Medical Post-December 2022

POWER TO REDUCE EXACERBATIONS IN PATIENTS WITH COPD1

BREZTRI™ AEROSPHERE® is indicated for the long-term maintenance treatment to reduce exacerbations of chronic obstructive pulmonary disease (COPD) and treat airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema who are not adequately treated by a combination of an ICS/LABA or a combination of a LAMA/LABA.1

Clinical use:

BREZTRI™ AEROSPHERE® is not indicated for:

• Treatment of acute episodes of bronchospasm or asthma.

• Use in pediatric patients <18 years of age.

Relevant warnings & precautions:

• Risk of serious asthma-related events, including hospitalization, intubations, and death

• Should not be used in patients with deteriorating COPD

• Excessive use with other LAMA and LABA products

• Anticholinergic activity: use with caution in patients with symptomatic prostatic hyperplasia, urinary retention or narrowangle glaucoma

• Cardiovascular effects, including arrythmias and changes in pulse and blood pressure, QTc prolongation

• Driving and operating machinery

• Candidiasis

• Risk of systemic effects, including Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, hypokalemia and hyperglycemia, cataract, intraocular pressure, and glaucoma

• Hypercorticism, adrenal suppression

• Adrenal insufficiency in patients transferred from systemic steroid

• Patients with symptomatic prostatic hyperplasia, glaucoma, convulsive disorders, thyrotoxicosis, sensitivity to sympathomimetic amines, severe hepatic impairment/hepatic disease, or urinary retention

• In rare cases, eosinophilic conditions

• Susceptibility or decreased resistance to infections

• Monitoring of hypokalemia, hyperglycemia, bone and ocular effects,

and corticosteroid effects in patients with hepatic impairment

• Paradoxical bronchospasm

• Increased risk of pneumonia • Pregnant and nursing women • Geriatrics (≥65 years of age) For more information: Consult the Product Monograph at breztri-en.azpm.ca for important information regarding adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling AstraZeneca Canada at 1-800-668-6000. ICS = Inhaled corticosteroid; LABA = Long-acting beta2-agonist; LAMA = Long-acting muscarinic antagonist.

Monograph.

Solve my problem

Cover artist

We asked Gracia Lam, the Toronto illustrator who created all the covers of the magazine in 2022, about the theme of this issue: Charity.

Q: Do you donate to charity?

Each year, I donate to three LGBTQ local charities and hold space for two probono projects for this community. These organizations are important and I’m grateful to take part in the opportunity to make a difference.

Q: What would be the ideal type of charity work you’d like to do? I would love to volunteer at the Inside Out 2SLGBTQ+ Film Festival next year. The films and stories from the creators change lives.

Q: What is next for you?

Last year, I spent six months in Asia being with family and I look to do the same moving forward. Creating illustrations as a career is a privilege I’m thankful for because there is freedom in where I live and work as long as there is internet.

Q: How do you feel changed by the pandemic?

Like many, the pandemic has made me reflect on my priorities. I’m finding more power in saying no and practising on choosing to fuel my mental, emotional and physical health.

Next Issue:

THE CHANGE ISSUE: The next issue—hitting doctors’ mailboxes in late February— is about renewal. We’re aiming to look at innovations, what doctors would most like to change about themselves and how to change patient behaviour. Here’s the “themes” we’ll be looking at in our 2023 issues of the Medical Post magazine:

February: The Change Issue

April: The Politics Issue

June: The Prescribing Issue September: The Patient Relationship Issue October: The Jobs Issue December: The Ends and Beginnings Issue

NEW PEDIATRIC FORMATS

Pediatric indication

I d a o :

S a o a

BLE EN® (bilastine) is indicated for the symptomatic relief of nasal and non-nasal symptoms of seasonal allergic rhinitis (SAR) in patients 4 years of age and older with a body weight of at least 16 kg.

C o Spo a ou U a a BLEXTEN® (bilastine) is indicated for the relief of the symptoms associated with chronic spontaneous urticaria (CSU) (e.g. pruritus and hives), in patients 4 years of age and older with a body weight of at least 16 kg.

Co a d a o :

• History of QT prolongation and/ or torsade de pointes, including congenital long QT syndromes va wa a d p au o :

• QTc interval prolongation, which may increase the risk of torsade de pointes

Two new formulations:

• Orodispersible Tablet

• Oral Solution

• Use with caution in patients with a history of cardiac arrhythmias; hypokalemia, hypomagnesaemia; significant bradycardia; family history of sudden cardiac death; concomitant use of other QT/QTc-prolonging drugs

• P-glycoprotein inhibitors may increase plasma levels of BLEXTEN® in patients with moderate or severe renal impairment; co-administration should be avoided

• BLEXTEN® should be avoided during pregnancy unless advised otherwise by a physician

• A study was performed to assess the effects of BLEXTEN® and bilastine 40 mg on real time driving performance compared to placebo. Bilastine did not affect driving performance differently than placebo following day one or after one week of treatment. However, patients should be informed that very rarely some people experience drowsiness, which may affect their ability to drive or use machines.

Fo mo fo ma o : Please consult the product monograph at https://www. miravohealthcare.com/wp-content/ uploads/2021/08/Blexten-PMENG-Aug2021.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-866-391-4503.

Σ As of August 31, 2021, the estimate from internal data of patient exposure is based on units sold of the defined daily dose of 10 mg bilastine and the mean treatment duration of 3 weeks.

ow ava ab fo d 4 y a of a a d o d w a body w of a a 16 k

EDITORIAL

The Charity Issue

“You give but little when you give of your possessions. It is when you give of yourself that you truly give.” Kahlil Gibran

Doctors are generous people—with their time and their money. In fact, Canadians in healthcare professions have a higher donation rate to charity than those working outside healthcare, as our story on page 12 notes.

This shouldn’t surprise: At its core, people go into medicine because they want to help people.

But medicine is very demanding work and a series of crises have come for Canada’s physicians: the main body of the pandemic, then patient’s re-engaging with the healthcare system at the same time as a labour shortage, and then this fall, the ER and pediatric care crisis. All this in a healthcare system that has been struggling.

So I can understand doctors who

say, like one did in our annual survey, “I used to work at a charity clinic in the U.S. Eventually I realized just doing my job properly despite being paid only for a fraction of my work was charity enough.”

VOLUNTEER

I freely admit feeling similar at times. A few years ago, I was part of a ninemember Rainbow Railroad settlement team that brought an LGBTQI+ refugee to Canada (this person was a gay activist in Bangladesh and was being hassled by the police there). The volunteer work involved organizing a fund-raising event and other things. After the refugee came to Canada (training as a nurse now), some in the group wondered about bringing another refugee to Canada but I felt like, this volunteer work is a lot like my day job! And I declined.

But some of the writings in this issue of the magazine have reinspired me. On

DR. CHRISTINE NICHOLAS plastic surgery

DR. BRIDGET REIDY family medicine

some level thinking about how (or if) we donate our own time or money is partly an opportunity to think about our own priorities. The great article “24 ways to give” on page 15 offers up ways to contribute without giving money, time or expertise.

The article on page 20 is a guide for Canadian doctors interested in doing overseas medical missions. This work is so important and one of the ways we extend the excellence that is Canadian medicine to other countries.

I like a quote found by my mother, 82, who is living in Victoria (the city I grew up in). It’s by an unknown author: “Volunteering is the ultimate exercise in democracy. You vote in elections once a year, but when you volunteer, you vote every day about the kind of community you want to live in.”

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Charity is partly about considering our own priorities

COLIN LESLIE EDITOR-IN-CHIEF

national licences and business options for physicians outlined

dismayed to learn that most doctors aren’t doing other jobs on the side. I always wondered how any doctor could make it with just insufficient healthcare payments. The profession is going down in financial flames because of miserly healthcare policies that underpay physicians.

Fixing the national licence crisis (Oct.)

Dr. Stephen Cashman of Winnipeg wrote: “Hope we can see this soon—national licensure is basically good for everyone. It’s good for doctors and nurses certainly by giving us more options. But it’s also good for the payors—they don’t need to fork out money to pay for people’s licences in underserved areas (that is, having to effectively pay out-of-province doctors extra to come). It’s good for the patients—there are lower barriers to coming to work in underserved areas. It’s good for tracking complaints/ professionalism violations— better to have it all accessible in one database.”

Docs with second jobs (Oct.)

Dr. John Fernandes of Calgary noted: “I was

“I realized this very early in my career and bought several businesses after being inspired by other like-minded physicians. I’ve been going now for almost 25 years with a great deal of satisfaction and joy in my medical career because the financial pressures from the inadequate pay have been ameliorated by my other businesses. Healthcare is being badly bungled by our politicians and administrators, and something good will evolve out of the inevitable ashes once the increasingly angry voting public has its way with them . . . but in the meantime, opportunities outside of healthcare abound for motivated doctors.” Dr. Fernandes then went on to list business ownership options doctors should consider: • rental property management business • nutraceuticals, cleaning supplies and shampoos

and other products that can benefit from being “physician-owned and designed”

• ownership of a gas station or “charging station”

• a geriatrics navigation business

• buy a small pub

• partner with a realtor who knows their area well and flip homes with a small reno crew

• buy a grease trap truck and hire a crew—there are not nearly enough of them and you can sell the grease to a biodiesel manufacturing firm.

Dr. Tony Vannelli of London, Ont., replied: “This is a creative list. Have we forgotten that medicine requires time, attention,

continual renewal and education, and is more than a full-time job in itself?”

Knee’d: What to tell patients about knee injections for osteoarthritis (Oct.)

Dr. Ramunas Saplys of Mississauga, Ont. wrote: “Practising for 30 years as an orthopedic surgeon, this was my ‘lived’ experience: 1. Weight reduction had by far the most benefit.

2

. Physio/exercise to maximize the strength of the quads helped.

3. Cortisone worked best for those wanting to walk on a holiday or get shortterm relief while waiting for surgery.

4. Viscosupplementation has minimal benefit for the cost, and is dealer’s choice.

5. Platelet-rich plasma injections and, even worse stem cell injections, are frank money grabs for desperate well-off patients.

“When a surgeon gets $800 all-in for a two-hour total-knee replacement but a sports med doc gets $5,000 for a knee injection, the system is in trouble. Of course patients come to docs and want the doc to ‘do something’ (like an injection) so that they don’t have to do anything themselves. As we all know, that doesn’t usually end well,” Dr. Saplys wrote.

The value of

“I was dismayed to learn that most doctors aren’t doing other jobs on the side.”

VITALS Concerns and actions

BY COLIN LESLIE

Top five most important social issues

Healthcare

Top five issues that affect physicians personally

How do doctors get involved?

Source Medscape

LONGITUDINAL CARE

B.C.’s new pay plan a lure for FPs

B.C.’s just-announced Longitudinal Family Physician Payment model is intended to lure FPs from high-paying, no-overhead sub-specialties to longitudinal community care. One million people in B.C. do not have a family doctor. Meanwhile, there are around 7,000 FPs in B.C., only half of them currently working in longitudinal care (not necessarily full-time).

The new model was developed collaboratively between representatives of Doctors of BC, BC Family Doctors and the B.C. Ministry of Health. Its anticipated cost has not been shared, but Doctors of BC’s senior manager of communications and media relations Sharon Shore clarified for the Medical Post that its funding is not included in the $708-million, three-year physicians’ master agreement (PMA)—which is totally separate, though it was announced simultaneously.

The new model “is not a contract . . . it is an agreement,” Shore said.

For those who opt in, the new plan will pay FPs $130 per hour, including hours spent in indirect patient care—filling out forms, etc. (which would be unpaid time under fee for service). Add to that $25 per regular patient encounter (phone or in person) and extra fees for capitation, rural retention, complex care.

Office overheads are not covered. Still, FP’s with a full-time panel (1,250 patients) can expect a 35% to 40% increase if they sign on to this plan.

Some doctors are angry they didn’t get to vote on the plan. They worry it lacks the legal protections of a PMA and is vulnerable to government bad faith.

Dr. Goldis Mitra is optimistic. A young FP and researcher, she told the Medical Post the plan is just a beginning. Additional systemic upgrades for FPs need to follow. But she likes the plan’s flexibility, likes that FPs are finally getting paid for their time, and she has been waiting for an alternative to FFS.

“I know a number of FPs interested in starting up a practice as a direct result of the introduction of this model, and I’m planning to as well,” she said. “Based on the reaction so far, I do think it will increase the number of FPs practising longitudinal medicine.” —ANN GRAHAM WALKER

—Dr. Kristjan Thompson, an ER physician in Winnipeg, on the overload on ERs this fall.

AUSCULTATIONS

—Dr. Ted Jablonski, a blogger based in Calgary, on CFPC’s Family Medicine Forum attendance, down from historic numbers of 3,000 to 5,000 participants.

—Dr. Michael Warner, a Toronto intensivist, on how little is being heard from politicians during the crisis in Ontario’s pediatric healthcare system.

Source: CBC • CanadianHealthcareNetwork.ca • Twitter

because each province has different needs.”

HEALTH FUNDING

A unified voice for national licences

With the straining health system creaking nightly on evening newscasts, last month presented a golden chance for Ottawa and the provinces to reach an agreement on more health funding. But that isn’t what happened when Canadian health ministers met in Vancouver.

The feds came to the meeting saying they’d increase health funding to the provinces (by an unspecified amount) if the provinces would sign on to: • a pan-Canadian health-human-resources action plan, and • a pan-Canadian health data strategy

The provinces said “no,” falling back on their traditional argument, which goes like this: “You guys were supposed to pay for 50% of health system costs (the feds currently pay 22%). We have the responsibility, as outlined in the constitution, with delivering healthcare. You haven’t been giving us that money, so don’t question how we spend it,

The way ahead is surely for the provinces to come up with a counter offer—some kind of “Accord of the Federation.” They’d outline joint measures they think would be additive. Even if not every province agreed, it would have weight if a group of provinces said, “We’ve thought about it and we’ll all do these following things—but you, Ottawa, have to raise your pay per cent to 33% of health costs.”

Physicians have a lot to gain if they can convince the provinces that pan-national licensure is something the provinces should include as part of this “accord.”

How to do this? Former Nova Scotia Premier Stephen McNeil, during the first event in the CMA’s Health Summit Series: Bold Choices in Health Care, said: “Strengthen your relationship with your sister organizations—and I would do it provincially—and take them into premiers’ offices, into ministers of health’s offices, and lay out a consistent plan that’s well thought out.”

NcNeil was talking about the need to change the delivery model in Canada—he argued “if we don’t shift the delivery model, I don’t see us making progress”—but pan-national licences have to be for nurses and other health providers as well as doctors. A unified voice from health professionals has the potential to produce seismic change. —COLIN LESLIE

“We cannot keep doing this dance. Something has to change.”

“(FMF) in-person registration was approximately 2,200 this year, down substantially.”

“It’s shocking that our elected leaders simply aren’t showing up for our kids.”

Go further. Fuel your financial well-being.

In this three-part series, we explore how Canadian physicians can take their finances further at every stage of their medical career.

We consulted with financial professionals from MD Financial Management and Scotiabank who together bring well over 50 years of physician-focused financial advice and healthcare professional banking expertise. Using fictional examples, we will highlight their unique ability to anticipate and address the needs of physicians through advice-led solutions.

In this third segment of the series, meet “Dr. Jacob Stern.” He is an early-career physician who is looking to purchase his first home and pay down his student debt.

The scenario

Dr. Stern has just completed his residency and entered the workforce as a newly incorporated physician. He is 31 years old and married to Andrea, who is a teacher.

Recently, the couple has been contemplating whether to buy their first home. Dr. Stern also wants to pay off the $150,000 balance of his student loans in the same time frame but does not know where to start.

His questions:

• Can I purchase a home with 5% down?

• Is it possible to pay my debt in three years?

We turned to Scotiabank Healthcare and Professional Advisor Rod McFadden to provide Dr. Stern specialized advice and banking solutions. Rod has extensive experience working with new to practice physicians and brought in MD Advisor* and Early Career Specialist Kristine Greenfield to build Dr. Stern and his family a sound financial strategy. Together, they were able to guide him on how to best proceed.

From the lens of the specialists

If Dr. Stern paid off his student loans and bought a home at the same time, it would not only limit his financial flexibility but hinder his long-term savings plan.

Taking a holistic planning approach

“We focus on goal planning with early-career physicians and look at their short- and long-term financial priorities. For recent graduates, paying debt is often their immediate concern, but we explain there are many financial strategies available that focus on more than debt repayment,” says Kristine.

The shift from residency into the workforce is a big milestone that sparks many questions. Rod and Kristine

are specialized in helping new physicians like Dr. Stern understand what they can do today to prepare for a financially secure tomorrow.

Dr. Stern thought it would be possible to pay his debt and purchase a home in the same time frame. Instead, Rod and Kristine proposed a flexible, customized solution that would allow him to achieve both over the long term, while saving for the future.

First, Rod opened Dr. Stern a corporate bank account to separate his personal and professional transactions for accounting purposes. Previously, he was using his personal account to process business expenses, which was complicating his finances.

Rod and Kristine then helped Dr. Stern identify his financial priorities as it was not possible to repay his debt and buy a home in the time frame he imagined. Homeownership was a greater priority, so he and Andrea pursued this first.

Dr. Stern didn’t have substantial savings, so Kristine recommended that he and Andrea open registered retirement savings plans (RRSPs). With these, they could both take advantage of the Home Buyer’s Plan, and each withdraw up to $35,000 from their RRSP tax-free to buy a home. This would help them save for a down payment, while helping Dr. Stern budget to pay his debt and lower his tax bill as an incorporated physician.

“I also connected Dr. Stern to a Scotiabank mortgage advisor who helped him get approved for a mortgage based on his projected income,”◊ explained Rod. “This program helps residents and new physicians like Dr. Stern qualify for a mortgage at the start of their careers.”

Despite his student loans and not having enough for a down payment, Scotiabank and MD Financial Management identified a solution that would allow Dr. Stern to purchase a home, while positioning him to achieve his goals and prepare for the next phase of his career.

Physician-focused solutions

Scotiabank and MD Financial Management deeply understand the financial concerns physicians have upon entering the workforce. Scotiabank opened the door to professional banking solutions and tailored offerings from its Healthcare+ Physician Banking Program, while working closely with an MD Advisor to ensure the physician’s financial plan supported their goals. Together, they are well-positioned to provide customized financial advice and solutions to help physicians at any stage of their career.

Take your finances further

MD Financial Management and Scotiabank have decades of combined experience enhancing the financial well-being of physicians.

Together, their team of dedicated financial advisors and specialists deliver wealth management advice, strategic borrowing solutions and customized banking support, helping physicians take their finances further.

Visit our websites or contact one of our advisors directly:

Healthcare

rod.mcfadden@scotiabank.com Phone: 519 642-3017

Financial

MD Management Limited kristine.greenfield@md.ca Phone: 226 235-7355

†Mutual Funds Representative with Scotia Securities Inc. distribute mutual funds at Scotiabank

◊ For residents, fellows and new-to-practice physicians, the mortgage amount qualified for is based on estimated projected income. The projected income is an average estimated amount based on available industry data and is subject to change. Your actual income may vary. Terms and conditions apply.

* MD Advisor refers to an MD Management Limited Financial Consultant or Investment Advisor (in Quebec), or an MD Private Investment Counsel Portfolio Manager.

MD Management Limited was the first of the MD Group of Companies to be founded, in 1969. MD Financial Management Inc. wholly owns MD Management Limited.

MD Financial Management provides financial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.ca and visit scotiawealthmanagement.com for more information on Scotia Wealth Insurance Services Inc. All banking and credit products and services available through the Scotiabank Healthcare+ Physician Banking Program are offered by The Bank of Nova Scotia (Scotiabank). ® Registered trademarks of The Bank of Nova Scotia, used under licence. Credit and lending products are subject to credit approval by Scotiabank. All offers, rates, fees, features, reward programs and benefits and related terms and conditions are subject to change.

Rod McFadden

& Professional Advisor and Mutual Fund Representative,† Scotiabank

Kristine Greenfield

Consultant ECS,

Charity: What doctors care about

BY MARJO JOHNE

Go to any charity event and chances are you’ll encounter a few doctors as you network your way through the room.

“You’ll always see doctors at charity events and fundraisers,” observed Mike Sheffar, a financial planner and partner at SPM Financial in London, Ont., whose client roster includes several dozen doctors. “They do a lot of personal

giving of money and time. I think it’s part of their DNA.”

The most recent Statistics Canada social survey on giving, volunteering and participating suggests doctors may be among the most generous when it comes to charitable giving. According to this 2018 survey, Canadians in healthcare professions have a higher donation

rate, at 76%, than those working outside healthcare. They also give more, donating an average of $713 a year, compared to $561 for everyone else.

Canadian doctors are also habitual givers. In an online poll by the Medical Post at the start of 2022, close to 80% of doctors said they make regular financial contributions to charitable or nonprofit organizations and just over 40% said they volunteered their time regularly.

An October 2022 Medscape survey of 540 Canadian physicians across nearly 30 specialties confirms this profession’s ethos of giving back, with close to 55% of doctors reporting they either donated to or helped raise funds for a charity or organization that aids social issues. Almost 30% said they donated their time to help people affected by social issues.

“I have some clients who are really, really engaged and involved with charitable causes, even though they’re very busy,” said Sheffar. “A number of them sit on the boards of charities.”

While many of his physician clients make “some sort” of charitable contribution each year, Sheffar said these gifts tend to be in the hundreds of dollars. Only a handful of clients have made significant gifts.

“I’ve seen a couple do planned giving, like buying life insurance with a charity as beneficiary or naming a charity in their will,” he said. “But even the uber wealthy ones I work with aren’t doing any advanced planning right now for philanthropic giving. Maybe they’re not ready to start thinking about legacy. My guess is those planned giving discussions will happen over the next 10 years.”

ISSUES AND CAUSES

So what causes matter most to Canadian doctors? Medscape’s survey found one out of two doctors were concerned about healthcare access while one in five were worried about climate change. Close to one in 10 doctors were troubled about domestic violence.

While there aren’t any statistics that track, on an aggregate level, what charitable organizations doctors actually open their wallets or calendars for, anecdotal evidence suggests they favour

health-related causes.

Sheffar observed that some doctors prefer to give to causes within their areas of specialization, or that address a particular health issue they encounter often in their work. One doctor he knows, a nephrologist, donates an “immense amount of money” to kidney research and kidney-related charities.

Another doctor, who works as an emergency physician, directs his charitable giving to organizations focused on mental health.

“I’m guessing he deals with this a lot in his work,” said Sheffar.

MONEY AND TIME

Dr. Sarah Gower, a family physician in Elora, Ont., said the bulk of her charitable financial donations goes to Médecins Sans Frontières (MSF). The rest goes to local food banks and kids’ meal programs.

When it comes to volunteering, these days she’s spending a lot of time working to build a six-bed, 370-square-metre hospice in her community.

“I’m leading that project along with another doctor and a steering group,” she said. “It’s a passion project that we’ve always talked about and now we’re working to make it happen. We now have the land—donated by the county— we have a building plan and we’re working on incorporating.”

To get government approval and funding, Dr. Gower and her team need to come up with a portion of the project’s budget.

“Our goal is to raise $6 million,” she said. “We’ve already started getting donations.”

Other doctors have lent their time to help build healthcare facilities, added Dr. Gower. She pointed to two Ontario hospices—Mariposa House Hospice in Severn and Chapman House in Owen Sound—as examples of projects that were led by volunteer physicians.

For some doctors, volunteering their time requires getting on a plane to distant communities. Dr. Steven Moss, a Toronto pediatrician and inventor of Nosebrush—a medical device shown to effectively collect and remove viruses from the nose—recently travelled with his wife and daughter to Tanzania, Côte d’Ivoire and Ghana to provide vision screening to underserved children.

“This trip will produce sustainable testing and a research paper,” he told the Medical Post in an email that included a link to a GoFundMe page created to support the project. As of midNovember, he had raised $5,408 against his goal of $10,000.

Dr. Duncan Etches, a retired family doctor in Vancouver, has taught doctors in places as far as Nepal, Argentina, Rwanda, Ethiopia, Kenya, Pakistan and China.

“Was I ever in danger? Maybe,” he said. “When I was in Pakistan, they had armed guards meet me at the airport and there was one at the compound where I was staying.”

DOES AGE MATTER?

According to Statistics Canada’s survey on charitable giving, Canadians tend to donate more as they get older and as they attain higher levels of formal education. These findings may be true as

well among the country’s doctors.

Dr. Etches said being a young doctor just starting out in his career certainly made it harder to dig deep into his pocket for the causes he cared about. But as he advanced in his profession and accumulated wealth, he also upped his charitable giving.

“For a long time I had a young family and I had student loans—it was hard for me to give as much as I wanted to,” he said. “Now that I’m financially secure I can give more, about 20% of my income.”

Dr. Etches has, over the years, also increased the number of charities he gives to. Today, he supports about 30 charities in total. He takes a strategic approach, starting with local organizations then expanding to regional, national and global.

“Close to home, I give to a number of charities related to Indigenous communities, like Kinspire, which is focused on educational activities for First Nations, and Raven, which does legal advocacy on behalf of First Nations people,” he said.

Like Dr. Gower, he donates to MSF but also spreads his financial gifts to international charities such as Hope in Healing and Farm Radio International, a non-profit that empowers African farmers to help themselves.

Dr. Etches said he also directs a significant portion of his giving—in both money and time—to political parties. “Because they are the agents of change,” he said. “By giving money and being involved, I’m supporting people who can actually make change happen.”

MDs as volunteers

Canadian doctors volunteer their time to a wide range of charities and non-profits.

At the beginning of the year, the Medical Post surveyed Canadian doctors and got almost 200 responses. We offered folks an open text box to describe any work they have done with charitable or nonprofit organizations that was personally meaningful to them.

“Where to start?” one doctor wrote. “I have been doing this for 40 years for various groups in three different cities. I enjoy it. It gives me energy and is a break from medicine.”

Here’s a few of the areas doctors mentioned:

Volunteering for community groups in general Offered assistance in sports, for immigrant families, animal

shelters, schools, food banks, holocaust education, literacy and housing. On boards too.

Church volunteer Bible study and Sunday school.

Volunteering for medical community groups Down syndrome, lung association, COVID education advocacy, MSF, hospice and overseas medical assistance.

Medical governance

Such as for women’s global health, task force on teenage pregnancy and advocacy for provincial medical associations.

Several doctors noted something like this physcian: “I have little free time to volunteer now and feel my time is best spent doing what I was trained for. Instead I donate (money) to charities.”

The pressure on physicians is constant. So is our support.

The Canadian Medical Association, MD Financial Management and Scotiabank are investing in physician well-being to support the medical profession. Through our landmark collaboration, Scotiabank is investing 115 million dollars over 10 years to support physicians and the communities they serve across Canada. To date, we have invested in 18 physician-focused associations across Canada that are driving system-wide change and prioritizing physician health and wellness.

Well Doc Alberta is working at the grassroots and leadership levels to increase the system’s capacity to address physician needs and advance a collaborative, pan-provincial approach to their wellness.

Doctors Manitoba is connecting physicians and promoting key wellness supports through its Community of Practice pilot hubs, while combating the stigma of seeking help.

The College of Family Physicians of Canada is innovating peer interactions in small groups as a proven, positive way to foster wellness. Learn more at cma.ca/physiciansfirst

New Brunswick Medical Society is providing unique one-on-one crisis counselling and coaching so that physicians don’t need to struggle alone.

MD Financial Management provides financial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies and Scotia Wealth Insurance Services Inc. For a detailed list of the MD Group of Companies visit md.ca and visit scotiawealthmanagement.com for more information on Scotia Wealth Insurance Services Inc. The trademarks of the Canadian Medical Association are registered and used under licence. The Bank of Nova Scotia (Scotiabank®) provides banking and credit products and services. Visit scotiabank.com. ®Registered trademarks of The Bank of Nova Scotia, used under licence.

We’re putting physicians first and supporting their wellness from coast to coast.

We’re pleased to share some of the programs we have supported:

24 WAYS TO GIVE

As a physician, most calls to contribute to charities are asking you for money, time or expertise. Sometimes, you can’t give any more of those three things. Here’s a list of other ways to donate to charity or do good in the world.

BY KYLIE TAGGART

Air miles or travel points

With in-person medical conferences starting up again, your travel points may begin to accumulate. Donating points is easy with most travel point programs; the hardest part may be deciding on which charity will get your points. Aeroplan, for example, partners with 128 charities that accept Aeroplan points, from Médecins Sans Frontières to the Regina Food Bank. One quarter of the Aeroplan points donated to date have gone to health-related causes.

Artistic talent

So many physicians have artistic skills or hobbies, be it sewing, writing, painting, woodworking or others. Why not share your gifts? If you’re a quilter, there are many places to donate your work, with groups that give quilts to cancer patients, survivors of trauma, new parents or children who are ill.

If you’re an artist, local centres or groups might want artwork for their walls or to sell in craft sales. Whatever

your skill, promising to donate your art may inspire you to do something you love, for a good cause.

Athletic skill

If you’re going for a run or a bike ride, why not raise some funds while you’re at it? From events that happen on a certain day—think the Terry Fox Run—to joining a charity’s team at any event—like Team Diabetes— many organizations make it easy for you to fulfill athletic goals while raising funds.

Some events offer unique opportunities. For example, teams of 20 people pulled a FedEx Boeing 757 airplane across a tarmac in Calgary, Vancouver and Toronto earlier this year to raise funds for Orbis Canada. Or you can climb Toronto’s CN Tower in April 2023 to raise money for the World Wildlife Federation and climb it again in October 2023 to raise funds for the United Way.

Baby gear

There may be an organization in your area that accepts gently used baby gear to redistribute to families. One example is Baby Go Round in Vancouver. It works with dozens of referring agencies in the Lower Mainland to help families get the gear they need. Community health clinics often run baby cupboards that provide diapers and formula; some take donations of diapers.

Bicycles

For more than 20 years, Cyclo Nord-Sud has been sending used bicycles to partners in 21 countries in Africa, Latin America and certain neighbourhoods in Montreal. They also provide bikes to aid workers completing internships or overseas placements, who then give the bikes to local residents before returning home. You can donate bikes at drop-off locations listed on their website cyclon ordsud.org. Other organizations across Canada refurbish used bikes and donate them to community members in need.

In Toronto, contact Bikes Without Borders; in New Brunswick, there’s the New Brunswick Bike Exchange; Winnipeg has the Winnipeg Repair Education and Cycling Hub (WRENCH); B.C. has Pedal Society and Bikes for All. Bicycles for Humanity also has chapters across Canada.

Blood and blood products

As a mother—and chief of emergency medicine at Sunnybrook Health Sciences Centre in Toronto—Dr. Aikta Verma said on Twitter in November that donating blood was the most relaxing part of her day. They also gave her potato chips. Canadian Blood Services has a

handy guide to who is eligible to give blood and who is not.

You can also donate stem cells: According to Canadian Blood Services, 1,000 Canadians are currently waiting for a stem-cell transplant. To join the stem-cell registry, go to blood.ca

Don’t forget umbilical cord blood. Dr. Rebecca Munk, a pediatric anesthesiol ogist at B.C. Children’s Hospital, and her husband, decided to donate the umbilical cord blood after the birth of their second daughter in 2021. “I work with children undergoing cancer treatments and I see the difference a stem-cell transplant can make in their lives and that of their families,” Dr. Munk said in a Canadian Blood Services press release. “So the decision to donate Eliza’s cord blood was easy.” While for-profit private cord blood banks exist, Health Canada, the Society of Obstetricians and Gynecologists of Canada and the Canadian Paediatric Society all recommend using Canadian Blood Services. For more information, visit blood.ca.

Books

Donating books can be tricky because a mouldy tome treasured by you (or the person whose house you’re cleaning out) might actually belong in a recycling bin. Gently used books in good condition with a recent publication date are welcomed by some organizations, including public library foundations or local programs that provide books to prisoners or new parents.

Cars and other vehicles

A number of organizations take donations of cars or other vehicles to raise funds for charities such as the Heart and Stroke Foundation or the Kidney Foundation. Cars are resold or recycled. Make sure you read the fine print to learn about pick-up service, transfer of ownership and the amount of your tax receipt.

Clothes

You may already donate old clothes, but donating certain clothes strategically may make a bigger impact than sending them to a

charity shop. Consider donating business attire to Dress for Success, which has chapters across Canada. It helps women prepare for job interviews, and once a client lands a job, Dress for Success supports them with a work wardrobe and job retention skills.

Gently used snowsuits and winter wear can go to refugee support groups and family service organizations. For example, the Snowsuit Fund in Ottawa has been helping kids and adults stay warm for more than 30 years.

Electronic waste

Finally getting rid of the fax machine? Some organizations take e-waste and recycle the components. Most chapters of Habitat for Humanity take e-waste, but contact them before donating.

Eyeglasses and hearing aids

Lions Club International provides recycled eyeglasses to people in need. Glasses can be donated to the Canadian Lions Eyeglass recycling centre. Collection locations are on the group’s website at clerc.ca. Some chapters also refurbish hearing aids.

Food Got leftovers from a staff party? Why not take them to a local shelter or out-of-the-cold program? It’s a good idea to call first and to ask if it’s wanted. Donations to food banks are also always needed, and fresh produce usually welcomed. When planning your garden, consider growing an extra row of produce to donate to a food bank.

Furniture or appliances

There are three main ways to donate furniture. One, donate it to a furniture bank that gives it directly to people who need to furnish a house. These furniture banks benefit refugees, people who need to be re-housed for various reasons or people who are getting a home for the first time. Furniture banks are often run locally. Toronto’s furniture bank has a list of others across Canada on their website furniturebank.org. Two, donate it to an

organization that will resell it in their stores and use the proceeds to finance good deeds. For example, the Salvation Army, Goodwill or Habitat for Humanity do this. Third, give it to Value Village, a for-profit company that sells your goods and supports local charities. Whichever way you choose to donate, make sure to find out about pick-up options—or find a friend with a van.

Hair

Have you got eight to 12 inches of extra hair? Contact a group that collects hair to make wigs. Some ask for a monetary donation along with the hair.

Home

Canadians opened their homes to refugees fleeing Ukraine after the Russian invasion in February. This kind of offering is coordinated by local community groups. The best ones screen the homes before allowing refugees to stay there, protecting newcomers from bad situations.

You can also help if you own a rental property. Airbnb works with refugee resettlement agencies to offer transitional housing in times of crisis. More information is at Airbnb.org.

Jobs

Giving people jobs is not an act of charity because you and your business benefit, but it could help people join the labour force who might struggle finding employment through traditional routes. The March for Dimes makes it easy for employers to hire people with disabilities by providing employer services that help with recruitment, accommodation and retention. The Ontario Disability Employment Network is a professional body of 140 employment service agencies that work to help businesses hire people with disabilities. They provide recruitment, training and consulting services. Other groups specialize in finding work for refugees or newcomers to Canada, such as Hire a Refugee in Winnipeg. The government of Canada’s Job Bank even has a special

section for jobs for Ukrainian refugees in Canada. For odd jobs around the house (e.g., snow removal, gardening) see if your local shelter, drop-in centre or job bank has a way to hire clients.

Land

Landowners who donate ecologically sensitive land—or a partial interest in land—to conservation groups benefit from the federal government’s ecological gifts program, which provides significant tax benefits. You can also donate land through your estate. Or, keep your land but create a conservation agreement on your land. This is a contract between the landowner and a conservation organization saying the landowner will conserve natural features of the land. In return, the landowner is paid or given a tax benefit for making the agreement. The Nature Conservancy Canada or local conservation groups can provide advice on the options, and you should visit your lawyer to finalize the process.

Medical supplies

Surplus medical supplies can be given to Not Just Tourists, who put them together in suitcases for travellers to take to various destinations around the world. Going on a trip? Why not take a suitcase to a clinic? Find out more at njt.net.

Mobility aids and other personal medical equipment

ALS Canada welcomes donations of walkers and wheelchairs and other items for their equipment loan program. The Canadian Red Cross can accept donations in some provinces. Depending on the province, their Health Equipment Loan Program (HELP) usually accepts wheelchairs, walkers, crutches, cans, bath seats, commodes or toilet seats and other durable medical equipment. Local groups may also redistribute used equipment.

Musical instruments

Public libraries in 10 Canadian cities lend out musical instruments and accept donations of gently used instruments.

To donate, contact the public libraries in Vancouver, Calgary, Regina, Toronto, Kitchener, Ottawa, Montreal, Fredericton, Halifax or St. John’s. Other local organizations, such as youth orchestras, may accept used instruments. Giving away a piano is trickier, and will probably cost money for appraisal and removal.

Organs

Make sure you register as an organ or tissue donor in your province. Some might even consider living kidney donations to help a loved one or even a stranger. There’s information at blood.ca. You can listen to stories from living donors at livingdonationstories.org.

Paper shredding

Most paper shredding companies offer community shredding events to support charities. This way you can dispose of files securely while supporting a good cause. These are usually one-day events and are often held on a weekend, so you’ll have to plan ahead to get this done.

Technology

ReBOOT Canada accepts donations of used computers, printers, cell phones and other technology to refurbish and distribute to charities and people in need. It also provides training and funds wifi access at various locations in Toronto.

You can also donate items made on your 3D printer by joining E-Nable. This community makes artificial hands and other devices for people in need. More information is at enablingthefuture.org

Tools

Local tool libraries often have a wish list of tools they need. Schools or employment assistance programs may also take gently used hand or power tools, as well as sewing machines. Habitat for Humanity’s ReStore is a popular option for used tool donations, where funds from the sales fuel their work to provide housing for those without appropriate shelter.

Beyond ‘voluntourism’

BY ABIGAIL CUKIER

Thinking of joining an overseas humanitarian medical mission?

The first question to ask yourself is: “Who am I doing this for?” said Barry Pakes, global health lead, Temerty faculty of medicine, University of Toronto.

“You may want to experience other cultures and see new things. That’s OK, as long as you’re thinking about it in an appropriate way and it’s somewhat secondary to the motivation of wanting to use your skills to do something good to help those in need,” Dr. Pakes said. “Many people in the humanitarian world are not running toward something but running away from something in their lives. That’s a motivation you want to avoid.”

A FINE LINE

So, once you decide your motivations are sound, how can you make sure a humanitarian organization you are con sidering is doing good work? Much has been written about the fine line between beneficial work and “voluntourism,” which can do more harm than good.

From a 2017 article in Tropical Diseases, Travel Medicine and Vaccines: “It has been argued that much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteers’ grasp of the damage caused.” Would-be volunteers also have to make sure they are joining an organization that is not just out to take advantage of their good intentions.

Finding the right medical mission and doing it for the right reasons takes research— and some self-reflection

“The first thing to find out is how much money are you expected to contribute? It should not be a large sum,” said Dr. Myron Semkuley, a retired Calgary family physician and co-founder of Medical Mercy Canada. “For example, we ask for a small donation to cover some of our organization’s expenses and for you to pay for your own travel.”

A TRUSTY DOCTOR WHO HAS DONE IT

Owen Campbell, human resources manager at Doctors Without Borders/ Médecins Sans Frontières Canada, recommends speaking to someone you trust who has worked with the organization about their experience.

“And if it looks too good to be true, it often is. Do your research,” Campbell said. “The most important thing with any global health project is, who are their partners on the ground? You can’t just parachute into a country and start doing medical work.

“Even countries going through a difficult situation have a ministry of health. They have a legal framework. So if an organization has no information on who they work with and how it is formalized, that’s a red flag for me. There are a lot of organizations doing great work, but you have to do your homework. There are organizations that do more harm than good.”

For example, a World Journal of Surgery article outlines The Seven Sins of Humanitarian Medicine, which include, “failing to match technology to local needs,” “failing to have a followup plan,” “allowing politics, training, or other distracting goals to trump service” (even though the mission is represented as service oriented), failures in organizational cooperation, and “doing the right thing for the wrong reason.”

To avoid being involved with these sins, Dr. Pakes recommends getting answers to questions such as: How long has the organization been doing work in a country? Are they replacing health services that are otherwise offered by the government or others? Do they have a team there all the time or are they there infrequently? What does the population think about what they are doing?

“A large organization that has no partnerships or is moving around to a lot of different places may have had to move because the communities haven’t responded or been positively disposed to what those organizations are doing,” Dr. Pakes said.

He also warns against working with organizations that go abroad with a mission to “save” a community. “Some will focus on the health aspect and others will try to save their souls. There are a lot of ethical issues related to that.”

understanding of it. “Practising in other countries is profoundly different than practising in Canada,” he says. “Not only because of different health systems and the different resources that are available, but the different epidemiology of diseases and the different ways in which you work.”

A LOCAL LIFE

While a degree or course in global health is best, Dr. Pakes recommends at least choosing an organization that delivers pre-trip training. He also suggests doing research on websites such as the Institute for Health Metrics and Evaluation, to learn the profile of a country. “You can see what illnesses they are seeing and the basics of epidemiology and demographics. For example, if you’re going to an agricultural community, you can expect to see farm injuries or pesticide toxicity,” he said.

Dr. Semkuley says you must also be willing to fit in with the people in the community you will be working in. “That means you try to live with them as much as possible—eat their food, learn their language, learn their culture. We’re not trying to change people, we are trying to help them improve their own life,” he said.

PERPETUATING WHITE SAVIOUR COMPLEX?

Indeed, many criticisms of voluntourism centre around perpetuating the white saviour complex, where volunteers from wealthy countries travel to rescue the poor.

“Research an organization’s mission and values and make sure they are things you identify with. Google to see if there have been issues with the organization. Do they have ulterior motives?” Dr. Pakes said.

Many academic institutions are forming partnerships with institutions in other countries and Dr. Pakes suggests searching these out. “There is often a higher standard or a different level of accountability when organizations have partnered with academic institutions. So that would be a green flag.”

Dr. Pakes also says it is important to have training in global health and an

“We focus on health and medical care, but we also provide education and help them see how they can improve their health facilities and train them so they can carry on the work.”

Elaine Semkuley, a retired pharmacist and co-founder of Medical Mercy Canada, adds that it is important to listen to the local community. “Get it to one-onone. Go for a walk with just one person and listen to them. You have to really listen,” she said. “It’s amazing what we have learned over the years. It has made a lot of difference in the way we operate.”

Campbell says doing humanitarian work can take an emotional toll. “But it’s also rewarding,” he said. “You’re helping people and using your skills. You learn from people who aren’t able to rely on expensive diagnostic tools and you learn how to practise medicine in a lower resource setting. So, you can rely on new skills and build up new skills. You come back invigorated.”

“We focus on health and medical care, but we also provide education and help them see how they can improve their health facilities and train them so they can carry on the work.”

Prioritizing conversations on technologies to help Canadians age in place

By 2035 one in four Canadians will be over the age of 65 – a demographic group that is now the fastest growing in the country. As Canada’s older population grows, so too does the risk of age-related emergencies that can lead to serious health consequences.

“The reality is, as our population ages, we’re dealing with more falls and other personal medical emergencies amongst our older patients,” says Dr. Samir Sinha, director of geriatrics at Sinai Health and the University Health Network in Toronto. “We know from previous studies that one in three older Canadians will fall at least once in a given year and that half of falls that lead to hospitalization occur at home.”

Many older adults can’t get immediate help after a fall and, as a result, often experience severe health outcomes. One study published in the British Medical Journal found 82% of falls happened when an older person was alone. In at least one incident of falling, 80% could not get up and 30% had lain on the floor for an hour or longer.

“Beyond falls, there are other things that can happen – like a heart attack or someone with a cognitive condition wandering from their home – that can threaten a person’s health and wellbeing,” adds Dr. Sinha, who also led the creation of Ontario’s Senior Strategy and is director of health policy research at the National Institute on Ageing (NIA) at Toronto Metropolitan University. Yet despite these known risks, there appears to be a widespread lack of conversations by healthcare professionals with their patients around the critical role of personal emergency response systems (PERS) – wearable communications technology that provides access to emergency response operators in case of an emergency, such as a fall – in improving health outcomes for older Canadians. In a recent TELUS Health survey of healthcare practitioners, 95% of respondents said they had conversations with patients about emergency situations at least once a year but only 11% of these discussions touched on PERS technology for access to emergency support.

When asked why they didn’t bring up PERS without prompting from their patients, 89% said they didn’t know enough about the technology.

“There’s a real gap in knowledge, even though there’s evidence showing PERS technology can improve outcomes,” says Dr. Sinha. “In healthcare it can take years from the time study results are published to the time the findings are integrated into practice.”

The small but growing body of research on PERS technology effectiveness points to widespread and still-expanding adoption over the last 50 years, especially in western countries.

Studies on user experiences have been largely positive. In a 2016 review of 33 PERS studies,1 the authors found that “many end users were satisfied with the PERS overall, since it enabled them to summon help if necessary …The ability to get help faster provides a sense of security.”

Today, that sense of security is more important than ever, says Dr. Sinha. A 2020 NIA and TELUS Health survey found that 91% or Canadians of all ages and almost 100% of those 65 years and older plan to live independently in their own home for as long as possible.

This desire for ongoing, lifelong independence means more older Canadians will strive to “age in place” and many will continue to move around in their communities, says Dr. Sinha.

“We know for a lot of people, experiencing a fall or health emergency can destroy their confidence – as well as their family’s confidence –in their ability to age in place,” he says. “Fortunately, assistive technology such as PERS has evolved to help allow their owners to live with greater independence in their home and community, while providing a level of assurance to family members.”

Chris Engst, Managing Director of consumer health at TELUS Health, says PERS technology has come a long way since the earliest iterations in the 1970s, when PERS were restricted to a small area such as the user’s home or a care facility.

Today, solutions such as TELUS Health’s LivingWell Companion provide access to emergency support at the push of a button and come with advanced features such as fall detection technology and GPS on certain devices, says Engst. LivingWell Companion also provides support in five languages: English, French, Mandarin, Cantonese and Punjabi.

“We have four different devices with different options to give our users the flexibility of choice and we recently became the first in the country to make PERS technology available on the Apple Watch,” he says. “Regardless of which device they choose, our users will find our PERS solution easy to use, with 24/7 access to live, trained operators who will communicate with them quickly through a two-way speaker in the event of an emergency.”

“These technologies can really play a role in helping patients more safely age in place, so it’s important that more information is available about the PERS solutions out there for busy healthcare professionals,” he adds.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4965612/

To access an accredited CME course to close the PERS knowledge gap, presented by Dr. Samir Sinha, please visit bit.ly/TechnologyNIA. This program has been accredited by the College of Family Physicians of Canada (CFPC) for 1 Mainpro+ credit. For more information on the role technology plays in supporting healthy and independent ageing, and about how TELUS Health LivingWell Companion can help your patients, visit us online at telus.com/LivingWellHCP.

Only 11% discuss PERS in their practices, overlooking a key tool for patients

RUNNERS-UP AND FINALISTS

The inaugural Medical Post Awards were adjudicated by panels of physician judges. Of course, “awards” means there are chosen “award winners,” but given the high-quality candidates, these awards are a celebration of excellence for every finalist and runner-up too.

MEDIA ENGAGEMENT AWARD –CHANGEMAKER

The Medical Post

AWARDS

There is such tremendous work happening in Canada among physicians, and after coming through more than two years of the pandemic, the time seemed right to stop and celebrate these accomplishments. Indeed, right from when we called for nominations in the spring to the enthusiasm the physician judges had for the inaugural Medical Post Awards, plenty of folk recognized the value of a morale boost for Canada’s doctors.

Thanks to presenting sponsors: MD Financial/Scotiabank. The Medical Post is thrilled to be able to shine a light on the innovations, tireless work and accomplishments of Canada’s physicians with these awards.

Thanks to our 2022 physician jury members

Dr. Alykhan Abdulla

Dr. Melanie Bechard

Dr. Alysa Fairchild

Dr. Howard Goldstein

Dr. Jabir Jassam

Dr. Francine Lemire

Dr. Franco Rizzuti

Dr. John Sehmer

Dr. Mike Simon

Dr. Christopher Sun

Dr. Ruth Wilson

Dr. Hirotaka Yamashiro

Honours a Canadian doctor who is leading change in healthcare through media and social media communications and has the backing of a large organization.

Dual Runners-Up: Dr. Allan Grill & Dr. Gigi Osler

Finalists: Dr. Adam Kassam, Dr. Johny Van Aerde

MEDIA ENGAGEMENT AWARD – TRAILBLAZER

Honours a Canadian doctor who is leading change in healthcare through media and social media communications as an individual doctor at the grassroots level.

Dual Runners-Up: Dr. Swapnil Hiremath & Dr. Samir Sinha

Finalists: Dr. Peter Lin, Dr. René Wittmer

MEDIA ENGAGEMENT LEARNER AWARD

Honours a med student or resident who is leading change in healthcare through media and social media communications.

Dual Runners-Up: Abrar Ahmed & Dr. Anser Daud

Finalists: Kalpesh Hathi, Tharsan Kanagalingam, Jeremy Levett, Dr. Kaylynn Purdy

MAKING A DIFFERENCE AWARD

Honours a physician in recognition of their work for marginalized communities.

Dual Runners-Up: Dr. Sumantra Monty Ghosh & Dr. Kari Sampsel

Finalists: Dr. Anju Anand, Dr. Oyedeji Ayonrinde, Dr. Sheri Bergeron, Dr. Mikhail Epelbaum, Dr. K. Sonu Gaind, Dr. Marie-Ève Goyer, Dr. Rabiya Jalil

INNOVATIVE PRACTICE AWARD

Honours a physician whose practice has found new ways to improve patient care.

Dual Runners-Up: Dr. Sam Lee & Dr. Alan Russell

Finalists: Dr. Mohamed Alarakhia, Dr. Rithesh Ram, Dr. Karim Vellani

INTERPROFESSIONAL TEAM AWARD

Honours a team (must include at least once physician) with different health professionals working effectively to advance patient care.

Dual Runners-Up: Focused COVID

Communications and Hospice of Windsor & Essex County Palliative Medicine Program

Finalists: Hemophilia Treatment Centre Pilot Project; Inclusive Communities Canada I-CCAN; Kawartha Centre – Redefining Healthy Aging; St. Joseph’s Health Sciences Centre, Unity Health, COVID at Home Project; UHN Emergency Department Sickle Cell Working Group

READER ENGAGEMENT WINNER

TOP BLOGGER AWARD

Not selected by our juries but by physician-confirmed clicks: Winner: Dr. John Crosby

Awards for media engagement, helping communities, innovation and more were presented to Canadian physicians

ALL WINNER PROFILES BY LOUISE LEGER

CELEBRATING

The inaugural Medical Post Awards were celebrated Nov. 10, as winners, runners-up, finalists and other guests gathered together at the Arta Gallery in Toronto’s Distillery District. The evening featured award presentations and a Q&A with past CMA president (and award-winner) Dr. Katharine Smart.

Blogger Dr. Howard Goldstein, Dr. Sonu Gaind and his son Dante

Orthopedic surgery resident Dr. Anser Daud

Toronto’s Dr. Anju Anand

Patient advocate Serena Thompson, Medical Post editor Colin Leslie and UHN ED Sickle Cell Working Group’s Dr. Jennifer Bryan

Dr. Ruth Wilson

John Goldstein / Gold Media

CANADA’S DOCTORS!

Pharmacist Sylvain Grenier, Medical Post’s Scott Tweed and Tharsan Kanagalingam

ON MASKS: Some people had masks on for most of the evening and then took them off to be photographed.

Quebec’s Dr. Johanne Morel

Caroline DaBreo, a Scotiabank healthcare rep, and Tharsan Kanagalingam

Focused COVID Communications Dr. Andrea Chittle, Dr. Kate Miller, Adrian Poon, Rosemary Killeen and Kelly Grindrod

C4 Command Centre’s Dan Gabay, Serge Cloutier, Dr. Shannon Fraser, Andre Poitras, Mary Lattas, Suzette Chung and Carol Viegas

Dr. Francine Lemire, Dr. Peter Lin and Dr. Lemire’s husband Jamie Graham

Dr. Katharine Smart, CHEO’s Anick Losier, CMA PR woman Elissa Freeman and Dr. Hayley Harlock, a physician wellness guru

Unity Health’s Dr. Pamela Liao, former OMA president Dr. Adam Kassam and Oak Valley Health’s Dr. Allan Grill

Dr. Katharine Smart: Speaking out for Canadians – and healthcare workers

WHY SHE WON

Pediatrician Dr. Katharine Smart took up the post as president of the CMA at a challenging time in healthcare: August 2021. In the tumultuous months since then, Dr. Smart has participated in more than 350 media interviews for outlets such as CBC and CTV, fiercely advocating for Canada’s healthcare workers and Canadians generally. In addition to these interviews, Dr. Smart has written for the Globe and Mail and the Toronto Star on Canada’s healthcare crisis. She has gone viral after sharing her thoughts on COVID-19 and Canada’s healthcare system on both Twitter and Instagram, where she boasts a combined 25,000 followers.

Dr. Smart, who makes her home in Whitehorse, primarily serves marginalized children who have experienced childhood trauma. Several of Dr. Smart’s past articles and media appearances focused on promoting the COVID-19 vaccine as a means of protection for young children. In an unprecedented time when healthcare workers looked to leadership for support and direction more than ever before, Dr. Smart stepped up to the plate and was a voice for physicians all over the country.

What one judge said… “We were fortunate to have many wellspoken, responsive and thoughtful doctors leading our medical associations during the pandemic, but none of them captured the attention of television, social media, radio and print media like Dr. Katharine Smart did—sending clear and engaging messages.”

Q&A

What has been most gratifying about this work? Most challenging?

The most gratifying for me has been hearing from colleagues that what I did and said as CMA president made them feel seen, heard and supported. Being described by other physicians as authentic, courageous and inspiring made me feel like I achieved what I set out to do. The most challenging was dealing with online attacks and harassment.

What are you most proud of in terms of your career?

First, I am proud of how I leveraged my platform as CMA president to speak out about science, COVID-19 and the challenges to our healthcare system during a critical time in history. Second, I am proud of my work as a pediatrician in the Yukon where I believe our team has dramatically improved access and quality of care for children and youth.

No pressure, but… what’s next?

Whatever I do next, I want to make a difference for Canadians. I want to improve the information they receive about health and science and be part of transforming our healthcare system into something where physicians, other providers and patients can thrive.

What’s something about yourself you’re working to improve?

Managing my excessive passion syndrome. It propels me, but passion can be a two-edged sword. I have to be attentive to managing my emotions so that I can make rational decisions and show up as the best version of myself.

How do you turn around a bad day? Gratitude. I try to take control of negative thoughts, remind myself that I decide what I think about and refocus on things to be grateful for. A Peloton workout also helps.

When it comes to stress, what’s the best medicine?

Time with friends and family, exercise, laughter and re-focusing on my purpose and my “why.”

What brings you joy?

So many things: my children, music, dancing, travel, learning new things, a new challenge, being at the centre of chaos, and meeting colleagues from across the country.

What’s your secret indulgence?

Chocolate—preferably as ice cream.

WINNER: Media Engagement Award – Changemaker Dr. Katharine Smart

Dr. Johanne Morel: A beacon in the North

WHY SHE WON

Since 1981, Dr. Johanne Morel has been using her excellent clinical skills to faithfully serve Northern Quebec’s Inuit and Cree communities as a pediatrician. In addition to her clinical work, Dr. Morel spent six years teaching future nurse practitioners at McGill University, has organized and contributed to numerous conferences on pediatric care, and served on the Advisory Committee of the Canadian Institute of Child Health.

Dr. Morel was also a key agent in the founding and development of Minnie’s Hope Social Pediatric Centre, where she currently serves as medical leader. Minnie’s Hope is a non-profit organization that supports more than 140 children and families in the Nunavik region of Quebec. Minnie’s Hope offers families the opportunity to be seen, in a welcoming environment, by a multidisciplinary team made up of a social worker, physician, and a Cree or Inuk educator.

For 40-plus years, Dr. Morel has been making a difference by dedicating her time, skills and efforts to improving the healthcare of a vulnerable population of young people.

Q&A

What has been most gratifying about this work that you do? What’s special about my work is that it’s essentially working in a transcultural environment with the Cree and Inuit people of Quebec. The most gratifying part would be to work through this cultural barrier, to learn about the cultures of others, which has led to some understanding of my own culture and where I came from.

What is something your physician colleagues might find surprising about you?

Maybe that before I came to work here, I never even contemplated this work. This is something that happened by accident, and sometimes just following where life brings you can change the rest of your life. It was straight out of medical school and out of a simple internship. I had no clue what I wanted to do with

What one judge said…

“For over 40 years Dr. Johanne Morel’s life work has been dedicated to the infants, children and adolescents of the Inuit and Cree communities of Quebec’s far North. Her unwavering commitment to ensuring the vulnerable and socially disadvantaged receive optimal health care is inspiring and laudable. Her vision culminated in the creation of Minnie’s Hope Social Pediatric Centre, providing a beacon of hope to the children and a pathway to realizing their true potential.”

the rest of my life. I had a good friend who put her name on the list of locums for Northern Quebec. She accepted a job in Chisasibi, and it changed my life, not hers.

What are you most proud of in terms of your career? What I am most proud of is probably the social pediatric project we started in the community I am in right now. In December of 2008, I was driving and listening to a story on Radio Canada. The person being interviewed said, “Is there anyone out there who cares about our children?” I’d been a pediatrician there for years and years. I felt really touched by that. And I had to stop my car and think, “What can we do? How can we improve what we’re doing?” And this led, years later, to the development of this social pediatric project called Minnie’s Hope, which is thriving right now.

What is something you’re working to improve?

I think it’s being in the moment, being more and more present with the person I am sitting with when I’m working or even outside of my work life. We are so busy and we always think in the future. I need to work on that because it’s easy to be carried away and think, “Oh, what do I have to do next?”

How do you turn around a bad day?

Paying attention to the small joys, whether it’s the colour of the sky, the light, the day, or the smile of a child. I try to remember that we’re all in this together. It’s the common humanity. It’s the human destiny. Nothing is ever easy. And when it gets hard, I try to pull myself away from the Earth and watch it turn and roll in space. Then I realize that the concerns I have are maybe not that significant in the larger scheme of things.

What’s your secret indulgence?

I close the door and I put on old French songs and I dance and sing and have a good time. I have a terrible voice!

No pressure, but what’s next?

In fact, what’s next is I have no plan, because I find that life delivers the future. I did not plan to follow my friend up North 40 years ago, so I cannot say what’s next, because at that time, if you had asked me what’s next, I would never have said coming up North. So, I don’t plan. I just wait for life to bring whatever is next. I’m always open and receptive, which has served me very well, because I keep meeting people, and bringing all kinds of resources to Minnie’s Hope. If I meet someone who tells me about their wonderful nutrition project, I connect them with Minnie’s Hope, and now we have a nutrition project, and so on. I think there’s no plan for me—just being receptive.

WINNER: Making a Difference Award Dr. Johanne Morel

TAKE ON MODERATE-TO-SEVERE ATOPIC DERMATITIS WITH THE POWER OF

INCLUDING RELIEF OF PRURITUS

CIBINQO is indicated for the treatment of patients 12 years and older with refractory moderate-to-severe atopic dermatitis, including the relief of pruritus, who have had an inadequate response to other systemic drugs (e.g., steroid or biologic), or for whom these treatments are not advisable.

C4 Command Centre: Creating order in a crisis

WHY THEY WON

The CIUSSS COIM Command Centre (C4) Team was formed in December 2020 during the second wave of the pandemic after it was nominated by the Ministry of Health to be the designated pandemic centre for Montreal’s COVID-19 patients.

CIUSSS COIM is a healthcare network comprised of 35 institutions in West-Central Montreal, including the Jewish General Hospital (JGH), rehabilitation centres, long-term care sites, research facilities, and more.

Currently, more than 11,000 staff members and 750 doctors work at CIUSSS COIM.

Tackling the COVID-19 healthcare challenge with so many players from different institutions required high-efficiency, complex collaboration among the

various institutions and departments, as well as sophisticated communications. The C4 team’s goal was to make this collaboration workable on an ongoing basis—giving patients the right care, in the right place, at the right time. This interprofessional team is led by C4 medical director Dr. Shannon Fraser (who also serves as JGH Chief of general surgery).

The team works with the interdisciplinary team to efficiently transfer patients through the various stages of testing and care. Communication is facilitated through several electronic “daily huddles,” hosted by C4.

What one judge said… “All the interprofessional teams who were finalists are doing great projects but the C4 Command Centre project came out on top: It is affecting a very large group of people and showed very strong quantitative outcomes.”

The improvement in patient care was measurable. One example of the C4 team’s work and success was the reduction of the JGH’s NSA (alternative level of care) patients. The C4 team made it their mission to reduce the wait time and the overall number of NSA patients in their system The number of NSA patients went from approximately 67 (11.5% of total acute care beds) in 2020 to approximately 45 (7.8%) in August 2021.

Important safety information for CIBINQO Clinical use

Can be used with or without medicated topical therapies for atopic dermatitis.

Limitations of use: use in combination with other JAK inhibitors, biologic immunomodulators, or potent immunosuppressants, such as methotrexate and cyclosporine, has not been studied and is not recommended.

Most serious warnings and precautions

Serious infections: patients may be at increased risk for developing serious bacterial, fungal, viral and opportunistic infections that may lead to hospitalization or death; more frequently reported serious infections were predominately viral. If a serious infection develops, interrupt treatment until the infection is controlled. Risks and benefits of treatment should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection. Monitor for signs and symptoms of infection during and after treatment, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.

Malignancies: lymphoma and other malignancies were observed in patients taking JAK inhibitors to treat inflammatory conditions and were more frequently observed in patients with rheumatoid arthritis (RA) during a clinical trial with another JAK inhibitor versus TNF inhibitors. Thrombosis: including deep venous thrombosis, pulmonary embolism, and arterial thrombosis have occurred in patients taking JAK inhibitors to treat inflammatory conditions. Many of these events were serious; some resulted in death. Consider risks and benefits prior to treating

patients who may be at increased risk. In a clinical trial in patients ≥50 years of age with RA, a higher rate of all-cause mortality and thrombosis occurred in patients treated with another JAK inhibitor versus TNF inhibitors. Patients with symptoms of thrombosis should be promptly evaluated and treated appropriately.

Major adverse cardiovascular events (MACE): including non-fatal myocardial infarction, were observed more frequently in patients ≥50 years of age with RA during a clinical trial comparing another JAK inhibitor versus TNF inhibitors.

Other relevant warnings and precautions

• Driving or operating machinery

• Dose-dependent increase in blood lipid parameters, lipid monitoring and management

• Hematological abnormalities

• Use with potent immunosuppressants

• Vaccination

• Monitoring and laboratory tests

• Fertility

• Women of childbearing potential

• Pregnancy and breastfeeding

• Geriatrics

For more information

Consult the Product Monograph at http://pfizer.ca/pm/en/CIBINQO.pdf

for important information regarding adverse reactions, drug interactions and dosing, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001.

References: 1. CIBINQO Product Monograph, Pfizer Canada ULC. 2. Bieber T, et al. Abrocitinib versus placebo or dupilumab for atopic dermatitis. N Engl J Med 2021;384:1101–12.

† Results from a phase 3 randomized, double-blind, placebo-controlled, double-dummy, parallel group, multicentre study of CIBINQO in combination with background medicated topical therapies in patients aged ≥18 years with moderate-to-severe atopic dermatitis who had an inadequate response to topical therapy or had received systemic therapy, excluding dupilumab. 2:2:2:1 randomization to CIBINQO 200 mg (n=226), CIBINQO 100 mg (n=238), dupilumab (n=243) or placebo (n=131) for 12 weeks. CIBINQO dose: 200 mg or 100 mg taken orally once daily. Dupilumab dose: 300 mg administered subcutaneously every other week after a loading dose of 600 mg at baseline. Matching placebo was dosed accordingly.

WINNER: Interprofessional Team Award C4 Command Centre (CIUSSS West-Central Montreal)

Q&A

What has been most gratifying about this work?

Most challenging?

I think the most gratifying part of my work is being able to provide treatment in a field that has long been misunderstood. I work as an obesity specialist. My patients have been fat shamed and blamed for their weight all too often. They have been told that this is their fault and that their weight is a lack of will. Medicine has a great deal to answer for in this respect. I am so grateful to be able to change the conversation around weight. The world demands a new generation of kindness and compassion more than ever before. Science has shown us that obesity is the result of a complicated physiological mismatch; the result of genetic predispositions, environmental factors and a complicated biological dysfunction. Like any disease, the body does not do what it is supposed to do. But beyond any disease the world still prejudges patients as “lazy” and “unmotivated.” People living with obesity deserve the same respect and empathy we provide to anyone with a chronic disease. What has been most challenging? Battling

What one judge said…

Dr. Ali Zentner: Shedding light on a misunderstood challenge

WHY SHE WON

In 2012, Vancouver-based internist Dr. Ali Zentner opened the Revolution Medical Clinic: a multidisciplinary obesity clinic run solely through the public system, staffed by three additional internal medicine specialists, and other staff. It currently serves more than 5,000 patients, offering several programs. The clinic has also trained more than 350 physicians in obesity medicine, has 20 to 30 medical trainees per year and runs a peer support/ mentorship program for physicians. “We are the clinic where evidence and empathy meet. I believe we have left our mark on changing the culture of weight bias in medicine,” Dr. Zentner said.

weight bias is the greatest hill to climb here. It impacts every aspect of care: how patients are treated, what treatments are offered and available to them, and how they are received. Weight bias determines what medications are covered in obesity medicine and who gets care. It is a constant challenge in my every day and in the overall work I do but I know in the end that impacting this barrier will make the most significant difference in patient care.

What would you like physicians outside your area of focus to know about the work you do?

I want them to know that weight regulation is complex and that weight gain and obesity are the result of a number of genetic, physiological and environmental factors. I want doctors to understand that medicine at its purest should not care how people came to us—how they need care. Medicine should care how people get care and get treatment. No other disease has to EARN treatment as does obesity. I also want them to know that indeed we are upon a golden age of care and there is so much that can be done to offer treatment to patients living with obesity.

What are you most proud of in terms of your career?

When I was a kid, my father always told me that no matter what, my brain could be “my ticket” to something bigger than my beginnings. I never really wanted to be a doctor—it was his dream for me and not mine. But I realized that I was probably too independent to ever work for someone else and I loved science so medicine made sense. What am I most proud of? I’m proud that I took what I had in life and made things happen well beyond my station. I’d like to think I’ve made an impact in the lives of others—but also on this profession and that makes me feel that my father was certainly right. I’m proud that I never took anything for granted and that I worked really hard to get to where I am today. Overall, I’m proud that a kid from North End Winnipeg who grew up with a lot of love and very little money used grit and a ridiculous sense of optimism to make something happen that changed the narrative in an important way.

What’s something about yourself you’re working to improve?

I’m not great at patience. I started gardening several years

ago to help teach me that. I learned to grow things from seed. I have a 200-square-foot patio in downtown Vancouver, and I grow everything from artichokes to eggplants to garlic. I’m not sure that I’m that much more patient than when I started but my garlic is impressive.

When it comes to stress, what’s the best medicine? I could say something profound like having good supports and family and friends and a life outside medicine—but I have all that and I still get stressed. I think what we do is so stressful on such a different level that I am going to defer the answer to this question to someone wiser than me. If you find out the best medicine for stress, let me know—I’ll take a case of it.

What brings you joy?

So many things and some really special people. I like finding joy in both little things and grand gestures. Anything from the perfect cup of tea with a biscuit to a baked potato with caviar. From hanging out with my husband on the couch to a Broadway show with my best friend. I like being wowed by this world and the people in it and a range of experiences from the most fabulous to the mundane.

WINNER: Innovative Practice Award

Dr. Ali Zentner

“Dr. Zentner scaled up an innovative model of care to address what is arguably the greatest health challenge of our generation!”

What one judge said… “I was so impressed by his enthusiasm and vision, demonstrating that social media is the new frontier in healthcare.”

Dr. Mathieu Nadeau-Vallée: Fighting misinformation

WHY HE WON

Dr. Mathieu Nadeau-Vallée is a senior anesthesiology resident who has amassed more than 80,000 followers and 1.5 million “likes” on the social media platform TikTok, where he shares short videos responding to medical misinformation that has spread online. He joined TikTok during the COVID-19 pandemic, and took it upon himself to correct false information and promote peerreviewed, credible sources. He has been featured on CBC News and Radio-Canada, and has been credited with giving some Canadians their first true exposure to scientific critical thinking. Dr. NadeauVallée believes it is crucial for credible scientists to join and share the facts on social media in order to win the battle against misinformation.

Dr. Nadeau-Vallée completed a Ph.D. in pharmacology while obtaining his medical degree. So far in his short career, he has been published in more than 13 peer-reviewed medical journals. With the goal of preventing premature human birth, he has discovered and patented an innovative method to prevent preterm birth in mice. Dr. Nadeau-Vallée is committed to learning all he can about medicine (he is even pursuing an additional Masters degree in epidemiology) and sharing it with Canadians all over the country and from all walks of life.

Q&A

What has been most gratifying about this work?

Most challenging?

The most satisfying thing was reading the comments of gratitude from several people who listened to my videos to better understand vaccination, and seeing that my work bore fruit. Some even told me that they had been vaccinated after watching my TikTok videos. One of my viewers even gave an interview in a newspaper about her decision to get vaccinated!

What are you most proud of in terms of your career?

I am most proud of the

team discovery of an antiinflammatory molecule with a novel mechanism of action to prevent premature birth, which was discovered during my Doctorate in Pharmacology. Women’s health is an area of great interest to me since little progress has been made in the last 30 years, particularly with regard to premature birth. Even today, the percentage of premature births is around 10%, and no treatment has been found to significantly prolong pregnancy in these circumstances.

No pressure, but… what’s next? I intend to continue to inform

people about vaccines and COVID-19 because the pandemic is not over and the safety of a large part of the population still depends on staying up to date with their vaccinations. I am currently doing a Master’s degree in epidemiology in the field of public health to better my knowledge in this field.

What’s something about yourself you’re working to improve? I am trying to learn not to put too much on my shoulders, to say no to certain opportunities, and that I don’t have to please absolutely everyone. I’m in my

30s now and I now realize that time for myself is precious.

How do you turn around a bad day?

I like to sing and play the guitar. When I hear a song I like on the radio, I write down the title and I learn it and play it. It changes my attitude.

When it comes to stress, what’s the best medicine? Do something that changes your focus completely. And there’s no need to always be productive. On the contrary, playing a captivating video game or a sport can help ease stress.

WINNER: Media Engagement Learner Award Dr. Mathieu Nadeau-Vallée

Dr. Samir Gupta: A calm and credible science communicator

WHY HE WON

Throughout the COVID-19 pandemic, Dr. Samir Gupta became a trusted figure for many Canadians thanks to his calm demeanor and regular appearances on CBC News. Dr. Gupta is a clinician-scientist whose research revolves around communicating complex scientific concepts to a general audience. When the pandemic started, he quickly saw the need for accurate and credible science communicators. He has since given more than 280 television interviews and multiple COVID-19 related presentations at conferences across the world.

To reach Canada’s younger population, Dr. Gupta pitched and created, in collaboration with the CBC, a series of videos on COVID-19 that have amassed more than 11 million total views. He also founded a science communication brand, called “The Feed with Dr. G,” using funding from a Public Health Agency grant. The Feed with Dr. G wants to “make science obvious” and posts videos, on various social media platforms, that focus on topics such as COVID-19, vaping, and supplements.

Dr. Gupta has been actively engaging with Canada’s media outlets since 2014, guided Canadians through a difficult period in medical history, and brings his knowledge and communication skills to each and every interview and social media post.

What one judge said… “Dr. Samir Gupta is a powerhouse media personality of erudition, clarity and punchy one-liners, showing up in almost every media agency over the last few years, sometimes on more than one per day.”

Q&A

What has been most gratifying about this work? Most challenging?

In medicine we all have the fortune of having impact in many different ways, and the most immediate impact I think most of us feel is when we get to make things better for the patient directly in front of us and help them to make the right decisions for their health. This work feels like that but on a larger scale—an opportunity to relate important messages about health and science to a larger group of people than I could ever do in my own small practice. The biggest challenge is one that any physician or scientist doing public health work, in the last few years especially, will relate to, which is the growing prevalence of anti-science views, which ultimately manifest as attacks on physicians themselves, especially on social media.

What is something your colleagues might find surprising about you?

I think that many people recognize that myself and others have been particularly active in various forms of media throughout the pandemic, but most do not realize that I have had an interest in science communication since long before the pandemic.

What are you most proud of in terms of your career?

Doctors are blessed with lots of different opportunities to have impact and to feel gratified by the work that they do (best job in the world!). For me it’s a tie between some of the research that I have done that has had some impact, and a few patients who always come to mind, where my involvement changed their story.

What’s something about yourself you’re working to improve?

Everything is a work in progress! I seldom watch my own media segments, but periodically I force myself to do so, because I am always looking for ways to improve my style, content, and delivery to make it more accessible and “sticky” for the lay public.

How do you turn around a bad day? That’s easy. Barbie playtime with my seven-year-old daughter.

What brings you joy?

Lots of things—I’m easy to please. Aside from the obvious things like family, friends, good food, and vacation time, what really picks me up on my long clinic days is that rare patient where everything went perfectly well and you know you really helped them.

WINNER: Media Engagement Award – Trailblazer Dr. Samir Gupta

Congratulations to the winners!

Dr. Katharine Smart

Dr. Samir Gupta

Dr. Ali Zentner

Back Pages

COLUMN

DNR

It’s Sunday evening and I’m half-way through my eight-hour shift. I’ve spent the last 15 minutes reassuring a middleaged woman who thinks COVID is going to crystallize in her lungs and turn into fibreglass.

It’s April 2021. Had it been pre-orpost pandemic, I likely wouldn’t have been working because it was March Break—albeit a postponed March Break (in April). Instead, I’m in the midst of a stretch of more than 50 consecutive weekends of work. I don’t mind. It gives

me time to supervise at-home learning while my kids’ extracurricular activities remain on hold.

It is this woman’s second visit of the day and she wants to be admitted to hospital. She’s healthy, has a good job, and knows her request isn’t reasonable, but she’s the first one to admit that she hasn’t handled the pandemic well. In fact, she doesn’t even have COVID. Her roommate has it and she wants admission so that she can be safe.

Her multiple swabs thus far have been

BY DR. RAJ WAGHMARE

negative, and although she doesn’t have a cough, she was able to convince a doctor earlier in the day to order a chest X-ray, which was normal. She isn’t convinced, and I’m not sure what else to say when my phone rings. “Listen,” I say, leaving the room. “I have to get this. If you have any more questions, I’ll be back in about 10 minutes.”

It’s Hashim–one of the nurses from the Acute side. “I’m in 13—can you come?”

“Sure thing.” I’m there quickly and Hashim is standing outside the room of 90-year-old Judith Scott (all names changed), the first patient I’d seen that day. The curtain is drawn and the lights are down.

“Did Tara tell you about this?”

Tara is the nurse who was covering for Hashim while he was on break.

I peek around the blue curtain. Judith’s daughter is at the bedside, her mother’s hand in hers. The monitor in the corner of the room is off and all leads are disconnected from the patient. “No,” I say quickly. “What the hell happened?”

“Well apparently she came back from CT like this, unresponsive.”

“Why didn’t Tara call me?”

Earlier that shift

Judith was my first patient of the day. She lives in a local nursing home, uses a walker, and can make it to the dining hall for her meals, but when she missed breakfast and lunch, a nurse went to check on her.

Her daughter Anne is at the bedside.

A 90-year-old patient:

‘No heroic measures’ is the agreement but why is her monitor disconnected?

“The nurse at the home says she had slurred speech, and was leaning to the right, but that seems to have resolved.”

I ask Judith how she’s feeling and she has no complaints. I ask Anne if her mother has returned to normal.

“She’s definitely not herself,” Anne says.

I get the history from Anne, as well as Judith’s chart. She was fine the night before, having a normal dinner but suddenly became weak today. She has renal failure, COPD, congestive heart failure and because of these multiple morbidities, she’s being followed by a palliative care team. She’s on multiple medications, but the goal at this point, her daughter says, is to focus on comfort and quality of life.

Judith’s vital signs are stable. She has no fever, her blood pressure is a little low: 110 over 60, her heart rate 60 and her oxygen saturation 97%. On physical exam, there is no facial droop and no focal weakness in arms or legs, but she is generally weak. When I ask her to sit up, she reaches for the side rails but doesn’t have the strength to pull herself up.

She has a significant aortic murmur (stenosis), but her lungs are clear, her breathing easy. “She’s prone to urinary tract infections,” Anne says. “Can you check for one?”

Yes, I say, I’ve ordered blood work and urine and will be back to reassess her once everything’s back.

“What about a CT scan,” Anne asks. “To look for stroke.”

“She has no signs of stroke whatsoever.”

“Can you do one just to be sure?”

I’d reviewed Judith’s EMR before coming to the room and tell Anne that she’d had a scan for generalized weakness two months earlier. It was normal.

Ten minutes later

Ten minutes later, Hashim is beside me, a CT requisition in hand. “Will you just order the CT,” he says. “The daughter won’t stop coming to the desk. She’s badgering me and doesn’t understand why you won’t order a CT.”

The ER is getting busy and I don’t have time for this. Medicine was nothing like this when I started practising two decades ago. Now, patients pull out their phones and recite their Google search

results as if they’re medical professionals who’ve just published their latest paper in the British Medical Journal.

Two hours later

Two hours later, I’ve just pushed a 12-year-old’s patella back into place when Hashim calls to tell me there’s a panic result in Judith’s blood work. I update Judith and her daughter by the bedside. “Your mom’s potassium is critically high,” I say. “7.3.” This is why she’s palliative. During her last admission, her doctors had trouble balancing her congestive heart failure with her renal failure. On discharge, potassium-sparing spironolactone was added to her medication regimen and although her CHF is controlled, her kidney function has worsened and her elevated potassium is the greatest immediate threat. “I’m going to give her some I.V. medications to lower her potassium.”

“OK” Anne says. “Will she have to stay overnight?”

“Yes,” I say. “We have to stabilize her potassium and adjust her medications.”

Anne thanks me and before I leave the room, I ask about her code status. “In her chart it says that she’s palliative, and wouldn’t want resuscitative measures

if she were to become critically ill—no intubation, no CPR.” I look to Judith who is bright-eyed and smiling, but doesn’t seem to be in tune to the conversation.

“No heroic measures,” Anne says. “They told me last time that her heart wouldn’t tolerate it.”

“Of course,” I say, “but we’ll proceed with medical treatment if that’s in your plan.”

“Yes,” she says. “That’s why we’re here.”

Ninety minutes later

Ninety minutes later, Hashim saves me from the lady whose roommate’s COVID is going to turn into fibreglass. “I just got back from break,” he says. “Before I left, I told Tara that Judith was at CT and would be returning soon.”

“Why didn’t she tell anyone that she came back comatose?”

“She says because I mentioned she was DNR and followed by a palliative team.” She didn’t think she needed to tell anyone. “She actually had a long talk with the daughter and said that it looks like she might be passing. The daugther’s OK with it.”

I speak through my teeth, my eyes wide open. “But she wasn’t like this an hour ago!”

“The nurse says she didn’t tell anyone the patient came back from her CT comatose because I mentioned she was DNR and followed by a palliative team.”

2-in-1 SUVEXX

Formulated with a triptan and an NSAID fixed-dose combination:1

• Triptan – sumatriptan 85 mg

• NSAID – naproxen sodium 500 mg

Demonstrated efficacy in migraine pain relief

SUVEXX demonstrated pain relief at 2 hours post-dose in a single-dose study.1,2*†

Dosing

COUNSELLING TIPS

▶

It is advisable that SUVEXX be taken as early as possible during the migraine attack. SUVEXX is effective when administered at any stage of the attack.

▶ Maximum recommended dosage in a 24-hour period is 2 tablets, taken at least 2 hours apart.

▶ Tablets should not be split, crushed or chewed.

▶ SUVEXX can be taken with or without food.

Clinical use:

SUVEXX is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic, basilar, or ophthalmoplegic migraine. Safety and efficacy of SUVEXX has not been established for cluster headache, which is present in an older, predominantly male population.

SUVEXX should only be used if a clear diagnosis of migraine headache has been established.

• Significantly more SUVEXX patients achieved 2-hour headache pain relief vs. placebo (p<0.001).1,2

• SUVEXX significantly decreased migraine associated symptoms of photophobia and phonophobia at 2 hours postdose vs. placebo:2

▶ Photophobia: SUVEXX 58% vs. placebo 36%, p < 0.001

▶ Phonophobia: SUVEXX 61% vs. placebo 38%, p < 0.001

SUVEXX delivered sustained pain-free (2-24 hour) response (secondary endpoint)1,3‡§

The safety and efficacy of SUVEXX in pediatric patients (<18 years) and the elderly population (>65 years of age) have not been established. SUVEXX is not indicated for use in pediatric patients.

Contraindications:

• Ischemic coronary artery disease (CAD) (angina pectoris, history of myocardial infarction, or documented silent ischemia) or coronary artery vasospasm, including Prinzmetal’s angina.

• In the setting of coronary artery bypass graft surgery.

• Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders.

• History of stroke or transient ischemic attack or history of hemiplegic, basilar, or ophthalmoplegic migraine because these patients are at a higher risk of stroke.

• Peripheral vascular disease.

• Ischemic bowel disease.

• Uncontrolled hypertension.

• Recent use (i.e., within 24 hours) of ergotamine-containing medication, ergottype medication (such as dihydroergotamine or methysergide), or another 5-hydroxytryptamine1 agonist.

• Concurrent administration of a monoamine oxidase (MAO)-A inhibitor or recent (within 2 weeks) use of an MAO-A inhibitor.

• History of asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid (ASA) or other nonsteroidal anti-inflammatory (NSAID). Severe, sometimes fatal, anaphylactic reactions to NSAIDs have been reported in such patients. The potential for cross-reactivity between different NSAIDs must be kept in mind.

• Third trimester of pregnancy because of risk of premature closure of the ductus arteriosus and prolonged parturition.

• Breastfeeding women.

• Moderate or severe hepatic impairment or active liver disease.

• Severe uncontrolled heart failure.

• Active gastric/duodenal/peptic ulcer, active GI bleeding.

• Cerebrovascular bleeding or other bleeding disorders.

• Inflammatory bowel disease.

Adapted from Product Monograph

• 45% of patients who were pain free at 2 hours post-dose, remained pain-free at 24 hours without the use of additional rescue medication.

Pharmacokinetics—Median Tmax ¶

• Median Tmax for sumatriptan when given as a component of SUVEXX was 1 hour (range 0.3 to 4 hours) versus a median Tmax of 1.5 hours for sumatriptan succinate 100 mg alone.1

• Median Tmax of the naproxen when given as SUVEXX was 6 hours (range 0.3 to 12 hours), approximately 5 hours later than from naproxen sodium tablets (550 mg).1

Tmax =time to maximum plasma concentration

‡

* Randomized, phase 3, double-blind, parallel-group, single-dose study of 1,461 patients with acute migraine with or without aura utilizing placebo and each individual active component of SUVEXX as comparisons (SUVEXX, n=370; placebo, n=365; sumatriptan succinate 85 mg, n=365; naproxen sodium 500 mg, n=361). Co-primary endpoints were superiority of SUVEXX over placebo at 2h post-dose for the following endpoints: pain relief (no or mild pain); incidence of photophobia, phonophobia and nausea; and superiority of SUVEXX vs. the individual components for sustained pain-free at 24 hours.

† Headache relief was defined as a reduction in headache severity from moderate to severe pain to mild or no pain.

In a randomized, double-blind, parallel group, placebo controlled, single attack study of patients with a migraine attack with or without aura (n=576). SUVEXX or placebo was taken within 1 hour of onset of migraine head pain and while pain was mild. Rescue medication was allowed at any point 2 hours after study drug ingestion. The primary endpoint was the percentage of patients who became pain-free (grade 0 on pain scale with no rescue) 2 hours after treatment. Secondary endpoints included the percentage of patients who were pain-free at 0.5, 1, and 4 hours post-dose.

§ Defined as pain-free at 2 hours with no return of pain or use of rescue medication through 24 hours.

¶ Comparative clinical significance has not been established.

£ The safety of treating an average of more than 5 migraine headaches in a 30-day period has not been established. See the Product Monograph for complete dosing and administration instructions.

This Counselling Corner is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908. No part of this Counselling Corner may be reproduced, in whole or in part, without the written permission of the publisher. © 2022

Adapted from Product Monograph

• Severe renal impairment (creatinine clearance <30 mL/ min or 0.5 mL/ sec) or deteriorating renal disease (individuals with lesser degrees of renal impairment are at risk of deterioration of their renal function when prescribed NSAIDs and must be monitored).

• Known hyperkalemia.

Most serious warnings and precautions: Risk of cardiovascular adverse events: Sumatriptan, a component of SUVEXX, can cause coronary artery vasospasm. SUVEXX is contraindicated in patients with uncontrolled hypertension, ischemic CAD, cardiac arrhythmias, and those with history of myocardial infarction. SUVEXX is not recommended in patients with family history or risk factors predictive of CAD.

Naproxen sodium, a component of SUVEXX, is an NSAID. Use of some NSAIDs is associated with an increased incidence of cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) which can be fatal. The risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Caution should be exercised in prescribing NSAIDs such as naproxen sodium, which is a component of SUVEXX, to any patient with ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina), cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) and/or congestive heart failure (NYHA II-IV).

Use of NSAIDs, such as naproxen sodium, which is a component of SUVEXX, can promote sodium retention in a dose-dependent manner, through a renal mechanism, which can result in increased blood pressure and/or exacerbation of congestive heart failure.

Risk of gastrointestinal (GI) adverse events: Use of NSAIDs, such as naproxen sodium, which is a component of SUVEXX, is associated with an increased incidence of gastrointestinal (GI) adverse events (such as peptic/duodenal ulceration, perforation and obstruction of the upper and lower gastrointestinal tract, and gastrointestinal bleeding). These events can occur at any time during use and without warning symptoms. Elderly patients and those with history of peptic ulcer disease and/ or GI bleeding are at greater risk for serious Gl events.

Risk in pregnancy: Caution should be exercised in prescribing SUVEXX during the first and second trimesters of pregnancy. Use of NSAIDs at approximately 20 weeks of gestation or later may cause fetal renal dysfunction leading to oligohydramnios and neonatal renal impairment or failure. SUVEXX is contraindicated for use during the third trimester because of risk of premature closure of the ductus arteriosus and uterine inertia.

Other relevant warnings and precautions:

• Use only when a clear migraine diagnosis has been established.

• Use in cluster headache.

• Psychomotor impairment.

• Use in medication overuse headache.

• Not recommended for use with other NSAIDs, except lowdose ASA for cardiovascular prophylaxis.

• Serious cardiac events and fatalities associated with 5-HT1 agonists.

• Cerebrovascular events and fatalities with 5-HT1 agonists.

• Other vasospasm-related events.

• Increased blood pressure; use with caution in patients with controlled hypertension.

• Congestive heart failure and edema.

• Interference of platelet function.

• Use with anticoagulants.

• Anti-platelet effects.

• Blood dyscrasias.

• Increased liver enzymes; evaluate patients with signs of liver dysfunction.

• Hypersensitivity and anaphylactoid reactions.

• Do not use in ASA-intolerance.

• Cross-sensitivity to other NSAIDs.

For more information:

• Masking of inflammation and fever.

• Excluding other neurologic conditions.

• History of seizures.

• Serotonin syndrome; monitor patients on other serotonergic treatments.

• Blurred and/or diminished vision.

• Renal impairment; use with caution in patients with severe dehydration or pre-existing kidney disease.

• Sodium retention and hyperkalemia.

• ASA-induced asthma.

• May impair fertility; not recommended in women trying to conceive.

• Serious skin reactions (e.g., drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis and erythema multiforme).

• Use with caution during first and second trimesters; evaluate riskbenefit.

• Not recommended during labour and delivery.

• Use in breastfeeding women.

Please consult the Product Monograph at: https://www.miravohealthcare. com/wp-content/uploads/2022/01/Suvexx-PM-ENG-Dec2021.pdf for adverse reactions, interactions, dosing and conditions of clinical use.

The Product Monograph is also available by calling Miravo Medical Information at 1-866-391-4503.

References:

1. SUVEXX® Product Monograph. Aralez Pharmaceuticals Canada Inc., December 2021.

2. Brandes J et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA 2007 Apr 4;297(13):1443-54. 3. Silberstein S et al. Multimechanistic (sumatriptan-naproxen) early intervention for the acute treatment of migraine. Neurology 2008;71:114-121.

Aralez Pharmaceuticals Canada Inc.* 6733 Mississauga Road, Mississauga, Ontario L5N 6J5 *d/b/a Miravo Healthcare

F-SUV-012-04192022 EN

He mimics my whisper. “I know!”

Hashim and I enter Judith’s room and with an unhurried haste, he begins reconnecting her to the monitor. “What happened?” I ask Anne.

“When we came back from CT, she was like this. The nurse that was covering came in to check her and she was totally unresponsive. She said that like this, she would have to be intubated and of course, that’s not what we want.”

“It is true,” I say. “Usually when patients are completely unresponsive, we put them on a ventilator.” The monitor shows that Judith’s vitals signs are normal. Even her oxygen saturation is fine. I rub her sternum and there’s no response. Her skin is cold and clammy.

“Do you want to check the CT?” Hashim says. I shrug. “Not unless she fell on her way over there and hit her head.”

Anne shakes her head no.

I’m about to leave the room to quickly pull up the CT, when it hits me. “Wait a sec,” I say. “Check her sugar.”

“For sure,” Hashim says, knowing that’s likely our answer.

“We won’t intubate her,” I tell Anne, “but if there’s a reversible cause for her state, we’ll fix it.” Hashim returns with a handheld machine and pricks her finger while I continue. “I gave her insulin as well as a bolus of sugar to lower her potassium. Insulin shifts potassium into the cells and out of the bloodstream, but even with the bolus of sugar it can drop glucose levels to dangerous lows.”

There is a beep from the machine and Hashim holds it up. “One point seven.” He’s already leaving the room. “D-50?”

“D-50,” I say. “One amp.”

She’s given a dextrose bolus and minutes later she starts to rouse. I return to the other side of the ER and my patient who’s afraid of her roommate’s COVID has left. Judith is admitted to hospital and after 10 days is well enough to return to her nursing home.

RAJ WAGHMARE

DR.

is an ER physician in Newmarket, Ont.

“When we came back from CT, she was like this. The nurse that was covering came in to check her and she was totally unresponsive. She said that like this, she would have to be intubated and of course, that’s not what we want.”

Indications:

Seasonal Allergic Rhinitis

BLEXTEN® (bilastine) is indicated for the symptomatic relief of nasal and non-nasal symptoms of seasonal allergic rhinitis (SAR) in patients 4 years of age and older with a body weight of at least 16 kg.

Chronic Spontaneous Urticaria

BLEXTEN® (bilastine) is indicated for the relief of the symptoms associated with chronic spontaneous urticaria (CSU) (e.g. pruritus and hives), in patients 4 years of age and older with a body weight of at least 16 kg.

Contraindication:

• History of QT prolongation and/or torsade de pointes, including congenital long QT syndromes

Relevant warnings and precautions:

• QTc interval prolongation, which may increase the risk of torsade de pointes

• Use with caution in patients with a history of cardiac arrhythmias; hypokalemia, hypomagnesaemia; significant bradycardia; family history of sudden cardiac death; concomitant use of other QT/QTc-prolonging drugs

PRESCRIPTION ANTIHISTAMINE COVERED BY MOST PRIVATE INSURANCE PLANS

• P-glycoprotein inhibitors may increase plasma levels of BLEXTEN® in patients with moderate or severe renal impairment; co-administration should be avoided

• BLEXTEN® should be avoided during pregnancy unless advised otherwise by a physician

• A study was performed to assess the effects of BLEXTEN® and bilastine 40 mg on real time driving performance compared to placebo. Bilastine did not affect driving performance differently than placebo following day one or after one week of treatment. However, patients should be informed that very rarely some people experience drowsiness, which may affect their ability to drive or use machines.

For more information:

Please consult the product monograph at https://www.miravohealthcare.com/wp-content/ uploads/2021/08/Blexten-PM-ENG-Aug2021.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-866-391-4503.

Σ As of August 31, 2021, the estimate from internal data of patient exposure is based on units sold of the defined daily dose of 20 mg bilastine and the mean treatment duration of 3 weeks

Reference:

1. Blexten ® Product Monograph. Aralez Pharmaceuticals Canada Inc. 2021.

Aralez Pharmaceuticals Canada Inc.* 6733 Mississauga Road, Suite 800 Mississauga, Ontario L5N 6J5

*d/b/a Miravo Healthcare MA-20-12-16-2021-E

© 2022. BLEXTEN is a registered trademark of FAES used under license by Aralez Pharmaceuticals Canada Inc.

CLINIC

All about ADHD meds

Pharmaceutical management of ADHD in children, adolescents and adults

BY KYLIE TAGGART

Managing effective ADHD treatment for children, adolescents and adults takes skill, patience and perseverance. While the two main classes of medications— methylphenidate and amphetamines— have similar safety and efficacy profiles, how patients respond to them differs from patient to patient. Their response to medication can also change over their lifespan.

Two experts in the field shared insights into the pharmaceutical treatment of ADHD. Dr. Doron Almagor, psychiatrist and director of the Possibilities Clinic in Toronto, and

Dr. Shimi Kang, psychiatrist, founder of Future Ready Minds in Vancouver and clinical associate professor at the University of British Columbia, provided tips for managing treatment.

Select a starting medication

Current guidelines for ADHD treatment provide similar recommendations, but differ in the specifics of what should be considered first-line therapy in adults and children with ADHD. For example, the U.K.’s NICE (National Institute for Health and Care Excellence) guidelines recommend specific medications, where the European, American and Canadian

guidelines focus on classes of medications.

Canadian physicians should follow the Canadian ADHD Resource Alliance (CADDRA) guidelines, Dr. Kang said. Dr. Almagor was an author on the most recent version.

The guidelines list methylphenidate and amphetamines as first-line treatment. In Canada, this includes the methylphenidates Biphentin, Concerta, and Foquest and the longacting amphetamines Adderall XR and Vyvanse. Both classes should be tried before moving to second-line therapy, which includes atomoxetine (Strattera), guanfacine XR (Intuniv XR) and short-/ intermediate-acting psychostimulants (Ritalin, Dexedrine), which are taken twice a day. Third-line treatments are for patients who are resistant to other treatments, and include bupropion, clonidine, imipramine and modafinil, as well as antipsychotics for patients with comorbidities.

Unfortunately, there’s no way of determining what medication will work best. While useful, family history and psychoeducational testing don’t predict what treatment will bring an appropriate response. The CADDRA guidelines note that physicians should prepare patients that each person reacts differently to medications, and trying one medication does not mean they have to stay on it if it’s intolerable or not effective. The guidelines also advise that patients may be more willing to try a medication that has helped someone in their family.

A 2018 meta-analysis compared the efficacy and tolerability of ADHD medications. It included 133 randomized clinical trials involving thousands of children, adolescents and adults. The researchers concluded that methylphenidates should be preferred as first-choice treatment for children and adolescents, and amphetamines should be preferred as first-line treatment for adults. While this provides some guidance for the first 12 weeks of treatment, there was insufficient data beyond the three-month treatment mark. The meta-analysis was published in The Lancet.

Consider cost when choosing firstline medication. Unfortunately, patients

welcome to

without third-party coverage may not be able to afford some ADHD medications. CADDRA has a table outlining what medications are covered by which provincial and territorial health plans. Ideally, pharmaceutical treatment is combined with psychosocial treatment to allow patients to better overcome functional impairments.

Titrate doses until you get an effective dose

The CADDRA guidelines suggest starting on the lowest dose and titrating up in steps to help people tolerate the medication and to determine the appropriate effective dose. Before treatment, work with the patient to decide what symptoms they want to address with medication.

“The advantage of psychostimulants is you can see the advantages very quickly,” Dr. Almagor said. He noted that they act much more quickly than antidepressants.

It takes about a week to see how the dose is affecting targeted ADHD symptoms, and after seven days the dose can be increased if needed. The guidelines suggest increasing doses by smaller increments than suggested in some product monographs. For example, the product monograph states that Adderall XR can be increased by five to 10 milligrams a time, but CADDRA suggests increases of five milligrams.

Titrating up can take time. “I can’t give people an exact timeline because some people are very sensitive to these medications, and you find that out with the lower doses,” Dr. Almagor said.

Don’t be afraid to increase doses until you get the needed response. “One of the common things that you see is people maintaining an ineffective dose for a long period of time, hoping that the effects will take some time to happen as they do with antidepressants. It’s not the case with psychostimulants. They’re effective immediately once you have the right dose,” he said.

When to switch medications because of adverse effects

Adverse effects can be detected early. “Side effects often take about a week

to stabilize once you’ve started a psychostimulant,” Dr. Almagor said.

Common adverse effects would be impaired appetite, impaired sleep, headache and anxiety or agitation. “For children, the main thing is they are all more pronounced,” Dr. Kang said. The other adverse effect common in children is an impact on growth before puberty.

If the patient is having immediate intolerable side-effects, such as severe headaches or panic attacks within a few days, consider switching medications, Dr. Kang said.

For side-effects such as poor appetite or sleep, see if they can be managed by behaviour. This could include reminding children to eat, or taking the dose a bit earlier in the day or improving sleep hygiene. Dr. Kang advises adopting healthy lifestyle behaviours prior to treatment. “The best way to onboard a medication with fewer side-effects is to really practise good self-care before you start the medication,” she said. Routine, regular sleep, hydration, exercise, good diet and positive social connections are basic self-care that can help reduce adverse effects.

For all ADHD medications, watch for any new mental health disorders (e.g., substance use, mood disorders) and monitor blood pressure. Patients may also experience peripheral vasculopathy,

including Raynaud’s Phenomenon, where fingers or toes turn different colours in response to stress such as cold. Patients on second- or third-line treatments must be monitored for other conditions. For example, patients on atomoxetine must be monitored for symptoms of liver injury.

Watch out for comorbid conditions Anxiety is both a comorbid condition of ADHD and a side-effect of some treatments.

If the anxiety is impairing function more than the ADHD, Dr. Kang suggests treating the anxiety first, before starting ADHD medication. For example, a 12-year-old with ADHD having daily panic attacks should have the anxiety treated first.

If the patient is already taking ADHD medications, try to see if a different type of psychostimulant produces fewer anxiety side-effects before adding an anti-anxiety medication.

“If you’ve tried an amphetamine and it causes anxiety, I would switch to methylphenidate to see whether that class causes anxiety before adding an anti-anxiety,” Dr. Almagor said. You may also want to try a non-stimulant medication. In Canada, the nonpsychostimulant approved for use in adults is atomoxetine. “It does take a

“If you’ve tried an amphetamine and it causes anxiety, I would switch to methylphenidate to see whether that class causes anxiety before adding an anti-anxiety medication.”

OPSYNVI® (macitentan and tadalafil) is indicated for1:

• the long-term treatment of pulmonary arterial hypertension (PAH, World Health Organization [WHO] Group 1) to reduce morbidity in patients of WHO functional class (FC) II or III whose PAH is idiopathic (iPAH), heritable (HPAH) or associated with connective tissue disease (CTD) or congenital heart disease (CHD).

OPSYNVI® should be used in patients who are currently treated concomitantly with stable doses of macitentan 10 mg and tadalafil 40 mg (20 mg x 2) as separate tablets.

Please consult the Product Monograph at https://www.janssen.com/canada/products for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, dosing information and conditions of clinical use, which has not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-567-3331 or 1-800-387-8781.

UPTRAVI® (selexipag) is indicated for2:

• the long-term treatment of idiopathic pulmonary arterial hypertension (iPAH), heritable pulmonary arterial hypertension (HPAH), PAH associated with connective tissue disorders and PAH associated with congenital heart disease, in adult patients with WHO functional class (FC) II–III to delay disease progression. Disease progression included: hospitalization for PAH, initiation of intravenous or subcutaneous prostanoids, or other disease progression events (decrease of 6-minute walk distance [6MWD] associated with either worsened PAH symptoms or need for additional PAH-specific treatment).

UPTRAVI® is effective in combination with an endothelin receptor antagonist (ERA) or a phosphodiesterase-5 (PDE-5) inhibitor, or in triple combination with an ERA and a PDE-5 inhibitor, or as monotherapy.

longer time to work,” Dr. Almagor said, but it tends not to increase anxiety.

If they don’t improve, don’t wait longer than three or four weeks to add anti-anxiety medication, Dr. Kang said.

Any assessment of ADHD should include an assessment of anxiety, depression and comorbid addictive behaviours, including technology addiction.

Adherence to medications

Some patients may be keen to take “drug holidays,” which, strictly speaking, is non-adherence to treatment. The CADDRA guidelines suggest that patients don’t skip doses.

“All our research is showing that the best results we have of treating ADHD is early and sustained treatment,” Dr. Almagor said.

Be alert to reasons patients may want to skip doses, Dr. Almagor said. It could be due to stigma or that they are having trouble tolerating the medication.

Young people might want to see how they eat and sleep without the medication, Dr. Kang said.

“I’m OK when young people do this,” she said. “I think this is case dependent.”

countered by the psychostimulants and they might not realize they are as intoxicated as they are,” Dr. Almagor said.

Patients should also avoid cannabis. There’s no good data of the interaction between cannabis and psychostimulants, but there is increased risk of triggering psychosis, especially in younger adults. “The advice is to refrain from using it,” Dr. Almagor said.

Dr. Kang said that a big issue for patients with ADHD is technology overuse and addiction and its numerous physical, mental and developmental consequences. “Children with ADHD are more at risk for technology-related problems and are more at risk for the comorbidities and consequences of them,” she said.

Since psychostimulants used to treat ADHD are sometimes sold illegally, counsel patients to keep their medications safe. “You absolutely have to monitor abuse and diversion issues,” Dr. Kang said.

Keep monitoring response throughout lifespan

The CADDRA guidelines do suggest stopping treatment for a short period if it is hindering childhood growth. The treatment should be stopped at a time when symptom control is less important, such as school holidays.

Counsel about caffeine, alcohol, cannabis and technology use

REFERENCES: 1. OPSYNVI® Product Monograph. Janssen Inc. October 14, 2021. 2. UPTRAVI® Product Monograph. Janssen Inc. November 22, 2021.

Please consult the Product Monograph at https://www.janssen.com/canada/products for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, dosing information and conditions of clinical use, which has not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-567-3331 or 1-800-387-8781. Janssen

www.janssen.com/canada

Since coffee is a stimulant, it may help reduce some symptoms of ADHD. Dr. Almagor said he often sees patients with ADHD who use coffee to treat their symptoms, but added that the effects of caffeine are short-lived and not sustained like the effects of ADHD medications.

Coffee may also interact with ADHD medications and could increase blood pressure and heart rate. Dr. Almagor said that in his clinic, they often recommend people to cut down on their caffeine consumption.

Patients taking ADHD medications should be cautious when drinking alcohol, because they may not feel its effects. This is because, “it is being

Dr. Almagor calls ADHD treatment a moving target. As a person ages, their brain changes and the environment they’re in tends to change as well. “People’s challenges might be quite different at different stages of their lives,” he said. There are people who can cope quite well during stable periods of their lives, but then when a change happens, they need more compensation strategies and may require a change in their treatment. This could be a move away from home for schooling or becoming a new parent.

Dr. Kang recommends monitoring patients with ADHD closely when they face transitions, especially in schooling.

In women, the three Ps that signal hormonal changes—puberty, pregnancy and perimenopause—cause shifts in ADHD too.

“Don’t assume the medication that was working a year ago or even six months ago is still working now,” Dr. Almagor said. “You want to continue screening for response.”

The tools used to diagnose ADHD can be used to monitor drug response. Appropriate tools are listed in the CADDRA guidelines.

Consider for the

moderate-to-severe

Pr ILUMYA™ (tildrakizumab injection) is indicated for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

For more information: Please consult the Product Monograph at: info.ilumya.ca/Product_Monograph for important information relating to contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use.

The Product Monograph is also available by calling our medical information department at: 1-844-924-0656.

REFERENCE:

Current ILUMYA™ Product Monograph, Sun Pharma. © 2022 Sun Pharma, or its subsidiaries and affiliates. All rights reserved. ILUMYA™ is a trademark of Sun Pharmaceutical Industries Limited. Used under license.

CARTOON

Contest: Caption the cartoon

WHAT WOULD BE A FUNNY LINE FOR A CHARACTER TO SAY HERE? Use your smartphone to scan the QR code at left—or go online to canadianhealthcarenetwork.ca/captiondecembers-cartoon—and you can enter your answer on the Medical Post’s online home. If your answer is selected, you’ll receive a $75 Amazon gift card and this cartoon will re-run in the Feb. issue of the Medical Post magazine with your caption! So you get money—and the doubtless esteem and accolades from your colleagues!

Caption contest winner

We had a lot of great entries for the caption-the-cartoon contest in the October issue of the magazine, but we thought Dr. Irv Salit’s entry below was the funniest. Dr. Salit, a staff physician in the division of infectious diseases at the University Health Network in Toronto, will receive a $75 Amazon gift card as a prize.

Hawkins

Johnny

Wes From remembers a client who had earmarked a $160,000 donation to his favourite charity. Problem was, the gift was in securities and by the time the client decided to hand it over, the stocks were worth only $112,000.

“Had he made the donation sooner he would have been able to give the full value he had intended when he had first made the decision to donate,” said From, a certified financial planner and investment representative at From Financial in Winnipeg. “So the charity lost out on almost $50,000 and the donor was disappointed he couldn’t give more.”

As market fluctuations and other economic forces—such as rising inflation and interest rates—wreak havoc on the net worth of Canadians, those who have put aside assets for philanthropic giving

Giving in full

BY MARJO JOHNE

may want to think about how they can preserve the intended value of these gifts.

The risks to their philanthropic plan go beyond the markets and the economy. Unexpected events—such as a prolonged illness requiring privately paid home care, or an expensive divorce—can also diminish their net worth and, in turn, what they’re able to give.

So what’s the best way to protect your charitable giving from market and economic forces, or from other circumstances that could whittle away at the future cash value of your generosity? From and two other financial experts offered their advice to doctors.

Watch will’s wording

A will is a statement of your wishes, so make sure you articulate those wishes

in a way that accurately represents your intentions and protects your beneficiaries. If your intention is to allocate your estate so that each beneficiary gets a percentage at the time of your death— regardless of the estate’s market value at that time—then go ahead and state those disbursements in percentages, said From.

But let’s say you’d like to leave the lion’s share of your estate to your three children, and you assume that after you die and they get their inheritance there’ll be approximately $500,000 left for charitable giving. If your will stipulates that $500,000 be directed to your favourite charity and what’s left is to be divided equally among your children, you could be risking your kids’ inheritance.

“What if markets plunge just before you die or you’ve spent down your

How to market-proof your planned donation given stock market fluctuations

money to pay for your long-term care?” asked From. “Or what if, because of poor planning, your estate gets a big tax hit? Your charity will still get the $500,000 you stated in your will but now your children will be left with much less to split up between them. It’s not what you wanted but because of how your will is worded, that’s what will happen.”

Donate insurance policy

Instead of naming a charity in your will, you might consider either donating an insurance policy or naming the charity as a beneficiary, suggested Sara La Gamba, a senior advisor and certified financial planner at SPM Financial in London, Ont.

“When you donate a policy directly to a charity you’re essentially giving up control of the policy and transferring its ownership to the charity,” she explained. “And when you do this, you get a tax receipt.”

Because of changes to tax rules in 2016, the value of the tax receipt may not reflect the full value of the policy, added La Gamba. “You or the charity may need to bring in an actuary to figure this out,” she said.

As an alternative to transferring ownership of a policy, you could also just name a charity as your life insurance beneficiary, said La Gamba. But with this approach you won’t realize any tax benefits at the time of giving, although your estate will after the death benefit is paid out.

“Whichever way you decide to do it, what’s also good about using insurance for charitable giving is that it keeps the donation private,” said La Gamba.

Consider segregated funds

Another effective way to ensure the value of your planned charitable gift is by buying a segregated fund contract that names the charity as a beneficiary.

Segregated fund contracts typically offer guarantees of between 75% to 100% of the original investment value and come with a death benefit guarantee that ensures your beneficiary will get either the guaranteed value or the market value of your investment, whichever is higher at the time of your death.

“For clients who want a guarantee that all or part of the original value of their investment will be preserved and who also want the potential for growth, we advise that they set up a segregated fund,” said From. “So if you put $100,000 into a segregated fund, in 10 years that could be worth $400,000 depending on the rate of return. But if markets drop and you’ve chosen a 100% guarantee, your original $100,000 is guaranteed. We’ve provided guarantees right up to the age of 90.”

accounting and legal fees, not to mention the time it takes to set up and administer a foundation.

Ian Sterling, president of Ottawabased private investment firm Doherty and Associates, offered an alternative route toward the same goal: a donoradvised fund.

“It’s basically a holding account for charitable investments, administered by a public charity but that can be managed by you or your own advisor,” he explained. “When you set up a donoradvised fund, it’s like having your own private foundation but without the same setup costs.”

Donor-advised funds

There are other costs associated with a donor-advised fund. For example, Benefaction, a registered public charity in Ottawa that administers donor-advised funds—including ones set up by some of Sterling’s clients—charges a 1% donation fee for funds with less than $1 million, 0.5% on funds with $1 million but less than $2 million, and 0.35% on funds with $2 million but less than $3 million. Fees are negotiable for funds with $3 million and more. Benefaction also charges an annual administrative fee.

Technically an insurance contract, segregated funds are investments—made up of stocks, bonds or money market securities—held and managed by an insurance company. Segregated funds are named as such because they’re managed separately from the insurance company’s other investments.

For those who want value guarantees that go beyond their original investment, most segregated funds also give the option of locking in a higher value—for an additional fee—once the gains reach a certain level.

A foundation, but not

If you’ve considered setting up a private foundation, then you’re likely aware of the tax advantages as well as the costly

“Benefaction’s fees are relatively modest and donors get a lot of control and flexibility,” said Sterling. “Let’s say you want to donate $50,000 to various charities, you can set up an account with Benefaction and donate $50,000 worth of securities. You get a receipt for $50,000 and you can decide to, for example, direct $10,000 a year for the next five years to your charity This allows your investments to continue growing in the fund. If you want to play it safe, you can even convert your securities to GICs.”

Gains within a donor-advised fund are sheltered from tax. The fund donor won’t get a tax receipt for these gains and cannot withdraw them from the fund.

“Ultimately, the charity or charities you named as beneficiaries of the fund will get the monies that accumulate there,” said Sterling. “I typically advise clients to donate the stocks that have done the best so they don’t get taxed on the gains.”

“Had he made the donation sooner he would have been able to give the full value he had intended when he had first made the decision to donate.”

How to avoid charting after hours

Getting home with today’s work done may seem like a fantasy for many physicians, but there are tools and tricks to make it happen

BY LOUISE LEGER

n the Medical Post 2022 annual physician survey, almost 20% of respondents said they spent 14 to 20 hours per week on paperwork; 30% spent nine to 13 hours; about 12% spent between 21 and 31 hours or more. They also reported much of this work was being done outside of clinical hours. Some of that work is filling out forms but much, doctors said, is patient charting. In fact, about 60% of physicians who responded said they either agreed or strongly agreed that “Charting is a significant source of stress for me.”

Dr. Sarah Smith, a rural family physician in Edson, Alta., has been there. She loved her patients and loved

medicine, but was spending her evenings charting and began hating her job. She felt she was missing out on important aspects of her personal life. Dr. Smith searched for answers, eventually teaming up with a life coach who helped give her back her life. “There was finally the distinction between working and not working. I wasn’t constantly thinking, ‘I can’t because I have paperwork.’ I don’t have to delay joy until this insurmountable task is finally over.”

Dr. Smith then became a life coach herself, and in turn became a charting coach, and started the Charting Champions Program (chartingcoach.ca), a program and ongoing community for

doctors who want to “get home with today’s work done.”

Though the charting solution for each physician is different, generally the goal is the same: “We want you to be able to see patients and close chart,” said Dr. Smith. “That’s the foundational step because that’s going to help your brain be at its freshest all day, and get you home with today’s work done.”

Dr. Smith takes a holistic approach to coaching doctors and says there is no quick fix for the charting woes facing physicians today, and the process and solutions will be different for each one. But there are some key concepts:

Ready for change: Physicians need to be “ready for different. They need to be done with evening work. They need to be at the point of, ‘I don’t want this anymore,’ and they’re determined that they want it different. Because it’s going to be uncomfortable. Doing new things is not the easy part. It’s hard.”

Ready to take control: “I spent 15 years kind of stuck in this ‘It’s-allhappening-to-me’ frame of mind. I have no control over when patients are booked in, how long they’re booked for, interruptions, or other jobs I have to do. It takes a lot of courage to turn up differently in your encounters . . . and think about it from the point of view of being the executive decision-maker in what can be achieved today and what can’t be and then helping the patient, for example, understand that.”

Becoming a curious observer: “We want you to be able to see patients then close chart, but then that brings up a whole other set of concerns, doesn’t it?” Finishing charting with each patient can mean being late for the next appointment.

“I’m running 45 minutes behind. I’ve got three patients waiting. They’ve just fit in another patient. The patient’s got five problems,” Dr. Smith says. “So if you’re half an hour behind at 11:30, it’s stepping back in curiosity and saying, “OK, why am I behind? Let’s go back and revisit what happened in the day. What time did I start my rounds? What time did the patient arrive? What time were they put in the room?” Dr. Smith says to bring a kind, curious eye to the day and then ask, “What am I noticing about my

day? How else could I set this up? I have choices here.”

Smart charting

Vancouver family physician Dr. Eric Cadesky is an advocate for sustainable healthcare for patients and for doctors, and has written and spoken about the impact of paperwork on doctor burnout. He offers this practical advice for smart charting:

• Templates: “Use templates and other predictive text for common histories, examinations and plans.”

• Up your skills: “Invest in a typing course to get your stroke speed up.”

• Speak up: “Invest in specialized medical dictation software. Or just use your smartphone, which is often remarkably accurate.”

• Copy and paste: “For complicated reassessment visits, copy and paste the previous visit and edit the changes. This will save time and allow you to compare the progress.”

• Choose a good EMR. “Or at least a less bad one.”

Dr. Noah Crampton is a family physician with the Toronto Western Family Health Team and peer leader with OntarioMD, which supports physicians in adopting digital health technology.

He is also a strong advocate of templates and dictation tools, as well as using pre-visit questionnaires (which patients fill out before the visit and which are automatically entered into the EMR).

“Having a nurse or physician assistant do a pre-visit history and physical exam, where they write an initial note before the physician sees the patient” can help, said Dr. Crampton, while noting that all the offered suggestions depend on a physicians’ preferred approach to patient interactions and their comfort with technologies and multitasking.

“I also suggest using other EMR userassistance tools (examples of companies in this space include Suki, Phelix, Tali. AI, Caddie Health), some of which are powered by AI. These tools try to autoprepare EMR actions thereby minimizing the number of clicks by the clinician.”

Speaking of AI, Dr. Crampton is

also founder and CEO of Toronto-based Mutuo Health Solutions, which has developed an AI tool called AutoScribe. “We’re not quite there yet,” he said, but as technology evolves, machine learning AI could be part of the solution for overburdened human physicians.

“One of the nice advantages of our tools is that we do have a personalization algorithm built in. Each doctor likes to chart in their own specific way, stylistically. And so the way our system works is: Upfront the doctor provides a template of how they like to do their charting. A human scribe is then made aware of that and is able to make the notes according to that template. Then with time, the more a doctor uses it, the AI is able to predict that for this doctor they want it in this format and will output directly in that format. And that will never be lost like with human scribe turnover because that (AI) guy never forgets.”

Human scribes

One of the advantages of AI scribes is that the cost of their service is much lower than that of their IRL counterparts.

Dr. Peter Graves is an emergency physician at Ottawa’s Queensway Carleton Hospital and co-founder of Medical Scribes of Canada, a company that runs medical scribe programs

in ERs and to a lesser extent in other healthcare settings. Most of the scribes are pre-med students who are eager to learn and undergo extensive training.

“Scribes allow physicians to completely engage with patients, and then later completely recharge when they leave work,” said Dr. Graves. “Physicians who have scribes talk about getting to do the work they love rather than paperwork, and no longer feeling beaten up at the end of the day.”

But he acknowledges that even though scribes usually cost only about minimum wage, that is still costly for many doctors and they can take months of training. “The goal is that governments or institutions chip in for the cost of scribes, but we are not there yet,” he said.

Still, many physicians swear by scribes, he said, especially because not only do they do real-time transcription of doctor-patient interactions, they record patient history and updates, exam results or follow-up appointment details. They have no direct interaction with patients.

For doctors who want to hire their own scribe, Dr. Graves says they should expect to pay minimum wage, invest in training and talk to the colleges or the CMPA about insurance required, confidentiality agreements and other legalities.

“Invest in specialized medical dictation software. Or just use your smartphone, which is often remarkably accurate.”

SOLVE MY PROBLEM

An acquired skill

When patients start to go off track from the presenting issue, I gently interrupt them and redirect the discussion. As a senior MD who does a lot of teaching and mentoring, I actually point out to learners how I did so—and emphasize that this is a skill that takes time to acquire. If needed, I honestly explain to the patient that we need to end the appointment to be fair to the patients scheduled next, and that if I run late, others are affected. I will say something like, “It sounds like there are other issues or concerns that we still need to discuss,” and suggest they book another appointment. I also remind them of the amount of time that is set aside for their appointments. Of course, if there is something lifethreatening, all this goes down the drain!

—DR. ELLEN GREENBLATT

Respecting complexity

Here are some phrases I use: 1. “This sounds complicated but important. . . . Let’s not rush through this with simple answers. Email me with a summary of details and lists, and let me think about it.”

2. “It’s been a while since we met, let’s plan how to get caught up over the next few appointments.”

3. “I am a bit behind and want to be fair to other people. . . . Do email me or book again so we can pick up where we left off.”

4. “Let’s work on your health concerns in digestible chunks—better for both of us.”

—DR. ADAM CHEN

Patient engagement

This is a really tough issue. I usually start by trying to make sure I’m prepared for any patient encounter—reviewing the reason for their visit and their relevant past medical history so they know I’ve made some effort to know them even before our visit. I then try to make sure to set expectations for their visit— unfortunately, I won’t be able to solve all their problems in one visit but at least can address their most pressing concerns and try to get them feeling better. I also try to arrange a plan for followup. I think we are seeing more and more patient anger regarding the limitations of medical care, so trying to show one cares and at least can point toward a positive direction is

important. That being said, unfortunately, I normally can’t solve all their problems in one visit so patient engagement is very important. Giving them instructions on what they can do to help themselves can be very helpful too.

—DR. RYAN CHUANG

Kindness and levity

Acknowledge the difficulty. Most patients aren’t being deliberately obstructive, they are genuinely concerned and often dealing with multiple health worries and other psychosocial stressors. After addressing the most pressing issues, make the patient feel heard by explaining that you recognize that they have other health concerns. Offering to schedule timely followup (either in person as appropriate or virtually if safe and preferred), being kind, and trying to end with some levity or common ground can sometimes deescalate a challenging clinical encounter.

— DR. KERRY GALENZOSKI

Next Problem

“Negative comments on RateMD are so harsh. How do I handle it?”

Send solutions to lleger@ensembleiq.com by January 5, 2023. You will receive a $25 gift card if your answer is chosen for the next print edition. Need a solution to a problem? Please send along your questions.

DR. ELLEN GREENBLATT

A reproductive endocrinologist in Toronto

DR. ADAM CHEN

A family physician in Oakville, Ont.

DR. RYAN CHUANG An emergency physician in Calgary

DR. KERRY GALENZOSKI

A psychiatrist in Winnipeg

How do I end an appointment without upsetting or angering a patient?

“This sounds complicated but important. . . . Let’s not rush through this with simple answers. Email me with a summary of details and lists, and let me think about it.”

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