my longportfolio is destined to fail. The evidence term happiness?” supports this position, but many don’t Our early attempts at investing taught believe it until they experience it firstus the difference between smart-simple hand. In the end, we realized that passive and autopilot-simple. Like most residents index investing was easy, evidence-based we started out investing with a company and accessible. We learned that buying that bought us lunch, gave us a free the entire stock market through an index backpack and was owned by a nonand holding it for decades would get us profit organization. We gladly handed to financial independence. over our money and the autopilot was Now, managing our investments engaged. Over time we started to squint takes less than a couple of hours every at the fine print of the mutual funds we year. Each January the RRSPs, TFSAs were sold and we realized that we were and family RESP are maximized. paying high fees that never appeared on Every three months, we take corporate a bill, fees that would cost hundreds of money that has accumulated in our thousands and delay our goal of financial corporate bank account, transfer it to

46 DECEMBER 2019 THE MEDICAL POST

BY DR. JANE HEALEY

our brokerage account and invest it.

The newly transferred money joins the dividends and interest from the existing investments. The corporate investments generate an income and have become a third, reliable “worker” in our household.

Our investment portfolio slowly, steadily, reliably adds money to our nest egg and doesn’t ask for any of our time in return. We purchase a mix of equity and bond exchange traded funds (ETFs) in an 80:20 ratio and rebalance with new money added. Now that the all-in-one asset allocation funds like Vanguard’s VGRO or BMO’s XGRO are available, it’s even easier for new investors. Simplicity in investing has made self-management feasible for busy doctors.

Ironically, these days we spend far more time speaking with colleagues about finances than we do on managing our own portfolio. In 2017, we formed the online Physician Financial Independence community where physicians from all life stages can learn from each other. It is a space free of industry bias that has grown rapidly to over 15,000 members. We emphasize frugality, evidence-based investing and maximizing happiness, but all financial topics are open for discussion. We have heard great feedback from many of our colleagues who tell us that learning about evidence-based investing has allowed them to take control of their financial future. Personal finance does not have to be complicated. It can be simple. is a hospital-based pediatrician at Trillium Health Partners Credit Valley site in Mississauga, Ont. She lives in in Oakville, Ont. with her husband Paul, an emergency physician, and their two children.

DR. JANE HEALEY

You saw 35 patients today.

And had 35 seconds for lunch.

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How long does grief last?

The life-long process of learning to cope with the loss of a dear friend

A

few months ago it was one year since Carol died. She was my dearest friend since childhood.

I hesitate to write about Carol because using words to describe a friendship like ours is like trying to carve a sculpture from water.

We met when we were seven years old and throughout our childhood we wandered our neighbourhood chatting and laughing. During our teens we talked intensely about every dream, every heartbreak and all the new feelings descending on us. As we became adults we discussed university—all our courses, all our insecurities and, eventually, our marriages. She shared her stories of students she taught in her lab and I

48 DECEMBER 2019 THE MEDICAL POST

shared stories of my patients.

When my children were born, she was the first one in the door. She spent countless hours with my children, wandering the woods, reading books and calling every birthday with her lovely rendition of Happy Birthday.

My children were almost in their teens before they realized that their beloved Aunty Carol wasn’t related to them.

Over our decades of friendship we never fought. We thought that was odd since we were both intensely passionate people. What we did do was to find the humour in every and all incidents in our lives—no matter how trivial or serious. The closest we came to fighting was when we had spirited discussions

about who would pay the restaurant tab.

We discussed this intensely and decided it was not as serious as a squabble but also more serious than a quibble, so we named these “squibbles.” We found that so funny and even our restaurant tabs became hilarious.

Once, as the tab arrived, I asked Carol if this was going to be another squibble.

She said it was going to be an outright squabble. We were grinning ridiculously at each other and the waitress asked— as we were often asked—about our relationship. People were perplexed by this viking beauty and woman of colour with a mass of curls and how we were so impossibly close. Carol, completely deadpan, replied, “Twins.” Then, without missing a beat as the waitress looked at us perplexed, Carol would point at me and say, “The lipstick always throws people.”

We chuckled about it all evening.

Over the nine months from her breast cancer diagnosis to her death, I visited, spent as much time as I could at her home. When she had her mastectomy, I was there and stayed for her recovery.

We chatted as we always did about everything. When we found out the breast cancer had spread to her bones, we continued talking about that, too. All through that time, we found so many things funny—including cancer. When she was in hospital I stayed in her room when she was frightened.

Near the end, I had left to go home when her sister called and said she was asking for me. I went immediately and

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DR. MARY FERNANDO

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spent the last conscious night of her life with her. She lay there so quietly when I walked into the room that I pulled up a chair and held her hand. She said, “Mary! I would know that tiny hand anywhere.” We hugged. And then she slept. As I watched her sleep, I marvelled how, with her brain full of cancer, she still knew my hand. Still loved me.

Many people have wondered when I’ll stop grieving Carol’s death.

A friend recently sent me an article that looked at a study where “They collected data from 26,515 people over 14 years, and found a range of negative consequences experienced by those who had a close friend die.” In the four years after a death, those people experienced significant adverse physical and psychological effects on their wellbeing.

This reminded me of a question I asked my supervisor when I started practice. I was trying to understand a patient who appeared to still be in mourning 15 years after the death of his child. I asked about the length of the normal mourning period. I was young, didn’t have children, but that question, quite frankly, was incredibly stupid. My supervisor kindly answered that the normal mourning period for a child was a lifetime.

But what about a friend? Not just any friend, but a friend who forged me, who made me who I am and when there is nothing, nothing at all I have ever done that Carol wasn’t a part of? That kind of friend. My supervisor was a wise and kind man. If he were alive today, I would call and ask. I long for that conversation.

There is something else about Carol and me.

I was never the person I wanted to be. I wanted to be carefree, bold and irrepressibly confident. What I am is hopelessly serious, full of thoughts when I want to just be easygoing. Carol was bold enough to climb apple trees without fear as a child and throw a knapsack on her back and head to Europe on her own after high school. She was far more carefree than I could ever be. She was a brilliant research scientist and a talented teacher. Maybe more so because she treated the meticulous and painstaking work of molecular biology like an

With cancer in her bones, spreading to her brain, unable to breathe—and this, this is what she worried about: not being there for me. Steel in her spine. Pure steel.

adventurous journey with pipettes and gene splicing.

But we were also similar. We were both totally honest, so we talked about our insecurities and our painful embarrassing incidents with ease. We were particularly sensitive to kindness and cruelty, so we talked endlessly about the treatment of animals, children and people of all ages. For me to have someone as wonderful as Carol love me so deeply, so loyally for so long, made me feel better. Somehow less serious. Less hopelessly awkward. Carol was beautiful.

Tall and blond. She was also strong. Until the last few months of her life.

This year has been tough. My father died. My mother is now ill. I so needed to talk with Carol—these were the first hardships that I haven’t been able to share with her. Also, my daughter won a prestigious award and got a cat. My son went to Australia and published some exciting papers. Carol would have been eager to hear all of this and we would have chatted endlessly—and then she would have called the children for more details. I miss hearing about the adventures in her life. Her story was cut off mid-sentence. I want to know what would have happened if her story went on until we were old and ornery.

In one of our last text message exchanges she wrote to me: “Thanks for coming. I have an idea how this must have been. I have never felt so protected and when I most needed it.”

“Always. You know that,” I responded.

“Are you ok with my not coming now? I can come if you need.”

“I know,” she wrote. “It’s kind of amazing though. I love you and am so sad that I won’t likely be able to be here for you.”

If there was ever a testament to the calibre of Carol, this is it. With cancer in her bones, spreading to her brain, unable to breathe—and this, this is what she worried about: not being there for me.

Steel in her spine. Pure steel.

This is the story of Carol and me, but each death leaves people with stories cut off in mid-sentence. While some friends wonder when I’ll get over my grief—my longing for Carol—my children and husband don’t wonder. They share these memories. Sometimes we cry, sometimes we laugh, but we always miss her. We expect nothing less.

Since I can’t ask my supervisor, I’m going to call this one: I will miss Carol for my whole life. When I die, missing her will be one of the last thoughts I have.

DR. MARY FERNANDO

physician.

is an Ottawa

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THE MEDICAL POST DECEMBER 2019 49

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CARTOON

Dogtor Daisy A Quebec hospitalist has started telling the stories of Dr. Daisy Bones, board-certified physician and dog BY DR. JOANNA LI When I was 12 years old, I proudly

announced to my parents that I wanted to become a professional comic book artist. My mother, the ever-practical and hard-working immigrant parent, responded “artists only become famous after they’re dead. Do it as a hobby instead.” She certainly didn’t win any Parent-of-the-Year awards for brutally crushing the dreams of a 12-year-old, but looking back, I am grateful that she steered me down a different career path.

It did allow me to discover medicine as my true passion.

Art has always remained a secondary

50 DECEMBER 2019 THE MEDICAL POST

passion, however. My love for comics never did die. I’ve dabbled with a whole slew of artistic media such as ink, oil, acrylic and watercolour painting since, but I’ve yet to find anything as fun, satisfying and challenging as trying to express ideas and humour through comics.

And so here I am, drawing comics about what I know best: medicine, dogs, and the joys (and pains) of being a mother. is a bilingual emergency physician and hospitalist working in Quebec.

DR. JOANNA LI

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THE MEDICAL POST DECEMBER 2019 51

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BY DR. MARIO ELIA

COLUMN

Clinical quality improvement made easy-ish

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F

Your EMR can be an untapped gem and getting there isn’t as painful as it sounds

or many clinicians, the phrases “quality improvement” and “EMR” elicit emotions ranging from annoyance, to frustration, to anger.

Quality improvement may remind you of that boring residency project you were forced to do. Maybe you always hear that keener physician in your office blabbering about the need for quality improvement, as if you don’t have enough to do seeing patients day-today. For some of you, your EMR is a source of burnout. You are adamant that your practice ran smoother with paper charts, and wish you could go back in time and decide never to switch. Most physicians understand the benefits of an EMR in theory, but for too many the

implementation has been just a series of headaches.

Let me start by giving you hope.

When done right, your EMR can be the key to both improving clinical care and making your clinical life more fulfilling. As a physician peer leader with OntarioMD, I frequently go into physician offices to work with them to improve their EMR utilization to implement tools and processes that will help them day-to-day. I have hundreds of point-of-care reminders, searches, and tools to share, and the response I get from physicians is rarely “That’s completely useless” or “I have zero interest.” The response is almost universally, “Wow, I didn’t know my

EMR can do that; show me how,” because physicians want to improve their clinical processes. We like improving.

We crave it. But most feel they don’t have the time or energy to do an ounce more work than they are doing right now.

So, many shy away from any initiatives that mention “quality improvement” or “EMR optimization.”

All of this starts with good data quality. It sounds boring, but it’s the secret sauce to all of this. You need to be able to identify which patients have certain diseases/conditions and which don’t; which patients have had certain diagnostic tests done and which haven’t; etc. You need to have established data standards across your office/group/region.

KNOWLEDGE TRANSLATION AT WORK

Let me give you an example of why data quality is so important. In September 2019, the DAPA-HF trial was published in the New England Journal of Medicine.

The study found that in patients with congestive heart failure and an ejection fraction of 40% or lower, dapagliflozin (an SGLT-2 inhibitor) reduced the risk of worsening heart failure or death from cardiovascular causes (regardless of whether the patient is diabetic or not).

How do we translate this trial quickly to clinical practice? Do we wait until patients come in and hope we remember to discuss it? Or can we harness the power of our EMR to implement this trial immediately?

First you need to be confident that you can find all of your CHF patients.

How have you identified these patients in their charts? Free text in the problem list? Or by coding using ICD-9, ICD-10 or SNOMED codes? (Hint: coding is far

THE MEDICAL POST DECEMBER 2019 53

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The response is almost universally, “Wow, I didn’t know my EMR can do that, show me how.”

more reliable and consistent than free text.) Do you have a search in your EMR to quickly and accurately find all of these patients? What about those with CHF with reduced ejection fraction versus preserved ejection fraction?

Here’s what we did in our practice.

We have previously cleaned our data to ensure that our cohort of patients coded as having CHF is accurate. This took some work, looking for any patients who had certain free-text keywords in their problem list, or those on certain meds (spironolactone or furosemide), but now we are confident that our cohort is accurate. Moving forward, we have a form called a coding assistant which quickly codes any new clinical diagnosis (in this case, ICD-9 of 428 for CHF).

When echocardiograms come in, our standard is to use the code “@LVEF:” followed by the ejection fraction value, which acts as a vital sign that can then be searched to break down patients by ejection fraction.

This seems like a lot of work initially, of course, but consider how powerful it is moving forward. The DAPA-HF trial came out, and because we had already coded our CHF patients by ejection fraction, we were able to instantly create a search to identify which CHF patients had an ejection fraction of 40% or lower and were not already on an SGLT-2 inhibitor, and brought these patients in for review within a few weeks. This is knowledge translation on steroids.

PLUG-AND-PLAY REMINDERS

In our physician group, the London Lambeth Family Health Organization,

54 DECEMBER 2019 THE MEDICAL POST

we have designed a program called Clinical Effectiveness in Primary Care, which is a series of plug-and-play searches and reminders for our EMR that can be used by family physicians (not proprietary, we share this freely with local colleagues).

The program is broken down into seven domains: chronic disease, routine screening, cancer screening, cancer followup, immunizations, medications and billing. Each domain has a handful of clinical issues that are addressed by the searches, reminders and overall processes. Point-of-care reminders are automatically created to be viewed in the patient’s chart, but searches can also be run outside of office visits to identify all patients who are due for certain interventions. In the billing domain, we have processes that optimize billing for diabetes codes, CHF codes, mental health codes, pregnancy codes and smoking cessation codes. Examples in the immunization domain include routine childhood vaccinations (e.g. which 14- to 16-year-olds are due for their Adacel), and vaccinations for high-risk populations (e.g. which LGBT male patients 26 years old and younger have not had their HPV vaccine, which is covered in Ontario for this cohort).

Medication domain includes reminders such as identifying patients on lithium or amiodarone who are due for a TSH. The cancer followup domain includes reminders like “finding patients with Barrett’s esophagus who have not had an upper endoscopy in the past three years.”

We have hundreds of examples of clinical issues we follow across all of the

domains, which we address according to a practice-wide QI schedule to ensure that certain issues don’t fall through the cracks (e.g. we review melanoma followup cohorts in January and July, tubular adenoma cohorts in February/ May/August/November, AAA screening cohorts in March and September, etc.).

It should be no surprise that implementing EMR quality improvement initiatives won’t happen without physicians being adequately supported. Funding from provincial payers will be key to resourcing in-office staff to do quality improvement work.

This sort of work simply cannot be done off the side of physicians’ already cluttered desks. Practice facilitation organizations must be scaled up to spread existing EMR resources and tools across practices. This type of work should not rely on individual physician champions, but should be ingrained into our system. Provincial organizations such as Health Quality Ontario are well-positioned to provide the clinical standards, with others like OntarioMD optimally suited to provide the staff and clinicians who have the EMR expertise needed for this work.

Bottom line: EMR quality improvement can be exciting and can actually help make physicians’ lives easier and improve patient outcomes.

We just need the right support and the right system in place to spread best practices. is a family physician in London, Ont. He’s also a physician peer leader with OntarioMD. DR. MARIO ELIA

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BY DR. GRETCHEN ROEDDE

COLUMN

A language deeper than words

Photo courtesy of the Temiskaming Speaker

T

What we learned writing the first Cree-English medical dictionary

he room smelled of dirty boots.

I looked around at a dozen Ski Doo suits unzipped to mid-chest.

Traces of cigarette smoke wafted from the damp clothes. There were 14 of us: one white woman doctor and 13 Cree people. Many were from Moose Factory, a community near the mouth of the Moose River where it empties into James Bay in Ontario’s far north. It would take the work of each person, and all of us together, over the course of one week, to create 100 new Cree words.

Those precious words were to become the basis of a Cree-English medical dictionary, to help explain symptoms and illnesses to patients who’d flown in to the hospitals in Moose Factory or Timmins, Ont. and spoke no English. It would help Cree patients feel more at home if their health workers could speak even a few words of their language.

We were in the Ojibwe-Cree cultural centre in Timmins. I had arranged for a neighbour on the lake to babysit, and came up on the train from Temagami, a community about 250 kilometres to the south. In the large classroom one cleanshaven trapper brought butchered meat parts and was carefully laying them on a plastic sheet on the table. Greg Spence, a Cree language teacher from Moose Factory, and his brother Alex, a justice of the peace, acted as translators.

“See, this is the moose liver. Is there a part like this in the human body? What does it do?” the trapper asked. Greg had translated the Cree for me, and talked back and forth to make sure he had faithfully understood and translated his comments correctly. I looked over at the liver. What does it do? What is important to know? I tried to think of what might be relevant for patients. Nodding, I tried to explain in English, looking carefully

at Alex, who would translate my words.

“You see it is very bloody? The liver filters the blood. If you take medicines, like Tylenol, it is processed in the liver, or kiskon(a).

“Alcohol goes through the liver too,” I continued. “It gets big if it has too much work to do. If you drink too much, the liver can get sick. There is a disease called hepatitis or miskonâspinêw, when the liver gets sick and some people turn yellow.” I stopped speaking, and Alex tried to explain these concepts.

Cree sounds so different than English.

Alex’s voice was deep, and the words were sort of held down in his throat, more guttural, more musical. With his eyes he was engaging with the Cree speakers in the room. A couple of times he asked Martha, a community health representative (CHR), how she would translate my words. They spoke Cree back and forth. I casually stretched out my wrist from the sleeve of my navy sweater and looked at my watch. The morning of our first day was almost over. At this rate, it seemed impossible we would meet the target in our grant proposal, titled “Developing a Medical Vocabulary in Cree.”

Two women elders wore floral-andwhite kerchiefs, mementos from times gone by, when some Russians in Moose Factory married into the community.

One of them, Dorothy, looked older, with a tired face. She and her friend, Amanda, spoke to me, Greg translating: “We both delivered babies for many years. Sometimes in the bush, out on the trap line. Sometimes in small cabins. We would usually have a wood fire to boil water to sterilize the knife we used to cut the baby’s cord, and the string to tie it.

The fire keeps the new mother and the baby warm. Mostly the babies were fine.

Sometimes a woman would go into her

THE MEDICAL POST DECEMBER 2019 57

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birthing time early, and the baby would be small.”

Greg nodded to me. Did I have questions? “So, what did you do if the baby was small? We call that ‘premature’.”

Another linguistic dance flowed between Greg and the women. Then Alex stepped in, with an answer in English. “We call that wîpac âhkosiw. We would help the baby stay warm, right on the mother’s breast. We would wrap the baby in furs. We could make a small bed that did not lose the heat from a wetted inner green tree bark lined with fur for the baby to sleep in. Sometimes, the smallest babies would die, but many did not.” We now had Cree phrases for “premature baby” and one for newborn: oshki-awâshish(ak).

Martha the CHR also wanted to share. She spoke to me first in English, then in Cree to the others. “I, too, have used wet green bark. It can be flexibly moulded, and dries in the shape of cast around a broken limb. I learned this from the elders. They taught me how to make a splint to keep a broken limb straight, and protect it before I transfer the patient to Moose Factory. I am happy the elders are there to teach me. I did not know about using bark to make a cast, or that kind of first aid in my CHR training in Sudbury.”

We had similar ideas. We had both learned how to cast a broken limb, only using different materials. I took my time, speaking slowly, which was not my custom. At first, I felt I was the professional, knowing English was not their first language. Then I noticed how patiently the Anishinaabe were explaining things to me, the woman who spoke no Cree. My inexperience dawned on me. Though I had worked with limited resources on Lake Temagami, I had not delivered babies by the light of a wood fire or managed a broken arm in the bush.

Martha looked over at me. “A lot of people get sick with coughing.

Sometimes they lose weight and die.

Sometimes they get better. Sometimes they need antibiotics, and sometimes they don’t. Why can a ‘cough’ be so many different sicknesses?” Greg and Dorothy took time to ask that question, of the others, in Cree. A few of them nodded.

58 DECEMBER 2019 THE MEDICAL POST

One spoke quietly, then Greg turned to me. “The elders know about TB. Many had this when they were younger.

Coughing, losing weight, and being sent to the sanatorium. The trapper said that last year his brother also had a cough, lost weight, and died. But it was lung cancer.” Now our dictionary had “cancer,” êkâ kâ-kinitokotâniwak âhkosiwin, and “TB,” minîwâtâmêw.

I went on to try to explain as well the difference between viruses (âkosiwin manicôsh) that did not need antibiotics and bacteria (âhkosiwi-manicôsh) that did, and that pneumonia (pâhkihpanê) was an infection in the lungs. Greg turned on a projector, and showed a slide of the lungs and the respiratory system, labelled in Cree. The elders nodded and talked excitedly among themselves. They pointed at the image projected onto the wall, asking Dorothy, Greg and Alex questions.

I reached into my brown leather doctor’s bag and pulled out my stethoscope. I passed it around, offering my back for the elders to listen to my breathing. Slow, deep breaths in and out.

The elders chuckled as they tried it, and took turns listening to each other. They spoke to each other in Cree, those slushy, guttural sounds punctuated by slow laughs. They called out, “We’re taking a smoke break to further test out our lungs!” Martha and I shared a discreet smile. This was fun. We were doing it. We were finding the right shared words.

Martha was flying back up the coast

to Fort Albany, a First Nations reserve north of Moose Factory on James Bay. I went with her. We would continue our work up there, and share what we’d done in Timmins with other elders who might be able to help us refine the words and phrases we had created.

This was my first time in Fort Albany.

We stayed in a guest house run by the priest. Martha had promised something special, a supper under the open sky, an hour’s Ski Doo drive away. We loaded up. I wore a borrowed snowsuit, helmet and boots. My much-loved deerskin gauntlets, embroidered with beads, came up to my elbows and still smelled of the smoke from tanning. An elder had given

them to me on a previous trip, and they made me proud—an invited guest in the home and world of another culture.

I had been asked to help the Anishinaabe on their terms. I could help write the grant proposal and share medical knowledge. But the decisions about what the priorities were and why it was important to develop the Cree language to handle new concepts had been made by the Ojibwe-Cree cultural centre after discussion with the elders.

They were building their own history, and their own resources.

The air was biting cold. We roared along on the Ski Doo, my arms were awkwardly wrapped around Martha’s waist. The snow crunched beneath us.

The sky above dazzled, fiercely blue bright. The air crackled. Snarling, the machine choked to a standstill as Martha cut the gas, and we shuddered to a stop.

“Here. Here is where we’ll make the fire.” Martha gathered twigs, branches, and bark. She scooped handfuls of lowbush cranberries into a small tin pot over the fire, cooking them till they softened to a warm sauce. Goose wrapped around two wooden sticks hissed as the fat drizzled onto the fire. Another small tin pot held tea soup—flour, tea, broth. We sat on the Ski Doo, relishing roast goose dipped and swirled in the cranberry sauce. The goose had been shot and dressed the night before.

As dusk set in, the last streaks of sunlight shot through the pillows of ombre clouds, violet-grey at the horizon, and fading upward into light mauve lilac.

Darkness dropped blue-black. Shivers of light flickered up, merry swirling shimmers of the northern lights against the blackness. Martha smiled as she gazed up. Her eyes met mine. We did not need to speak. is an assistant professor at the Northern Ontario School of Medicine and has worked in northern rural family medicine for 40 years. She has also worked in 40 countries in mother, newborn, child and reproductive health.

She practises in Latchford, Ont. DR. GRETCHEN ROEDDE

The above was excerpted from her 2018 book Deep Water Dream.

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When you purposely prescribe the original brand EFFEXOR XR, help make sure your patient gets it.

1

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

2

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

3

Encourage your patient to visit the Pfizer Originals Program website at PfizerOriginals.ca for tips on how to ask for their Pfizer original brand medication.

© 2019 Pfizer Canada ULC Kirkland, Quebec H9J 2M5

® Pfizer Inc., used under license.

Effexor ® Wyeth LLC, owner/Pfizer Canada ULC, Licensee TM Trademark of Pfizer Inc., used under license by Pfizer Canada ULC

PfizerOriginals.ca

PP-PFO-CAN-0108-EN

Consult the Product Monograph at http://www.pfizer.ca/pm/en/EFFEXOR.pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1-800-463-6001.

BACK PAGES

SOLVE MY PROBLEM

How do you build rapport with less privileged patients?

NON-VERBAL CUES AND CLOTHING

Ah. This is the $50,000 question in the ER. 1. Rapport starts before you even open your mouth. One woman told me that she felt comfortable as soon as she saw my mukluks. She knew that I was an ally to indigenous people. So nonverbal cues and clothing are more important than you think. Make eye contact and sit down.

2. Introduce yourself and listen. I try to shake hands with everyone, MRSA notwithstanding, ask appropriate questions and note responses.

3. Take the time you can afford. Sometimes, you have to stop and listen.

Sometimes, you can mobilize a social worker to fill in some of the gaps.

4. Try again. Book them for another appointment, or in the ER, let them know to come back. Every time, you can offer more resources.

We’re taught to do everything perfectly 100% of the time, but that’s impossible. You learn the art of medicine over a lifetime.

—DR. MELISSA YUAN-INNES

ATTITUDE IS PARAMOUNT

“Rapport” is the accumulated quality of engagement experiences between individuals. So my task is to seize the opportunity at each engagement to genuinely share wellness perspectives in

a respectful and meaningful way.

1. Attitude is paramount: Know that it’s a privilege to be trusted. See things from the patient’s point of view. How would I want my parents, children or myself to be treated?

2. Trust-building: Take time to get to know the patient.

This will save time later.

Make them comfortable.

Laughing together helps build trust.

3. Listen deeply: Identify what the patient wants, needs, and is ready to accept. What are the patient’s fears/hopes?

4. Delegate: We trained our staff to give injections, and they know the common chronic disease and cancer prevention guidelines.

5. Group engagements: By empowering patients to selfmanage root causes, patients are becoming healthier and requiring less attention.

6. Optimize EMR usage to improve workflow.

7. Be a role model: Don’t miss meals, exercise appropriately, act out of kindness and be grateful for the vividness of each moment.

—DR. CARLOS YU

THERE’S A PROBLEM WITH THIS QUESTION

The way this question is phrased makes those who are considered not privileged by the physician the “other.”

It treats patients as having no agency and removes physician responsibility to alter power dynamics. It

DR. MELISSA YUAN-INNES An ER doctor in Alexandria, Ont.

DR. CARLOS YU A family physician in Ajax, Ont.

DR. MONIKA DUTT A public health and preventive medicine specialist and FP in Sydney, N.S.

also gives us an out for not building a relationship with a patient because of time.

If we truly want to engage in patient-centred care, we can flip the question and consider it from the perspective of the person/ group that has been marginalized.

Some ways to frame the question to focus on how healthcare providers can create safe spaces include: “How can we engage patients from across the spectrum of privilege so they feel comfortable and are able to advocate for themselves?” Or perhaps: “How do we work to minimize power imbalances between ourselves and those who are systematically marginalized?”

If the question is phrased differently, we would find we need to address our own biases and meet each patient with curiosity and openness.

We would see it as our jobs to decrease power imbalances, centre patients’ voices in decision-making, avoid making assumptions, and advocate for policy changes to improve their health.

There is ample evidence of healthcare providers harming patients through unconscious and overt discrimination; we need to counter that, not reinforce it.

—DR. MONIKA DUTT

Next Problem

What do you do when your patient starts to cry?

Send solutions to cleslie@ensembleIQ.com

by Jan. 15.

THE MEDICAL POST DECEMBER 2019 61

UNEXPLAIN DYSPN EA ED

ORDER AN ECHOCARDIOGRAM SOONER & SEE WHAT THE RIGHT SIDE OF THE HEART HAS TO SAY

Suspect something unusual about your patient’s dyspnea

Detect the warning signs for PAH by ordering an echocardiogram

Refer your patients to a PH Centre for confirmation

IF IT’S PAH, YOU CAN HELP BY REFERRING SOONER

1

CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; PAH = pulmonary arterial hypertension; PH = pulmonary hypertension.

Reference: 1. Galiè N et al. Eur Heart J. 2016;37(1):67-119. DOI: 10.1093/eurheartj/ehv317. © 2019 Actelion Pharmaceuticals Canada Inc. All rights reserved.

PAH1812E

1

BACK PAGES

PRACTICE MANAGEMENT

A beginner’s guide to practice insurance What you need to know BY KYLIE TAGGART

Getty Images

I

nsurance is like the preventive medicine of financial planning. The MMR vaccine is to the measles virus what insurance is to fires, floods, theft or injury. And just like there are (thankfully) immunizations for many illnesses, there are myriad insurance products out there to protect your practice from potential future financial ills.

A physician’s clinic is not like other small businesses. Physicians need policies tailored to their unique situation. What type of medicine you practise, with whom you practise it, where your clinic is located, how many staff you have—all of these elements influence the kind of coverage you need, and how much you’ll pay in premiums.

Insurance sold in Canada is divided into two types: property and casualty

insurance, and life and disability insurance. To protect your practice, you’ll need both. In the property and casualty basket you’ll need office insurance, cyber-insurance and perhaps some extra malpractice insurance. In the life and disability insurance basket you’ll need to stock up on practice overhead or professional expense insurance, as well as your own personal life insurance.

OFFICE INSURANCE

Business or office insurance is essentially home insurance for the office. The policies cover the physical contents of the office in case of loss or damages from, for example, flood, fire or theft.

Also included in an office insurance policy is business interruption insurance.

“That is to pay for ongoing expenses while their practice is shut down due to an insured loss,” said Rick Dresher, a member of the board of directors of the Insurance Brokers Association of Ontario. For example, it would cover the costs if the practice has to move to a temporary location, as well as any loss of income due to the change of location, such as if there are fewer services provided or if patients have trouble getting there.

Most policies also provide commercial general liability, or business liability. This would protect you against legal liability for injury to people visiting your office, or damage to their property.

This liability coverage would protect you if a person slips in your medical office, for example, or if a spill ruins a patient’s expensive leather jacket.

The cost of premiums for office insurance depends on a number of factors, including the size of the clinic and the equipment needed. “The risk is low for general liability for a doctor’s office so any doctor’s office policy would be $1,000 to $2,500 a year,” Dresher said.

CYBER-INSURANCE

Cyber-insurance protects a practice in the event of a cyberattack or data breach.

It is generally sold as a stand-alone policy.

Dresher said that a few companies are adding cyber-insurance to office policies, but the amount of coverage is low. You can buy more coverage if it is done as a stand-alone policy.

“Certainly, cyber coverage is going to become more important to medical practitioners,” Vanessa Barrasa, media relations manager for the Insurance Board of Canada, wrote in an email to the Medical Post.

The Insurance Board of Canada states that many cyber-insurance policies cover the costs of remediating the data, notifying patients and investigating the causes of cyberattack or data breach.

It will also pay expenses if the practice needs to shutter after a cyberattack.

Dresher said that costs vary and are going down as more companies offer cyber-insurance. One million dollars worth of coverage may cost around $1,000 a year, he said.

THE MEDICAL POST DECEMBER 2019 63

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For office insurance and cyberinsurance, physicians should consider: • How much is the property (or data) worth?

• How long would it take to resume normal practice after a damage or loss?

• How much would it cost to relocate the practice if needed?

• How are benefits paid out?

• How long is the wait after the damage or loss until benefits are paid?

• How long after the damage can you make a claim (noting that some data breaches are detected months later)?

MALPRACTICE INSURANCE

If you employ allied health professionals in your clinic, you may need malpractice or professional liability insurance above what is offered by the Canadian Medical Protective Association (CMPA) program.

“There’s a vicarious liability whereas if the doctor is the owner of the overall clinic, they could be named in a suit for malpractice of one of the people that worked for them,” Dresher said. Because the physician did not administer the clinical services, they would not be covered under the CMPA program in this situation.

You may also require additional malpractice insurance if you practise in any way outside of Canada. For example, if you are being consulted on cases in other countries, or if you take a fellowship in another country that puts you in contact with patients.

PROFESSIONAL EXPENSE INSURANCE

Since a practice can’t run if the physician is sick or injured, there must be some way of paying the costs if the doctor can’t work. This includes covering rent, staff salaries, utility bills and equipment leases. Professional expense insurance, also called practice overhead insurance, is a type of disability insurance that allows you to pay the bills without dipping into personal disability benefits.

This type of insurance is particularly important in a group practice, so much so that it is often a requirement for joining.

“It is important to have professional expense insurance, in my opinion,”

64 DECEMBER 2019 THE MEDICAL POST

said Julie Kwan, an insurance adviser and business development manager in the Doctors of BC insurance program.

“Other physicians don’t want to be liable for when another physician is off work and they have to cover a locum coming in and will have lost revenue for a while.”

Kwan urges physicians to understand their financial responsibilities in group practices should they be unable to work. Even better, get it in writing. “Our recommendation is that clinics should have written agreements in place that say what would happen in a situation, and is it required that a person should have professional expense insurance.”

Kwan recommended that physicians buy a small amount of coverage early in their career, even if they are unsure if they’ll ever work in clinic setting.

Look for policies that offer a guaranteed insurability benefit, also called a future insurability option, that allows you to buy more coverage slowly over time without needing to provide proof of good health.

“I’ve had physicians in sticky situations where they are not medically eligible for that kind of insurance and they’ve been presented with an opportunity to join a clinic but the caveat is that they need to have this coverage in place,” Kwan said. “That’s a really difficult spot for people.

“It’s about planning ahead. It is hard to know what your practice is going to look like over the years, but just leaving that door open makes sense.”

Even if you don’t have an office, professional expense insurance would reimburse you for other expenses should you become temporarily disabled. This would include membership dues, college fees or CME costs. Kwan said with some policies you could even get money for your cellphone or car lease expenses should you be unable to work.

The cost of this type of policy depends on a number of factors, including the amount of coverage, the length of wait time for reimbursement, your age and other determinants of health. Premiums for professional expense insurance are tax-deductible because they are considered a business expense. However, if you are injured, the

benefits you receive from the policy are considered income, and are not taxdeductible.

For professional expense insurance, doctors should ask: • How long is the benefit period?

• How long is the wait period before you get reimbursed or paid out?

• Are you able to fund your office until the payouts arrive?

• Are you able to increase coverage over time without proof of good health?

• How are payments made?

• What happens if you don’t use or need all the coverage?

• What happens if expenses vary each month that you are getting reimbursed?

A physician would still require regular disability insurance to secure his or her own income during a disability. You may also need to protect your staff if they get sick, by providing them with health and/ or disability insurance as a benefit.

WHERE TO GET INSURANCE

You may be able to buy your insurance through your provincial or territorial medical association. They offer policies with cheaper premiums because of group discounts. Some of the larger medical associations also have salaried advisers to help you buy insurance from different companies.

Not all insurance agents or brokers are licensed to sell both types of insurance. Some physicians may feel more comfortable working with an agent who has both licences.

“A lot of doctors will deal with two different professionals but every time you add another person you run the risk of something falling through the cracks,” Dresher said.

While you need to be prepared with questions to ask when buying insurance, find someone who will ask you questions as well. “Ideally, (physicians) should have a broker who is asking them the questions about their practice/business and developing coverage solutions,” wrote Barassa.

Wherever you buy insurance, it is best to buy it from someone who understands the nature of your practice.

Helps relieve her menopausal symptoms.

1

Caroline Colbert BACKGROUND: Caroline is a working mother with three children. She is experiencing frequent hot fl ashes and has not had a period for 12 months.

TREATMENT GOALS: To help reduce the frequency of hot fl ashes she experiences on a daily basis.

TREATMENT: Caroline’s doctor prescribed Premarin oral tablets at the lowest effective dose once daily with a concomitant progestin. A three-month follow-up was suggested to evaluate treatment.

EFFECTIVE RELIEF OF MENOPAUSAL AND POSTMENOPAUSAL SYMPTOMS, DEMONSTRATED REDUCTION OF

HOT FLASHES.1* Premarin (0.625 mg) with MPA (2.5 mg) showed an approximately 90% decrease from baseline in the mean daily number of hot flashes vs. an approximately 50% for placebo at 12 weeks (p<0.05)1,2

Indications and clinical use: Premarin (conjugated estrogens sustained release tablets) is indicated for the following: • Relief of menopausal and postmenopausal symptoms occurring in naturally or surgically induced estrogen deficiency states including vulvar and vaginal atrophy • Prevention of osteoporosis in naturally occurring or surgically induced estrogen-deficiency states – When prescribing solely for the prevention of postmenopausal osteoporosis, Premarin should be considered in light of other available therapies and should only be considered for women at significant risk of osteoporosis.

Non-estrogen medications should be carefully considered – For older women who are not experiencing any more acute symptoms of menopause, use in combination with a progestin should only be considered for women who failed on, or were intolerant of, non-estrogen medication – Adequate diet, calcium and vitamin D intake, cessation of smoking, as well as regular physical weight-bearing exercise are required in addition to the administration of Premarin • Hypoestrogenism due to hypogonadism, castration, or primary ovarian failure • Atrophic vaginitis • Vulvar atrophy (with or without pruritus) – When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered • Not indicated for use in pediatric patients (< 16 years of age) In patients with an intact uterus, Premarin should be prescribed with an appropriate dosage of a progestin for women with intact uteri, in order to prevent endometrial hyperplasia/carcinoma.

INCLUDING HOT FLASHES, VULVAR AND VAGINAL ATROPHY AND THE PREVENTION OF POSTMENOPAUSAL OSTEOPOROSIS 1 WERE DEMONSTRATED.

0.3 mg

• Active or past history of arterial thromboembolic disease • Partial or complete loss of vision due to ophthalmic vascular disease • Known thrombophilic disorders • Migraine with or without aura Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years).

Risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis: estrogen plus progestin therapy (mean age 63.3 years).

Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication

Other relevant warnings and precautions: • Estrogen administration to nursing mothers has been shown to decrease the quantity and quality of breast milk.

Detectable amounts of estrogens have been identified in the milk of mothers receiving the drug. Where an assessment of the risk to benefit ratio suggests the use of this product in nursing women is unfavourable, formula feeding should be substituted for breast feeding • Possible risk of ovarian cancer • Monitor blood pressure with hormone replacement therapy use • Caution in women with pre-existing endocrine and metabolic disorders Contraindications: • May exacerbate endometriosis • May increase pre-existing uterine leiomyomata • Liver dysfunction or disease • Known or suspected estrogen-dependent malignant neoplasia • Abnormal vaginal bleeding • Risk of gallbladder diseases • Endometrial hyperplasia • May exacerbate systemic lupus erythematosus • Known, suspected, or past history of breast cancer • May induce or exacerbate anaphylactic reaction and • Undiagnosed abnormal genital bleeding angioedema symptoms • Known or suspected pregnancy • Active or past history of confirmed venous thromboembolism • Risk of developing probable dementia (women >65 years) • May exacerbate epilepsy or active thrombophlebitis © 2019 Pfizer Canada ULC, Kirkland, Quebec H9J 2M5 ® Pfizer Inc.,used under license PREMARIN ® Pfizer Canada ULC.

PP-PEM-CAN-0012-EN

0.625 mg

1.25 mg

• Caution in patients with otosclerosis • May cause fluid retention • Risk of estrogen-induced hypocalcemia: Caution in individuals with hypoparathyroidism • Caution is advised in patients with a history of liver and/ or biliary disorders • Particular caution is indicated in women with hepatic hemangiomas, as HRT may cause an exacerbation of this condition • Cerebrovascular insufficiency. Patients who develop visual disturbances, classical migraine, transient aphasia, paralysis or loss of consciousness should discontinue medication • Patients who have a history of depression should be observed For more information: Please consult the product monograph at http://www.pfizer. ca/pm/en/PremarinTablets.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

The product monograph is also available by calling 1-800-463-6001. *This randomized, double-blind, placebo-controlled trial evaluated the safety and effi cacy of lower doses of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) to relieve vasomotor symptoms (VMS) in postmenopausal women.

A total of 2,673 healthy postmenopausal women 40 to 65 years of age with an intact uterus (mean age 53.3 years), including a VMS effi cacy-evaluable population (n=241 at baseline), participated.

Effi cacy measures were frequency and severity of daily hot fl ashes. The baseline mean daily number of hot fl ashes was approximately 10 for both groups. Eight treatment arms were evaluated for 13 cycles over a period of 1 year: CEE 0.625 mg/day; CEE 0.625 mg/MPA 2.5 mg/day; CEE 0.45 mg/day; CEE 0.45 mg/ MPA 2.5 mg/day; CEE 0.45 mg/MPA 1.5 mg/day; CEE 0.3 mg/day; CEE 0.3 mg/MPA 1.5 mg/day; or placebo.

Reference: 1. Premarin Product Monograph, Wyeth Canada, December 1, 2014. 2. Utian W et al. Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate. Fertility and Sterility 2001;75(6):1065-1079.

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Being and somethingness What might we learn in the borderlands between life and death? BY TRISTAN BRONCA There’s this great movie, based on a

great book by a great doctor, where the doctor (in the movie/book) goes to speak to a specialist about a group of his post-encephalitic patients who’ve been rendered catatonic by brain damage.

“What’s it like to be them? What are they thinking?” the doctor asks.

“They’re not. The virus didn’t spare the higher faculties,” the specialist responds.

“We know that for a fact?”

“Yes.” “Because?”

“Because the alternative is unthinkable.”

In 2015 a totally different book by a

Canadian neuroscientist named Dr. Adrian Owen (PhD) was released. Into

66 DECEMBER 2019 THE MEDICAL POST

the Gray Zone was a popular explanation of Owen’s work exploring the possibility of consciousness in vegetative patients.

Through a series of clever experiments, Owen was able to communicate with some patients who were stuck in what he called the “gray zone,” the borderlands between a coma and brain death. The fact that he was able to do so was clear and groundbreaking evidence that these patients were conscious, and suggested that a great many more vegetative patients could be as well.

As a brief interlude, try to imagine what it would be like to learn that a vegetative patient under your care is conscious. To think they may have overheard conversations about important decisions which are completely out of their control. To think

For a scientific book, this one has a lot

of heart and it doesn’t shy away from difficult questions. Are these patients happy? Do they want to die? Once Owen finds that he can communicate with

Getty Images

BOOKS

they have been frozen in their bodies as you or the people around you poked, prodded, monitored and otherwise did all the work of keeping them alive. For me, such an idea would be nauseating, not because I did something wrong or somehow failed as a caregiver, but because (while I might not openly acknowledge it) some part of me would have believed I was caring mostly for a body, with the hope that by some miracle, the person inside would return.

To realize that that person never left would be, well, uncomfortable.

The most affecting part of Owen’s book is that it relates this sense of discomfort very well. In the opening chapter titled “The Ghost That Haunts Me” we’re introduced to Maureen, a woman with whom Owen studied and later came to love. About a year after living together, their relationship fell apart and even after breaking up and moving across the Atlantic from the U.K., it continued to take an emotional toll on him. Then came the accident.

Maureen had crashed into a tree on her bike and plunged into a coma. As Owen points out, Maureen could have ended up in one of his research studies but, of course, this registered completely differently. It prompted a number of seemingly obvious questions that simply never occurred to him in his work with patients who had experienced similar ordeals.

“What did being in a vegetative state mean? Was she dead or alive? Did she know where or who she was? She was gone, but she wasn’t.” The experience changed Owen, at least subconsciously, and in his telling, it led him to pursue the line of scientific questioning that defines the book—“something Maureen would have endorsed,” he writes.

“She had been so passionate that science should not be ‘science for science’s sake’: it should actually help people. Perhaps this was a chance for me to do just that.”

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them, he feels an obligation to ask.

Owen’s accounts of the experiments, their rationale and the stakes, are gripping and easy to follow. But beyond offering a reading recommendation, I am, admittedly, not qualified to evaluate the how exactly Owen’s discoveries have helped researchers or patients.

Nevertheless, the implications feel remarkable in a way that extends beyond this rarefied group of research subjects.

There are many practices at the core of medicine that exist, by necessity, to manage and mitigate uncertainty. That’s because terms such as “consciousness” and “death”—well-trod domain for selfimportant chin-strokers, writers, and stoned college freshmen—are not mere abstractions the way they are for most of us. Healthcare is one of the few areas of life—for some of you, daily life—where people are shoved directly into the messiness of it.

Owen’s work highlights the importance of probing the edges of the unthinkable, and demonstrates the profound gap that lies beyond what we can probe. Death, for most of us, will be a process by which we slowly wade across that gap. The value of Owen’s work for healthcare providers is that it encourages a sense of humility when you’re acting as our guides.

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Medical Post.

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PMHx

The FLQ crisis and the FMSQ

When it comes to the withdrawal of

services by physicians, the Quebec specialists’ strike of 1970 was arguably one of the most dramatic and successful Canada has ever witnessed. But as the work action took place during the height of the Front de libération du Québec (FLQ) crisis, it now forms a largely forgotten but fascinating piece of Canadian medico-political history.

In June 1970 the Quebec government introduced the Quebec Health Insurance Act, which outlined how the government intended to pay for all medical services covered by medicare in the province.

While deemed as workable by family doctors, specialists opposed the act which removed the right of physicians to opt out of the plan or to extra-bill.

According to a report in the CMAJ on Aug. 27 of that year, the FMSQ held a major symposium on medical care insurance in Montreal which was attended by more than 4,000 specialists, family physicians, government observers, labour representatives and the general public. The symposium was followed by a special assembly of the federation where 98.5% of members voted that the FMSQ should use all necessary means and resort finally to a confrontation if necessary to defend the professional freedom of the physician.

Negotiations between the government and specialists collapsed and on Oct. 8, 1970, the FMSQ ordered a withdrawal of services. The only exception was emergency services in 38 hospitals.

According to the CMAJ, while about 1,000 specialists staffed these hospital emergency departments, the remainder of the FMSQ’s 4,200 members withdrew services, with many leaving Quebec for Ottawa, Toronto, Lake Placid, N.Y. and

70 DECEMBER 2019 THE MEDICAL POST

other centres along the Quebec-Ontario and Quebec-United States border. The new Canadian Medical Association headquarters at 1867 Alta Vista in Ottawa had been officially opened on Oct. 2 and it was here that the FMSQ established its headquarters.

While these events were taking place, the October crisis had erupted in Quebec and was occupying headlines worldwide. On Oct. 5, 1970, members of the FLQ kidnapped James Richard Cross, the British trade commissioner, and then on Oct. 10, the FLQ also kidnapped the minister of labour and vice-premier of Quebec, Pierre Laporte.

Dr. Pierre Bertrand, a urologist, wrote in the official history of the FMSQ that an FLQ cell wrote to the federation threatening to kill one of the FMSQ leaders unless the strike was halted within 18 hours. Dr. Bertrand said FMSQ strike organizers unanimously chose to ignore the demand.

On Oct. 13, the FMSQ offered to call all members back to work, providing the government agreed to negotiate the matters of dispute when the FLQ kidnapping crisis was over. The gov­ ernment refused and demanded that the specialists return immediately and unconditionally.

For its part, the CMA had not commented on the dispute but had expanded a physician placement service to meet needs in Quebec. However, when the Quebec government issued a report that emergency services in the province were deteriorating, the CMA issued a release on Oct. 15 stating these services were operating satisfactorily.

Later that day, the War Measures Act was introduced and the Quebec government implemented its health insurance plan without a signed agreement with Quebec medical groups.

In addition, government passed Bill 41 which stated physicians had to return to their normal practice immediately and prohibited them from speaking against the order. The CMA protested against this legislation with thenCMA president Dr. Duncan Kippen, stating Quebec specialists had been “conscripted, muzzled and threatened with jail terms.”

On Oct. 17, 1970, it was announced that Laporte had been murdered.

The FMSQ called a special meeting of its members and on Oct. 18 an estimated 1,200 specialists crammed the rooms and hallways of CMA headquarters where both Dr. Kippen and FMSQ president Dr. Raymond Robilliard urged them to return to work immediately. According to the Montreal Gazette the decision to recommend ending the strike was also prompted by reports of “secret information about possible medical emergencies in the province” due to a planned student demonstration in Montreal.

On Oct. 18, the strike was over. Bill 41 was later repealed and the FMSQ signed an agreement with the provincial government in Dec. 1970. —PAT RICH

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Back in 1970: A terrorist threat against medical association leaders and when striking specialists decamped just outside provincial borders

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The National Advisory Committee on Immunization (NACI) recommends that SHINGRIX should be offered to adults 50 years of age and older (strong recommendation)1 According to NACI, a strong recommendation applies to most individuals and should be followed unless a clear and compelling rationale for an alternative approach is present.1 Refer to the NACI statement on the Public Health Agency website for further information.

Recommend SHINGRIX to your patients as young as 50 years of age.

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

Contraindications: • Patients with a known hypersensitivity to the active substance or to any component of the vaccine.

Most serious warnings and precautions: • Administration: Do not administer the vaccine intravascularly, intradermally or subcutaneously.

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

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

Learn more about SHINGRIX at ThinkSHINGRIX.ca References: 1. Public Health Agency of Canada. An Advisory Committee Statement (ACS), National Advisory Committee on Immunization (NACI) – Updated Recommendations on the Use of Herpes Zoster Vaccines. Ottawa, Ontario: Public Health Agency of Canada; June 2018. https://www.canada.ca/en/services/health/ publications/healthy-living/updated-recommendations-use-herpes-zoster-vaccines.html. 2. SHINGRIX Product Monograph. GlaxoSmithKline Inc., October 13, 2017.

Trademarks are owned by or licensed to the GSK group of companies. ©2018 GSK group of companies or its licensor.

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