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This year we’re profiling the folks who write for the Medical Post here. Up for this efficiency-themed issue is Abigail Cukier, whose article on frontdesk staffing efficiency is on page 58.
Q: Do you have any efficiency hacks? I have read so many books and articles on efficiency hacks, I could probably write my own book. Do I always follow the tips? Not at all. But I do have some that I have stuck to. If a task takes less than two minutes, I try to do it right away. I like getting up earlier than the rest of my family to either exercise or get some work done uninterrupted. I also plan my following week on Friday and plan each day the day before.
Q: Have you seen any of what appear to be inefficiencies during your interactions with the health system? When my husband was in the emergency room and had an ultrasound ordered, he had to go back to the ER the next day to get his results. This seems very inefficient to me, as he had to wait in the ER again for what was not an emergency and add to the wait times for other patients. I heard similar stories from other people.
Next Issue
THE ANNIVERSARY ISSUE: The next issue of the Medical Post magazine comes out in mid-September: exactly 60 years after the first issue of what was then a newspaper came out. To celebrate, we’ll be getting new data and input on some classic Medical Post investigations. Plus tons of other fun stuff!
EDITORIAL
The Efficiency Issue
The new National Registry of Physicians is a true step forward in healthcare efficiency
The call for national licensure has been long and consistent by doctors. And we’ve reached a milestone with the start of the Medical Council of Canada’s new National Registry of Physicians. The national registry is going to make getting a licence in another province administratively easier.
Ultimately it is going to mean as a doctor you’ll go through a big process to get your very first licence but any additional licence is easily done by a college of physicians and surgeons through that database. Doctors with a full unrestricted licence and a clean record won’t have to provide certificates of professional conduct, and they’ll go through a much easier process to get licensed in another province.
Currently the national registry has data uploaded for seven provinces (with the others coming online in a year or so), and there is a change-management process in place.
Now you may say, “That is a long way from a national licence! Are we still going to have to pay the regular fee for an additional licence?”
Those in the regulatory sector argue the national registry is an enabler of national licensure and that application fees may be reduced—but clinicians should know that the cost of regulation isn’t in licensing people; the cost is around the monitoring, the investigations, the creation of the practice standards, etc.
The national registry may ultimately lead to other potential harmonization efficiencies for doctors who have more than one licence.
Right now they have to report their maintenance of competence into different databases and renewing their licence has to happen several times—and that may be streamlined.
This is the Efficiency Issue, and while work is being done to improve systemic
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efficiencies like inter-provincial mobility, in the pages of the issue we explore other tools and strategies to improve your efficiency and protect your time personally and professionally for what matters most to you.
AWARD WINS FOR MEDICAL POST
The Medical Post cleaned up at the 2025 National Magazine Awards:B2B luncheon gala in Toronto, winning two gold and one silver awards.
GOLD: Best Column: For Bill Rogers’ law column in the Medical Post (page 54).
GOLD: Best How-To Article or Series of How-To: to writer Kylie Taggart for her Clinic features (page 52)
SILVER: Best News Coverage: I was honoured to win for writing “AI scribes roll out,” which appeared in our June issue last year.
Mail Preferences: Occasionally we make our subscriber list available to reputable companies whose products or services may be of interest to you. If you do not want your name to be made available please contact us at medicalpost@canadianhealthcarenetwork.ca
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FIND US ONLINE
The Medical Post’s online home is CanadianHealthcareNetwork.ca Registration is free and easy. Medical students and residents welcome.
COLIN LESLIE EDITOR-IN-CHIEF
For Canadian healthcare professionals only
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The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374.
There are three standalone boxes with time-saving tips that could go anywhere there is a hole in this issue (or they can run online):
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Feedback
CMPA not same as regulators
Editorial: The Regulatory Issue (April)
Dr. Lisa Calder, CEO of the Canadian Medical Protective Association (CMPA), wrote a letter to the editor: “I wanted to clarify CMPA’s role in the Canadian healthcare system. It is important for the readers of Medical Post to be advised that we are not a regulator. We do not set standards of practice or impose workload on physicians. We communicate the standards set by the colleges or regulatory agencies in each province and territory to our members to advise and assist them with medico-legal risk management.
“As Canada’s largest national medical association for physicians, with over 115,000 members, we are uniquely positioned to proactively enhance the safety of patient care and
reduce the risk of harmful events.
“Physicians contact us to get advice on how to provide safe medical care, prevent patient harm related to healthcare, and navigate situations where medico-legal issues arise. We are committed to being there for our members and supporting them through these challenging times.”
Handling a complaint (April) Dr. David Lounsbury of Alberta wrote: “This is the first time I’ve ever read about keeping additional notes (outside of the chart) in a little notebook (noting if the health system was particularly overburdened).
“Seems very strange and reactionary to me. Also, could it lead to subpoena of all of your devices and personal belongings or something?
“It would be better if the hospital or ER itself was responsible for tracking volumes and wait times in some accessible database. Besides, this could go downhill fast (not that charge nurse again, she’s clueless, and so forth) if people weren’t sure what ‘environmental factors’ were appropriate to record. Should we also track if we’re sleep deprived or sick that day?”
A brilliant past and bold future
The Medical Post has a rich Canadian history. At 60 years old, it has witnessed, reported on and celebrated many innovations, challenges and changes in medicine (and in publishing!).
Years ago we were a newspaper, printed weekly. While we’ll be looking back on our 60-year legacy throughout this anniversary year, today I want to focus on who we are in 2025. In contrast to the Medical Post of 1965, today we publish not only the magazine you’re holding in your hands, but also extensive digital content via our online home—CanadianHealthcareNetwork.ca—as well as our well-read Doctor Daily e-newsletter. What hasn’t changed is who we are at our core: We’re journalists, 100% focused on helping Canada’s working doctors by curating and sharing the most relevant news, information and insights—and creating and supporting a community where physicians can share their sometimes-difficult experiences and their hard-won wisdom.
As we celebrate our brilliant past this year, I am proud of our bright present and excited for our bold future—always with our original mandate to serve Canada’s doctors front and centre.
COLIN LESLIE Editor-In-Chief The Medical Post
Rounds
VITALS
Inefficiencies!
BY COLIN LESLIE
Asked to name the one most frustratingly inefficient aspect of the healthcare system, 165 physicians responded to the poll we ran in our Doctor Daily newsletter. Here are their responses:
32% Administrative paperwork and documentation (e.g., forms, insurance, disability, referrals)
21% EMR systems (e.g., poor design, multiple logins, lack of interoperability)
18% Public system bottlenecks (e.g., lack of OR time, long-term care placement delays)
10% Referral system
7% Payment models and billing complexity
6% Communication with other providers or facilities (e.g., faxing, delays in consult reports)
“They should do an Arnold Schwarzenegger clone, except instead of the rise of the machines, it should be called the Rise of the Administrators,” wrote one doctor in an online discussion with this poll.
“Administration has ballooned to the point of being ridiculous, and programs suffer with so much waste in management,” another wrote.
Some contributors criticized the negative impact of public sector unions, describing them as barriers to efficient care.
Concerns were also raised about resource waste through unnecessary tests and preventable illness due to poor public health education.
Finally, one doctor lamented the lack of competition in Canada’s single-tier system, arguing that it reduces incentives for efficiency.
DIVORCE CASE
Retired doc ordered to pay $25K
An Edmonton psychiatrist has been reprimanded and ordered to pay $25,000 after inappropriately speculating on the mental health of an individual involved in a divorce case.
The College of Physicians and Surgeons of Alberta (CPSA) said Dr. J. Rowan Scott engaged in unprofessional conduct by writing a 2020 letter that drew psychiatric conclusions about a person he had never met. The letter was written at the request of Dr. Scott’s patient—who was involved in a divorce— and was never submitted as evidence to the court.
The CPSA tribunal found that Dr. Scott accepted his patient’s account as fact and speculated that the other party was exhibiting “emotional spousal abuse and parental alienation.”
Dr. Scott, who has been retired for four years, argued the letter was not intended as a diagnosis and that CPSA offers limited guidance on preparing such reports. The tribunal disagreed, citing the seriousness of the misconduct and its potential to damage the profession. A full suspension was considered but ruled out due to his retired status.
Link FPs’ pay to their performance?
The Quebec government has unveiled a proposal to change how family physicians are paid, as part of negotiations to renew the 2015–2023 Framework Agreement with the province’s medical federation.
Under the proposal, 25% of the physician payment budget would be tied to performance metrics determined by the Ministry of Health. If physicians fail to meet these targets—such as caring for vulnerable patients—the funds earmarked for performance would not be paid, according to the Treasury Board document.
The plan also introduces a “colour code” system based on patient complexity. Physicians would
QUEBEC GOV’T PLAN
“Cold, wet, tired and so excited!”
—Dr. Jacques Lee, a Toronto emergency doctor, about how he was doing partway through a bike ride from Toronto to Montreal to raise money for emergency medicine research.
“A lot of health planners were thinking, ‘Oh, it looks like we’re doing OK and keeping up.’”
—Dr. Michael Green, dean of the Northern Ontario School of Medicine, saying pure numbers don’t tell the story. A study he co-authored found nearly 40% of FPs who entered the workforce in Ontario since 1993 do not do comprehensive care.
“Legislating medical therapy options is wrong, inappropriate and demonstrates serious government overreach.”
—Dr. Shelley Duggan, Alberta Medical Association president, in support of the CMA and three Alberta doctors filing an application for judicial review of the “gender-care legislation.”
Source CanadianHealthcareNetwork.ca • Globe & Mail • AMA president’s letter
receive annual payments ranging from $12 for a healthy “green” patient to $223 for a complex “red” patient. Half of a doctor’s income would be based on this capitation model, with 30% from fee-for-service and 20% from an hourly rate. Fees under the new model include $16.50 for virtual visits, $18 for inperson consults, and $79 for home visits.
Health Minister Christian Dubé did not comment on the proposal’s specifics but said the government released it publicly to ensure transparency for both doctors and the public.
The Fédération des médecins omnipraticiens du Québec has not yet formally responded to the government’s offer.
EARLIER DETECTION
New hypertension thresholds lowered
A new Canadian guideline has lowered the blood pressure thresholds for diagnosing and treating hypertension, meaning more adults will now be categorized as having the condition. Published in the Canadian Medical Association Journal and
developed by Hypertension Canada, the updated guidance aims to support primary care providers in earlier detection and better management of high blood pressure.
Hypertension will now be defined as a blood pressure of 130 mmHg or higher, with treatment targets also lowered. The authors say this change reflects strong evidence supporting earlier intervention to reduce long-term cardiovascular risks.
The guideline includes nine evidence-based recommendations across diagnosis and treatment, encouraging healthy lifestyle changes and a stepwise medication approach. For patients needing pharmacotherapy, low-dose combination pills from two of three major drug classes are recommended. If two-drug combinations are insufficient, a three-drug regimen is advised.
Canada was once a global leader in hypertension control, but recent years have seen declining treatment and control rates. The new guideline seeks to reverse this trend through clearer, more pragmatic guidance, based in part on international models such as the WHO’s HEARTS framework.
This is the first of two planned updates from Hypertension Canada. The second, forthcoming guideline will address complementary treatments and more complex cases.
Helping healthcare heroes succeed
RBC helps fund organizations like Windmill Microlending, which offers coaching, mentorship and affordable loans to internationally-trained physicians seeking to restart their careers. Ideas like this are helping improve Canada’s shortage of doctors and access to healthcare.
rbc.com/supporthealthcare
THE EFFICIENCY ISSUE
BEYOND THE TO-DO LIST: 8 STRATEGIES FOR PHYSICIANS
Some ideas and habits that just might help you gain control of your day
BY LOUISE LEGER
While apps and tech tools such as AI scribes are getting glowing reviews for helping physicians save time, some of the most transformative time strategies aren’t tech-based at all, but involve personal awareness, shifts in mindset and adopting new behaviours.
Chris Bailey is an Ottawa-based productivity consultant, and the author of The Productivity Project, Hyperfocus and How to Calm Your Mind. While acknowledging that physicians have particular time-management challenges due to patient load and life-and-death decisions, he believes where possible the more intentional we become with how we spend our time, the more productive we are.
“Productivity and time management are both about intentionality. There is usually some autonomy within the constraints that we’re operating inside of.
Productivity is about becoming more intentional with how we spend that (autonomous) time, shutting off autopilot and putting more thought into what we spend time on in the first place.”
With that in mind, here are some time management strategies from mainstream time management consultants as well as peer physician coaches. Dr. Mamta Gautam is a psychiatrist at the Ottawa Hospital, physician coach and president and CEO of PEAK MD Inc., which focuses on enhancing leadership development.
“There is no one size fits all,” when it comes to time management hacks, she said. “Discovering the strategies that work for you is based on reflection, assessment and self-awareness of what takes up much of our time and understanding why.” (See sidebar, “What are your blocks to time management?”)
1. SIMPLIFY, SCALE BACK
“Everyone will ask you to do more, it’s up to you to guard your time fiercely,” said Dr. Sarah Smith, a rural family physician in Edson, Alta., who runs a business called the Charting Coach and speaks on time management for physicians. “Try to simplify each requested task, fewer words, fewer clicks. Shorten meetings. Ensure there is an agenda ahead of time. What are the questions that need answering? Could this meeting be an email exchange instead?”
Part of simplifying is automating repetitive tasks and standardizing repetitive decisions—for example, using templates, wearing the same kind of scrubs every day, eating the same thing for breakfast and lunch, etc. This saves time and helps with decision fatigue.
“The most productive professionals consistently push themselves to simplify tasks, and guard themselves from the temptation to over-complicate. They consistently scale back, streamline and seek help,” said Ann Gomez, speaker, timemanagement consultant and author of Workday Warrior: A Proven Path to Reclaiming Your Time. “You can scale back by deferring certain decisions to others, saying no to certain events, and resisting the temptation to read everything.” Skimming books, papers and blogs is not only OK, it is advisable, she says.
2. SINGLE-TASKING
While multitasking can seem efficient, it’s been proven to diminish focus and productivity. Some productivity gurus recommend “task layering” as a safe alternative: for example, reviewing journal articles while on a treadmill, or listening to lectures during a commute. The key is to pair one low-focus task with one passive or high-focus task.
“This can work for some people; we need to be careful that we are not actually multitasking,” cautioned Dr. Gautam.
“Protect your focus by turning off alerts, minimizing e-mail, setting a timer, and committing to single tasking,” said Gomez. “These focus bursts can be as short or as long as you like.”
3. TIMEBOXING AND OFFLOADING
As an extension of single-tasking, timeboxing allocates a fixed amount of time for specific tasks, with no intrusions allowed. For example, a physician could put 30 minutes in a calendar for triaging labs, set a timer and move on when the time is up. This curbs perfectionism and helps avoid burnout by creating mental closure.
Dr. Smith recommends creating a task list, which could include, for example, script refills, lab results, patient messages, consult letters, etc.
“Keep focused—it’s so easy to be pulled into a rabbit hole of the patient chart when trying to finish a note or do that script refill. If you notice something else while doing the task, make a note and keep going in the task list.”
Bailey is a strong advocate of time-boxing for the periods of your day when you aren’t in appointments. It creates an artificial deadline, forcing you to expend more energy over a shorter period of time to meet a set deadline.
“One of my favourite tactics for deepening focus is to keep a distractions list. You keep a little notepad by your side, and if you’re hunkered down and focusing on something, whatever else comes to mind, you write it down. If you remember
“Everyone will ask you to do more, it’s up to you to guard your time fiercely.”
somebody you need to follow up with, or you need to send some email or you need to pick up cantaloupe, write it down to keep your focus and deal with it later.”
This strategy is in line with what time gurus call “cognitive offloading.” Use checklists, whiteboards, sticky notes or a simple notebook to externalize your mental load. This helps reduce anxiety and ensures follow-through on tasks that can slip through the cracks in a busy day.
Bailey also talks about doing email “sprints.” When you get a pocket of time, set a timer for 10, 15 or 30 minutes, and “blow through as many emails as humanly possible.”
Because physicians often don’t control their time, this is a good way to gain back a feeling of control, he says.
4. O-H-I-O (DO IT NOW!)
“Only handle it once”: It’s not a new concept but one that can be so effective in saving time it’s worth repeating.
For example, if you choose to read an email, do the associated task right away. That could mean:
• Complete it now (if it only takes a few minutes).
• Delegate it now (if someone else is better suited to handle the task, forward that email, or leave them a voice memo)
• Schedule it now (if the task requires more time, put it on your task list and/or schedule time to do it)
“Busy doctors need to do countless small tasks each day and it’s tempting to defer non-urgent tasks to later. But this approach can quickly lead to a lot of redundancy and wasted time,” said Gomez. ”If we read an email and determine we don’t have time to complete it now, we need to read it again later. This redundant reading can easily cost us an extra 30 minutes a day, 2.5 hours a week, 10 hours a month and 120 hours a year.”
Gomez, who has consulted with healthcare professionals, notes that physicians are most effective when they fully focus on updating charts in real time between patient visits. Trying to recreate this thinking at the end of the day or week will take far longer and can feel both overwhelming and less enjoyable.
5. ALIGN TASKS WITH ENERGY
Ultradian rhythms are the cycles our bodies go through: We have periods of alertness followed by a dip in energy, when the brain needs to rest and recover. Those periods of alertness are usually about 90 minutes, although knowing your own rhythms is key. Physicians often override these dips in energy but honouring them with short breaks can restore mental clarity. Consider when you are most alert (e.g., 8 a.m. to 10 a.m.) and reserve that time for critical thinking tasks like
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documentation, diagnoses or challenging conversations. A 10-minute pause every 90 minutes to hydrate or breathe deeply can dramatically improve cognitive performance.
“Ultimately, we all benefit by understanding our unique chronobiology,” says Gomez. “Then we want to match our work with our energy fluctuations. Specifically, we want to match our hardest tasks with our peak energy. Early birds want to protect focus time early in the morning. Night owls may shift their clinic hours to start slightly later than others, then protect time later in the day for their deep work.”
Dr. John Crosby, a retired GP who coaches physicians on time management, is a strong advocate of getting up early to get in exercise and tackle things like paperwork before appointments and other distractions and demands begin. “Getting up early is the biggest time-saver for me,” he said, “because no-one else is around.”
The notion that early-risers are more productive has gained popularity recently, with people embracing the “5 a.m. club.” However, Bailey says research shows there is no difference in productivity and success between early birds and night owls.“We all have different energy peaks. There truly are some of us that are natural night owls. There’s some who are natural early birds. It’s a normal distribution, with most of us clustered in the middle. So work around your own rhythms and your own constraints.”
6. SETTING PRIORITIES
Setting priorities and routines keeps us focused and helps to manage expectations with others. But of course, physicians need to be flexible when urgent needs arise.
“The most effective professionals create a plan for their week, with time protected for clinical work, practice management, team support and focus work,” said Gomez. “They are also realistic about the number of tasks needing their attention each day and avoid overscheduling themselves. There will always be exceptions and unexpected curveballs—especially in medical practice. But even if you have a few ‘off’ days, once you have a routine in place, you can always get back on track.”
And remember that unplanned tasks will come up each day, so your actual discretionary time is quite limited. Leave yourself some breathing room.
7. DELEGATE
Most physicians know they should delegate, but sometimes it is easier said than done.
Dr. Crosby suggests delegating administrative tasks as well as psychological or marital counselling to social workers or psychologists where possible. He recommends knowing and using services to refer patients, such as diabetes programs, COPD and CHF clinics, where patients can get information and support.
Says Dr. Smith: “Recognize the ‘non-physician’ tasks you are asked to do and see if you can hand these back to the appropriate team member. “For instance, ‘Mr. Jones is asking for an earlier appointment.’ Give the front desk staff permission to let him know that you are fully booked, he has the earliest appointment. Alternatively, if they have a wait list, they can put him on it. You don’t need to hear about this request.”
While physicians can often take an “It’s faster if I do it
What are your blocks to time management?
• Psychiatrist and physician coach Dr. Mamta Gautam suggests MDs reflect and examine what takes up so much of their time before applying new strategies. These are the questions she says to ask yourself:
• Is it that we are rescuers or people-pleasers and have taken on too much? Then we can work on setting priorities and establishing boundaries, delegating, and feeling more comfortable saying “No.”
• Is it because we are easily distracted? Then establishing routines in quieter spaces to help us focus might help.
• Is it because we are perfectionists and want to do things perfectly? Then it will help us to understand what others do as the standard, push ourselves to get started, and work to define and accept “goodenough.”
“Generally, things like prioritizing tasks, using tools like time blocks and delegation, and establishing routines to minimize distractions and burnout do work well consistently,” she said.
myself” approach, Gomez says, “Remind yourself that the upfront investment in training quickly pays off.”
And of course, Dr. Crosby recommends outsourcing home cleaning, getting a nanny and delegating other home tasks, either to a hired professional or even to kids.
8. TAKE BREAKS / SELF-CARE
Many physicians push themselves a lot each day, commonly skipping lunch and breaks. The reality is we all function better when we take breaks, which allow us to come back to work more refreshed and focused.
“Take a break at 10 a.m. and 3 p.m. and go for a walk around your building. Or get up and stretch and shake your sillies out. Do yoga and meditation,” said Dr. Crosby. “Take a weekend off alone once a year. Go to a nice hotel, order room service, turn off your phone, laptop, text and emails. Watch TV until your eyes turn square. Get a manicure and pedicure and massage. Sleep PRN and read fat books. Do nothing.”
Dr. Gautam agrees. “Make sure that you prioritize self-care. This is an investment in yourself that allows you to be better available for everyone and everything else,” she said, adding that research says for well-being we should be spending at least 20% of our time doing something we love. “It’s important to regularly review this and ensure that we are making it happen,” she said.
In conclusion, for physicians, effective time management is less about doing more and more about doing what matters most—with clarity, intention and energy. Through awareness, tasks or processes that don’t work can fall away, and a new habit or two can help physicians work a bit smarter, protect wellbeing, and sustain meaningful patient care.
Reimagining inbox management
Some doctors are using sophisticated techniques to triage faxes–and AI is taking inbox management up a notch
BY NORM TOLLINSKY
If you’re a fan of the Iron Man and Avengers films, you’ll be familiar with Tony Stark and his AI assistant JARVIS, short for Just a Rather Very Intelligent System. Looking to the future, Dr. Leah Feldman, a sci-fi fan and family doctor at the Atkinson Medical Clinic in Thornhill, Ont., thinks there’s a good chance that family doctors in the nottoo-distant future will have their own personal JARVIS to help manage their practice.
Dr. Feldman, a panelist at OntarioMD’s Digital Health Virtual Symposium 2025 in April, was one of three family doctors participating in a session on, “Conquering the Chaos: How to Tame Your EMR Inbox.”
“I’m very hopeful that one day we’ll be able to walk into our office and have our own
personal JARVIS like Tony Stark does,” she said. “We’ll have our own personal assistant who will learn from us and over time will become our clone. That’s how I see AI being able to help us in the future.
“Artificial intelligence can already manage our inbox. It can read PDFs. It can tell us you have a rheumatology consult from Dr. X for patient Y and put it in the chart, and it will just get better and better as long as we have the right checks and balances.”
Dr. Feldman may have been referring to companies like two Ontario-based med-tech startups—Phelix.ai and WaiveTheWait—that have developed AI-powered agents that crawl through unstructured faxes. The agent classifies them, identifies the sending physician, the intended recipient and other pertinent details. It can also flag a fax as urgent.
In the absence of an AI-powered inbox agent, every fax that comes into a clinic has to be tagged and classified manually by staff. “For our first implementations, we had staff review the agent’s results so all they had to do was click to approve. Now, we’re removing administration altogether,” said Phelix.ai CEO Hasaan Ahmed.
One Phelix.ai customer, the Doctors Office Toronto, has 13 family physicians collectively receiving about 5,500 faxes per month. “The issue was particularly pronounced on Monday mornings when staff would return to find 350 to 400 faxes from over the weekend. Each fax took five to eight minutes to process, making it a time-consuming workflow,” said clinic admin Melissa Gallippi.
“Due to multitasking responsibilities— including answering phone calls and assisting doctors—admin staff frequently misfiled documents, assigned them to the wrong physician or categorized them incorrectly, leading to a high error rate,” she added. “With backlog issues, physicians often received important test results and consultation notes late, causing delayed patient followups.”
Phelix.ai also has an Outreach Agent that automates key workflows and a Phone Agent that uses AI to answer clinic phone calls. A clinician who needs to see a patient about a lab result would normally assign the task to a staff
person. “Now, using the Outreach Agent, it’s assigned to Phelix and we reach out to the patient by SMS, email or phone,” said Ahmed.
The Phone Agent greets the patient conversationally and is able to respond intelligently to a request for an appointment or a lab result, for example, using natural language processing. It can also retrieve information from the EMR.
The Phelix.ai solution is compatible with the Accuro and Oscar EMRs, and a partnership with Telus is in the works.
Sudbury, Ont.-based WaiveTheWait developed what it calls a document triage solution at the request of a clinic the med-tech startup was working with in Vancouver. “They loved what we were building for them, but told us, ‘We have a problem. We’re receiving hundreds of faxes, and our staff are getting burned out. Can you help us?’ We decided to take on the challenge and it really worked out well for us,” said CEO Shrey Anand.
The administrative burden is particularly acute in specialist clinics receiving referrals because staff have to create a new patient record in the clinic’s EMR. In some cases, said Anand, “We’ve seen referrals that are over a month old that still haven’t been processed.”
The WaiveTheWait solution is compatible with the Oscar and Accuro EMRs. Neither company currently offers a solution for managing EMR inboxes. Phelix.ai’s Ahmed says the EMR inbox is on the company’s roadmap. WaiveTheWait CEO Anand, while “interested in exploring ways we can help,” points out that the EMR inbox is less accessible to third-party vendors and that, “Hospital and labs already do some sort of triage . . . it’s not nearly anywhere close to what we do. But it’s enough that doctors are OK with it generally. The biggest issue is all the unstructured medical documents coming in through fax.”
No fan of fax technology, Matt Leduc, executive director, products, integrations and service management for OntarioMD, said: “There’s a depressing reality that our medical system still relies a lot on faxes.” He added, “With any luck, anything that has to do with faxing in healthcare will be obsolete in fewer years than I can count on one hand . . . so let’s not invest
time to make faxing better. Let’s invest time to make faxing obsolete.”
HEALTH REPORT MANAGER
Leduc sits on an advisory committee responsible for advancing the recommendations from an OntarioMD task force on Health Report Manager (HRM), an Ontario digital health solution that enables clinicians to securely receive patient reports electronically from hospitals and specialty clinics. HRM is a major contributor to the deluge of reports clogging EMR inboxes, distributing approximately 3.5 million reports per month to some 15,000 clinicians, many of which are duplicates and not actionable.
Exacerbating the deluge of reports, hospitals often send the same documents both through HRM as well as by fax, forcing someone in the clinic to go through them line by line to determine if they’re the same or an update.
“We’re asking hospitals to make sure that if they’re sending something via HRM to not also send it via fax,” said Leduc. Clinicians can ask the hospitals in their region to stop faxing reports, but in some cases, there are either systembased or programmatic restrictions that make it difficult for hospitals to comply, forcing them to enlist the help of their health information system (HIS) vendor.
Hospitals are also being asked to cease sending clinically irrelevant spiritual care and dietician reports and to reduce the number of duplicate reports and near matches sent to care providers.
“We found through our analysis of HRM data that in the first six hours of a report being produced there are a number of updates as a result of normal workflow,” said Leduc. “The first six hours accounts for a disproportionate number of duplicates and near matches, so we’re asking hospitals to delay sending a report for six hours and only send the most up-to-date version. This will massively reduce the number of reports doctors receive.”
OntarioMD initiated a pilot with three hospitals—Queensway Carleton Hospital, Sunnybrook Health Sciences Centre and Lakeridge Health—in early 2024 to advance the task force recommendations. It is now working
with a larger group of 30 hospitals to reduce the volume of reports landing in EMR inboxes. While some changes can be easily made, others must await a government funding decision to cover the cost of HIS vendor fixes, noted Leduc.
Also filling up EMR inboxes are e-notifications, automated messages limited to informing clinicians that a patient has been admitted or discharged. In July 2024, OntarioMD launched a pilot with 200 clinicians to assess the impact of suppressing e-notifications, and as of December, allows clinicians across the province to turn them off by filling out a form on the OntarioMD website.
“Some clinicians love e-notifications. Others claim it distracts them from more important work,” said Leduc. So far, more than 500 clinicians have opted out of receiving them. They still get HRM reports with more clinically relevant information about their patients’ ER visits or hospital stays.
OntarioMD is also working with Infosys Public Services Canada to make it easier for clinicians to search through and work with HRM reports sent as PDFs. “We’re working with Infosys on an initiative to identify the key content of a PDF report and populate a metadata field that is searchable by an EMR,” said Leduc. “The idea is to extract key data from a report and provide a summary on page zero that allows for searching. We’re also asking Infosys to report if a document is an exact duplicate or a near match and flag any changes, so the clinicians know at a glance what they have to pay attention to.”
The initial plan was to go live with this functionality at the end of March, but it was postponed to ensure there is no risk of error. The anticipated go-live date is now later this summer.
While document triage solutions for fax inboxes and HRM changes will contribute to an easing of the administrative burden clinicians have to cope with, family doctors who participated in OntarioMD’s Digital Health Virtual Symposium in April shared many other ideas to streamline workflow and free up more time for both patient encounters and work-life balance.
Dr. Rebecca Lubitz, a family physician
in Kitchener, Ont., shared statistics revealing up to 40% of administrative tasks confronting clinicians can be either delegated or ignored. “In the airline industry, the terms ‘overloading’ and ‘task saturation’ describe situations when multiple alarms go off at the same time, creating a huge cognitive burden that distracts a pilot from flying the plane,” said Dr. Lubitz. “This can happen in medicine too when there’s too much to do and too much incoming data.”
In medicine, the EMR inbox is like the cockpit. “You’re the pilot, managing all this data that’s flying at you, and you have to decide what to do, what can wait and what doesn’t matter.”
Dr. Lubitz says she was spending two full days on paperwork in a practice of 1,200 patients before a CPSO auditor complimented her on the thoroughness of her work—but advised her she could be a little less thorough and spend more time with her family.
“I realized that it wasn’t valuable
EFFICIENCY TIP THE PLEASURE AND POWER OF MIND WANDERING
Author Chris Bailey points to the research of psychologists Jonathan Smallwood and Jonathan Schooler, who have uncovered the benefits of mind wandering, which include prospection (contemplating and preparing for situations that might happen in the future) and creativity.
Says Bailey: “It’s through mind wandering that we shut off autopilot. Focus is incredible but it’s through wandering that we consider what we wish to focus on in the first place. The research shows that we think about our goals 14 times as often when our mind is wandering versus when we’re focused. We plan more. We ideate more. If you think of when your best ideas strike you, you’re probably not focused. Maybe you’re taking a shower or you’re out for a run. At the same time, mindwandering is restful for the mind. So I don’t think it should be considered something that is unproductive.” In fact, he recommends physicians set aside time daily to allow for timewandering.
for me or my patients to spend tons of time charting and not have time to see patients clinically. The value was in the clinical encounter, the script, the referral, the imaging, the counselling and the conversation. It wasn’t in the beautiful note. As long as the note was correct, that was enough.”
Resolved to change how she managed her practice, Dr. Lubitz planted a SEED to reduce administrative burden. The acronym stands for Stop viewing unnecessary data, Eliminate duplicates and partial test results, Educate your staff, and Delegate.
In addition to taking advantage of the HRM and e-notification changes noted above, Dr. Lubitz advises clinicians to tell commercial labs to stop sending partial test results and to ask hospitals to stop sending lab reports because in most cases they are also communicated as part of admit notes and discharge summaries.
The advice was echoed by Dr. Kevin Samson of Guelph, Ont., in another session at OntarioMD’s Digital Health Virtual Symposium. “For one set of blood tests we can get three reports— one every time something is added until the final comes in,” he complained. “We can call Lifelabs and Dynacare and say, ‘Hold the partial reports. I don’t want to see them until the final.’”
Dr. Lubitz also educates her staff and employs a part-time nurse to help her with her EMR inbox, providing them with protocols and pre-signed templates for prescriptions and requisitions that don’t require her attention. Staff are authorized, for example, to process insurance notes for massage therapy and creatinine tests for pending CT scans.
She delegates staff to send MedsCheck and vaccination notifications directly to the patient chart and asks her nurse to review and summarize consult reports, flagging anything she needs to do or know. Detailed protocols to delegate the processing of other inbox items reporting abnormal eGFR and lipid results, for example, save time, while the flagging of urgent results relieves her anxiety about items of urgency lurking in her inbox.
Prescription refill requests, another source of inbox congestion, can be onerous to deal with when a patient is on
eight different medications that need to be refilled at different times. To avoid getting a refill request every few weeks for a different medication, Dr. Samson suggests co-ordinating prescription refill timing, “so there’s one message once a year instead of who knows how many messages I would otherwise get.”
He educates patients to have their pharmacy request refills because “when the pharmacy requests it, it’s a complete request with the dose.” Also, “sometimes, if pharmacies don’t get a response the next day, they send me another message. I tell them not to do that.”
All three doctors on the Virtual Symposium’s “How to Tame your EMR Inbox panel”—Dr. Samson, Dr. Feldman and Dr. Vineet Nair of London, Ont.— offered advice on managing their inbox while on vacation. “I do tend to find myself still checking my inbox when I’m away because it’s easier for me in the long run than coming back and having a week’s worth of messages to read,” said Dr. Nair.
“If you don’t want to manage your inbox while you’re away, you can hire someone to do that for you and take that off your plate,” added Dr. Feldman. “It depends a lot on your practice style, how long you’re away and the team you’re working with, so everyone will have a different strategy.”
“What was life-changing for me,” shared Dr. Samson, “was a decision I made a few years ago to book my first half-day back to go through my inbox.”
Efforts underway to reduce the volume of hospital and lab result reports will make a significant contribution to reducing the volume of reports and notifications in EMR inboxes, but Dr. Feldman’s wishful thinking about her own personal JARVIS, an AI-powered clone, doesn’t seem so unrealistic given the introduction of AI scribes as well as document triage solutions and outreach agents by companies like Phelix.ai and WaiveTheWait.
We are still in the very early stages of introducing artificial intelligence into family medicine practice, but the future looks promising given what we already know about the impact it can have on relieving the administrative burden that can lead to physician burnout.
Consider adding PrREXULTI®
PrREXULTI® is indicated for use as an adjunct to antidepressants for the treatment of major depressive disorder (MDD) in adult patients with an inadequate response to prior antidepressant treatments during the current episode.3
The 2023 CANMAT guidelines recommend that adjunctive strategies be considered early in treatment after limited response to the first or second antidepressant trial.1
Clinical use:
Discover the CANMAT guidelines’ first-line recommended adjunctive medications in MDD
When considering the use of REXULTI as adjunctive treatment in MDD, clinicians must take into account the safety concerns associated with antipsychotic drugs, a class of drugs to which REXULTI belongs. Safety concerns of this class include: weight gain; hyperlipidemia; hyperglycemia; tardive dyskinesia; and neuroleptic malignant syndrome. REXULTI should only be prescribed in patients with MDD by clinicians who are aware of the importance and are experienced in the early detection and management of the safety issues associated with this class of drugs.
The e cacy and safety of REXULTI in the adjunctive treatment of MDD were demonstrated in 6-week, double-blind, placebo-controlled trials in adult patients. Therefore, the required length of adjunctive treatment with REXULTI is not known. When prescribed as an adjunct to antidepressants in the treatment of MDD, REXULTI should be used for the shortest period of time that is clinically indicated. It is not known whether e cacy in adjunct treatment is due to REXULTI alone or from combined treatment with an antidepressant.
• The safety and e cacy of REXULTI have not been systematically evaluated in MDD patients ≥65 years of age. Use caution when treating geriatric patients.
• REXULTI is not indicated in pediatric patients (<18 years) and its use is not recommended in this population.
Most serious warnings and precautions:
Increased mortality in elderly patients with dementia: Elderly patients with dementia treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.
Analyses of 13 placebo-controlled trials with various atypical antipsychotics (modal duration of 10 weeks) in these patients showed a mean 1.6-fold increase in the death rate in the drug-treated patients. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature.
Other relevant warnings and precautions:
• Body temperature regulation
• Risk of falls and somnolence
• Contains lactose
• Orthostatic hypotension
• Risk of QT prolongation
• Evaluate patients for a history of drug abuse
• Driving and operating machinery
• Reports of hyperglycemia and diabetic ketoacidosis
• Weight gain
• Dyslipidemia
• Hyperprolactinemia
• Priapism
• Risk of leukopenia/neutropenia
• Venous thromboembolism
• Serious hypersensitivity reactions
• Neuroleptic malignant syndrome
• Tardive dyskinesia
• Risk of seizures/convulsions
• Risk of suicide
• Risk of impulse-control disorders/ compulsive behaviours
• Severe cutaneous adverse reactions
• Dysphagia
• Should not be used during pregnancy or breast-feeding
• Caution when used in geriatric patient populations due to potential increased risk of cerebrovascular adverse events, including fatalities
• Monitoring and laboratory tests: blood glucose, fasting lipid profile and body weight, complete blood count (CBC), white blood cell (WBC) and di erential counts, prolactin and blood pressure, should be monitored at baseline and periodically throughout treatment
For more information:
Please consult the Product Monograph at www.rexultimonograph.ca for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-877-341-9245
CANMAT: Canadian Network for Mood and Anxiety Treatments.
* See guidelines for complete recommendations.
References: 1. Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Can J Psychiatry. 2024;69(9): 641-687. 2. CANMAT. Data on File. CANMAT Letter to PAAB. 3. REXULTI Product Monograph. Otsuka Pharmaceutical Co., Ltd.
Introducing PrZORYVE® foam for seborrheic dermatitis
Designed for simple administration
• Can be used on all affected areas of skin, including face, body, and/or scalp‡
• Once-daily topical application
Formulated with HYDROARQ TECHNOLOGY™†
What is ZORYVE foam indicated for?
ZORYVE (roflumilast foam, 0.3%) is indicated for topical treatment of seborrheic dermatitis in patients 9 years of age and older.1
What was the efficacy data for ZORYVE foam in clinical trials?
In the Phase 3 STRATUM trial, ZORYVE foam demonstrated efficacy in the topical treatment of seborrheic dermatitis.1,3¶
CLEARANCE RATES
Significantly more patients achieved IGA success at Week 8 in the ZORYVE foam group vs. vehicle1,3¶§
20.6% difference in favour of ZORYVE foam vs. vehicle (95% CI: 8.2%, 33.0%)
ZORYVE foam demonstrated significant improvement based on IGA success as early as Week 2 (secondary endpoint)
IGA success—STRATUM trial patient photos (ZORYVE foam n=304; vehicle n=153)
Female – 63 years – face"
Female
Male – 61 years – ears"
DEMONSTRATED ITCH IMPROVEMENT DATA WI-NRS success over time (secondary endpoint)1,3¶£ ~7 out of 10 patients (66.5%) reported a baseline itch score of at least 4/10 (n=206 for ZORYVE foam and n=98 for vehicle)
Durability of response: In patients treated with ZORYVE foam in the long-term, open-label study of up to 6 and 12 months duration, there was no evidence of decreased efficacy.1
* Comparative clinical significance has not been established.
† Clinical significance unknown.
‡ When they are not wet.
¶ STRATUM was a Phase 3 randomized, double-blind, vehicle-controlled, multicentre trial that evaluated ZORYVE foam over 8 weeks as a once-daily topical treatment for seborrheic dermatitis. Patients (n=457) were randomized 2:1 to receive ZORYVE foam 0.3% (n=304) or vehicle (n=153) applied once daily for 8 weeks.
§ Defined as clear or almost clear (IGA 0 or 1) and ≥ 2-grade IGA score improvement from baseline. Actual clinical trial patient. May not be reflective of the general population.
£ WI-NRS success is a reduction of ≥ 4 points in patients with a WI-NRS score of 4 or higher at baseline.
# Erythema was assessed on a 4-point scale ranging from 0 (None: No evidence of erythema) to 3 (Severe: Intense [fiery red] erythema), with higher scores reflecting more severe erythema.
ø Scaling was assessed on a 4-point scale ranging from 0 (None: No scaling evident on lesions) to 3 (Severe: Coarse, thick scales, with flaking into clothes or skin).
Overall erythema score of 0 at Overall scaling score of 0 at Week 8 (secondary endpoint)1# week 8 (secondary endpoint)1ø
ZORYVE (n=304) VEHICLE (n=153)
26.8% difference in favour of ZORYVE foam vs. vehicle (95% CI: 17.36-36.27, p<0.0001) 20.9% difference in favour of
• ~9 out of 10 patients reported a baseline erythema score of moderate
• ~8 out of 10 patients reported a baseline scaling score of moderate
How is ZORYVE foam dosed?
ZORYVE foam provides simple once-daily dosing
• Can be used on all affected areas of skin, including the face, body, and/or scalp.‡
Counselling tips for your patients on how to properly apply ZORYVE foam
STEP 1: SHAKE
• Shake the can well before each use.
STEP 2: DISPENSE
• Turn the can upside down and press the nozzle.
• Dispense a small amount of foam into your hand.
STEP 3: APPLY
• Use enough ZORYVE foam to cover all affected areas with a thin layer and rub in completely.
• If you are treating your scalp, part the hair so that ZORYVE foam can be applied directly to the affected area on the skin.
• Wash your hands after applying.
ZORYVE® IT
ZORYVE (roflumilast foam, 0.3%) is indicated for topical treatment of seborrheic dermatitis in patients 9 years of age and older.1
What is the safety profile of ZORYVE foam?
ZORYVE foam was generally well tolerated.1
Adverse reactions reported in ≥ 1% of patients treated with ZORYVE foam for 8 weeks in two multicentre, randomized, double-blind, vehicle-controlled trials1
Gastrointestinal
Infections and infestations
Nasopharyngitis
Nervous system disorders
ZORYVE foam demonstrated an excellent safety profile.1
Observed discontinuation rates: 0.9% with ZORYVE foam vs. 2.2% with vehicle1
Open-label long-term study: The adverse reaction profile was similar to that observed in vehicle-controlled studies among 408 patients who continued treatment with ZORYVE foam for up to 24 to 52 weeks.1
Clinical use:
• The safety and efficacy data submitted in patients aged 9 to 17 years are limited
• Safety and efficacy in patients < 9 years have not been established
Contraindication:
• Patients with moderate to severe liver impairment (Child-Pugh B or C)
Relevant warnings and precautions:
• Topical use only, not for ophthalmic, oral, or intravaginal use
• Fertility
• Pregnant and breast-feeding women
For more information:
Please see the Product Monograph at http://arcutis.ca/zoryve-pm-hcp for important information on adverse reactions, drug interactions, and administration information not discussed in this piece. The Product Monograph is also available by calling 1-844692-6729.
References:
1. ZORYVE® Product Monograph. Arcutis Canada, Inc. March 2025.
2. Data on File. Arcutis Biotherapeutics, Inc.
3. Blauvelt A, Draelos ZD, Stein Gold L, et al. Roflumilast foam 0.3% for adolescent and adult patients with seborrheic dermatitis: a randomized, double blinded, vehicle-controlled, Phase 3 trial. J Am Acad Dermatol. 2024;90(5):986–993.
Arcutis Canada, Inc.
(pronounced cue -vi-vik )
A dual orexin receptor antagonist indicated in insomnia*
“ Help for my sleep.”
Shed light on
QUVIVIQ®
50 mg†
PrQUVIVIQ® (daridorexant) is indicated for the management of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance.1
Visit QUVIVIQ.ca for more information and to request samples
Consult the Product Monograph at https://pro.idorsia.ca/product-monograph for important information about:
• Contraindications in patients with narcolepsy, using concomitant strong CYP3A4 inhibitor.
• Relevant warnings and precautions regarding concomitant use of CNS depressants, alcohol use, next-day somnolence, sleep paralysis, hallucinations and cataplexy-like symptoms, worsening of depression and suicidal ideation, comorbid diagnosis, complex sleep behaviours, non-medicinal use of sedative drugs, withdrawal symptoms, rebound insomnia, driving or operating heavy machinery, patients with moderate to severe hepatic impairment, patients with compromised respiratory conditions, patients with severe obstructive sleep apnea, patients with severe chronic obstructive pulmonary disease, patients with thyroid abnormalities, breast-feeding, geriatric patients, pediatrics.
• Conditions of clinical use, adverse reactions, drug interactions (particularly interactions with CYP3A4 and P-gp substrates with a narrow therapeutic index), and dosing instructions.
The Product Monograph is also available by calling 1-888-646-1764.
* Clinical significance unknown.
† Some patients may be treated with QUVIVIQ ® 25 mg once per night. Please consult the Product Monograph for complete dosing information.
How doctors are fighting back against form overload
BY KYLIE TAGGART
Forms for insurance, summer camps, legal requirements, handicap parking permits, etc., are only a small part of the burden of documentation that could spring from a single patient visit. The actual filling out of the form may not take much time; “the real challenge lies in the administrative work surrounding these forms—sorting, reviewing and ensuring compliance—work that remains unpaid and unrecognized,” said Dr. Taylor Ferrier, a family physician and medical director of the Tay River Health Centre in Perth, Ont.
Is there a way to cut down on the time spent on forms?
CHARGE FOR FORMS
Patients need to know there may be a charge for filling out forms. Clear communication at the onset that there will be a charge helps manage expectations, Dr. Ferrier said. Most clinics communicate this on a website and through signs in the waiting room. University Plaza Family Practice in Victoria simply put a message by BC Family Doctors on their website, as
well as the whole list of uninsured fees approved by Doctors of BC and the ministry on the home page. His group uses a third-party service to handle fees not covered by the provincial health insurance plan.
Dr. Bridget Reidy, an FP in Victoria, has previously shared her time-saving tip with the Medical Post: Get the patient to fill it out, “as if they were me,” she said. Often, patients don’t know what’s on the form. By getting them to fill it out, the
patient may realize they don’t actually qualify for the service or benefit that requires the form.
To ensure patients are providing the correct form, Dr. David Satok, a family physician and chief medical officer for Rogers Communications in Toronto, gets the patient to read and sign the form before sending it in. This way, patients can realize ahead of time if they’ve sent the incorrect form, rather than sending several versions over
the portal. “It is pushing it back to the patient to say: Is it the right form? Make sure you sign it.”
Dr. Maryam Zeineddin, president of BC Family Doctors, gets patients to send in the form over a portal so staff can assess how much time it will take to do any assessment in order to properly address the requirements of the form. It also gives staff the opportunity to screen the form to see if it’s appropriate. She gave the example where patients are, “told by their accountants that they can get a tax disability form and they’re not actually disabled.” Patients can decide if they still want to go ahead with the cost of getting Dr. Zeineddin to complete the form. When it comes to paperwork, always ask if it absolutely requires a physician’s expertise. Could the task be delegated to another healthcare professional?
Completing the forms may require clinical judgment or understanding of the patient’s context, making delegation difficult. Add all the medico-legal requirements and responsibilities, sometimes the task can’t be passed on to another healthcare worker.
A nurse or physician assistant may also be able to complete some forms, Dr. Zeineddin said. One problem with this is the cost to hire someone else to do it, Dr.
EFFICIENCY TIPS
TACKLING THE TASK LIST
Dr. Sarah Smith, a charting coach, recommends creating a task list to tackle what you can, when you can outside of seeing patients. Here are the attack plans, depending on the timing.
At the best of times
Tackle your task list to optimise your executive function with these hacks:
1) Intentionally do task box items at a time of day when you are more rested, nourished and well hydrated.
2) Set up your environment to help you. If you are easily distracted by conversations, find a less busy location, have music or noise that helps you think.
3) Gamify the tasks. Use a timer or a small reward as tasks are completed to help keep your momentum going.
Reidy noticed. It could become a negative earning situation, but might be worth reducing the administrative burden.
In some cases, a portion of the task could be done by an administrative team. “We incentivize staff to begin filling out common forms immediately upon request, which I then review, add comments if needed and finalize,” Dr. Ferrier said. “This approach has notably increased efficiency.”
SYSTEM CHANGE
All the efficiencies can be in place, from having a portal for patients to submit forms to the EMR automatically populating some parts of the form, but the forms will keep coming unless there is a change in the system.
“Ultimately, this is a bigger conversation than just how fast you can fill out the form,” Dr. Zeineddin said.
The way to stop the flood of forms is to limit the flow at the source. There’s some good news here, with a number of provinces and territories finally bidding adieu to sick notes. From B.C. to Newfoundland and Labrador and a number of jurisdictions in between, employers can’t demand medical certificates or notes for a short-term illness. Other provincial and territorial
At the worst of times
“Many times, your task list is the last thing left at the end of the day as the rest of the day was in-person patient time,” says Dr. Smith. “If your task list will only get your leftover, tired and drained brain then BE KIND to yourself.”
1) Take a few minutes to hydrate and nourish your brain.
2) Go empty your bladder and stretch your neck and shoulders.
3) Find that funky tunes playlist that you made for yourself, put on your headphones and bop along.
4) Do ONE item in the task list, just one. Don’t look at the mountain. It all has to get done eventually so simply start. See if you can simplify your process for completing each task.
5) Give yourself a hard END time. Set a timer. “Be kind to you. Don’t be surprised when anger, guilt, shame and many other emotions accompany the overwhelm of that task list. Take a BIG breath, exhale, focus on the next one thing.”
medical associations are lobbying their governments to make that change. More needs to be done, and there are a number of targets.
Another way is to make changes so other healthcare professionals can complete the forms. “The question is, do you need to fill out the form? And are there other healthcare providers that can either aid or help decrease the administrative burden for doctors overall?” Dr. Zeineddin asked.
BC Family Doctors is currently working to make sure pharmacists are allowed to fill out special authority forms required to show a patient meets the clinical criteria for insurance coverage for specific medications. Another target is making forms more streamlined, something the College of Family Physicians of Canada and others have been promoting, working with form-makers, such as the Canada Revenue Agency and the Canadian Life and Health Insurance Association.
This change is currently happening mostly jurisdiction by jurisdiction; more national-level cooperation may be needed. BC Family Doctors has started to share knowledge with other provincial and territorial medical associations on how to negotiate master agreements, Dr. Zeineddin said. More pan-association talks on best practices for reducing administrative burden could follow.
Dr. Satok said that he has yet to “figure out forms.” He only recently started charging patients for his time completing them. “I have more respect for my own time now.”
In a caring profession it’s difficult to step back and protect your own time, he said. Dr. Zeineddin spoke about physicians needing to value themselves before they can change some of the processes that build up administrative burden. “We do so much for so little, and that’s a problem,” she noted.
“Addressing the administrative chaos in family medicine requires systemic change—better support, clearer policies, and appropriate remuneration,” Dr. Ferrier said. “Until then, we’re doing our best to manage this workload, often at personal cost, which many are no longer willing to do.”
Lean on LYRICA
LYRICA (pregabalin) is indicated in adults for 1:
• The management of neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, and spinal cord injury.
• The management of pain associated with fibromyalgia. The efficacy of LYRICA in the management of pain associated with fibromyalgia for up to 6 months was demonstrated in a placebo-controlled trial in patients who had initially responded to LYRICA during a 6-week open-label phase.
Help your patient get the Viatris original brand LYRICA**
1 Write the Viatris original brand name, LYRICA, and include “no sub,” when appropriate, on your patient’s prescription.
2
Encourage your patients to visit ViatrisOriginals.ca so they can:
• Download a payment assistance card if they have no insurance or if their insurance co-payment amount is a barrier to obtaining the Viatris original brand medication. This card can help them obtain the Viatris original brand medication at little or no additional cost compared to the generic version.*
Remind your patient to ask for the Viatris original brand LYRICA at the pharmacy. 3 ViatrisOriginals.ca
Consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph may also be obtained by calling 1-844-596-9526.
*Subject to change. The Viatris Originals Program is available in all provinces except Quebec. Availability and level of payment assistance vary by brand medication and province.
**Some insurers limit full-cost coverage for higher-cost interchangeable drugs to patients who meet certain criteria, and in some instances, documentation from the prescriber is required. There is a possibility that the patient may need to contribute out-of-pocket where those conditions are not met.
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Optimizing care with teams
There’s a patchwork of provincial supports for team-based care, but do they boost efficiency?
BY ANN GRAHAM WALKER
Team-based collaboration is widely considered to be the gold standard in Canada’s primary care. Working together with other skilled professionals can be a more satisfying, more efficient way for a family physician to practice. If you can afford to employ a nurse or nurse practitioner, that is, and if everyone on your team is working together smoothly, following the same script.
Nova Scotia has a network of more than 100 collaborative family practices, supported by the provincial government and the health authority. There are similar models across Canada.
If you work in one of these health authority-run centres, you aren’t worrying right now about having to pay nurses’ salaries— or bricks and mortar, for that matter. (But you may or may not be happy with the amount of input you get in the decisionmaking and the selection of team members.)
To grow team-based practice across Canada and perhaps increase patient attachment, provinces know they need to make team-building more affordable for autonomous private clinics, like Alberta and British Columbia have been doing, and other provinces like Nova Scotia are beginning to do.
AN EVOLVING PATCHWORK
Alberta’s system of Primary Care Networks has been operating since 2005, with the vast majority of private family medicine clinics participating.
There are financial incentives for maintaining and increasing capitation. The doctors get to decide what kind of skill is best suited for their team. They do the hiring. Maybe a nurse or an LPN, maybe a dietician or mental health counsellor—it is up to the private clinic to identify what it needs. There is also a unified provincial EHR: Alberta Netcare.
These are all strengths that foster team collaboration and efficiency.
British Columbia has been developing a Primary Care
EFFICIENCY TIPS
20 TIMESAVING TIPS
Dr. John Crosby (countryquack.com) has created a list of 62 timesaving tips for physicians. Here is a selection:
1) Get up early, make an appointment with yourself for exercise then go to your office to do paperwork.
2) Do paperwork 8 a.m. to 9 a.m. weekdays. Book an appointment with yourself in your calendar. Avoid distractions while doing paperwork. Sit in your car or an empty exam room if others try to talk to you.
3) Come back a day early from vacations to do
Network (PCN) initiative since 2018. It’s available to all longitudinal care FPs whether they’re paid on contract, fee-forservice or on B.C.’s new longitudinal care payment plan. But the B.C. program is different from Alberta’s in that the doctors often don’t have a say in the team hiring. It depends on the culture of the particular Division of Family Practice that manages their PCN.
The nursing staff generally comes from the health authority—which means those crucial team members are on a health authority career track. If a better job comes along and they get it, the clinic doctors have to spend hours training their new nurse.
The provincial government has just introduced a “Nurse in Practice” program that does give doctors the choice of hiring their own nurses.
Still, Dr. Vanessa Young, a Victoria family doctor, is not so sure that won’t actually create a different set of problems for the doctors who go for it.
“They are then competing with health authority wages and benefits,” she said in an email.
Commenting on other aspects of the PCNs, Dr. Young said: “Our (PCN) team is helping our efficiency. We have a 0.5 FTE (full-time equivalent) mental health and substance use social worker, and a 0.25 FTE social worker for accessing financial and social programs, as well as a 0.2 FTE clinical pharmacist. She is excellent with my complex chronic pain patients, and has helped significantly with de-prescribing of sedatives.”
The PCN-funded team members access their patients usually by phone, occasionally in person and chart in the clinic’s EMR.
“We sadly don’t have space for them in our clinic, nor is the pittance of overhead we receive that is attached to their positions anywhere near sufficient,” she said. “But (we) would happily move into funded space to be co-located with them. Dream on!”
Continued on page 31
paperwork then reward yourself with a nice restaurant meal when done.
4) Bring the patient in to help you with big forms to fill out.
5) With patients with lists, get them to pick two (concerns) and rebook for the rest.
6) Ask staff to tell multiproblem patients to bring in all their meds every visit.
7) Turn your dumb phone off at 5 p.m.
8) Urge families to have one substitute decision maker for a vulnerable elder.
9) In Ontario, get free help with your computer from the OMD Peer Leader Program.
10) If a patient complains about long waits for specialists or imaging, don’t apologize. It is not your fault. Refer them to
the premier of your province who is in charge of this.
11) Get online booking to free up your phone and staff.
12) Assume every patient has Googled their symptoms and ask them what they are worried about.
13) No time for exercise? Go on a treadmill or stationary bike while watching TV. Use the stairs if you can and avoid elevators. Park far away for exercise and to avoid the stress of fighting for a parking space.
14) Group therapy. Get together regularly with peers to bitch and then problem solve. Breakfast once a month?
15) Get a nanny.
16) Get a cleaning service.
17) Pay your kids to do chores. It cuts work for you and
teaches them the value of a dollar and how to budget.
18) Take a break at 10 a.m. and 3 p.m. and go for a walk around your building. Or get up and stretch and shake your sillies out. Do yoga and meditation.
19) Take a weekend off alone once a year. Go to a nice hotel, order room service, turn off your phone, laptop, text and emails. Watch TV until your eyes turn square. Get a manicure and pedicure and massage. Sleep PRN and read fat books. Do nothing.
20) Book a dinner with your spouse alone at a nice restaurant every three months. No cell phones. No kids. Just you two like when you were first in love.
Medication with indications in both chronic weight management and non-fatal MI risk reduction in adults with established CVD and BMI ≥ 27 kg/m2*
What is Wegovy® indicated for?
Wegovy® (semaglutide injection) is indicated:1
For adults with obesity ± CVD OR overweight + CVD or additional risk factors
• as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of 30 kg/m2 or greater (obesity), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, dyslipidemia, or obstructive sleep apnea.
• to reduce the risk of non-fatal myocardial infarction in adults with established CVD and BMI equal to or greater than 27 kg/m2
Wegovy® should not be used in combination with any other semaglutidecontaining drug (e.g., Ozempic®, Rybelsus®) or any other GLP-1 receptor agonist.
What is the mechanism of action of Wegovy®?**
GLP-1 is a physiological regulator of appetite and caloric intake.1
Semaglutide is 94% similar to human GLP-1 and acts as a GLP-1 receptor agonist that binds to and activates GLP-1 receptors. Compared to native GLP-1, semaglutide has a prolonged half-life of around 1 week. The principal mechanism of protraction is albumin binding, which results in decreased renal clearance and protection from metabolic degradation. Furthermore, semaglutide is stabilised against degradation by the DPP-4 enzyme.1
Are there guideline recommendations?
Semaglutide 2.4 mg is recommended as an obesity-management option by the Canadian Adult Obesity Clinical Practice Guidelines. 2
What was the efficacy data for Wegovy® in clinical trials?
STEP 5 TRIAL: At week 104, in adults with obesity or overweight and at least one weight-related comorbidity, Wegovy® demonstrated powerful double-digit weight loss at two years vs. placebo.3†
* Comparative clinical significance has not been established.
** Clinical significance has not been established.
∆ Based on treatment policy estimand.
† STEP 5 study design: 104-week randomized, double-blind, phase 3, placebo-controlled trial in 304 patients with obesity (BMI ≥ 30 kg/m2) or overweight (BMI ≥ 27 to < 30 kg/m2) and at least one weight-related comorbid condition; patients with diabetes were excluded. Patients were randomized 1:1 to once-weekly semaglutide 2.4 mg or placebo, in addition to reduced calorie diet and increased physical activity. The co-primary endpoints were percentage change in body weight from baseline to week 104 and achievement of weight loss of ≥ 5% of baseline weight at week 104.3
Adapted from Garvey, WT et al. (2022)3
The maintenance dose for Wegovy® is 2.4 mg once weekly.1 Please see the Product Monograph or the dosing section in this piece for more details on the recommended dosing protocol.
STEP 1 TRIAL: At week 68, in adults with obesity or overweight and at least one weight-related comorbidity, Wegovy® demonstrated effects across selected cardiometabolic parameters, glycemic control, and physical functioning (2° endpoints).1,4‡
Supportive 2° endpoints were not controlled for multiplicity. Wegovy® is not indicated to treat these cardiometabolic parameters or physical functioning.
‡ STEP 1 study design: 68-week randomized, double-blind, phase 3, placebo-controlled trial that enrolled 1,961 patients with obesity (BMI ≥ 30 kg/m2), or with overweight (BMI ≥ 27 kg/m2 to < 30 kg/m2) and at least one weight-related complication who were randomized 2:1 to semaglutide 2.4 mg or placebo. Patients with diabetes were excluded. All patients were on a regimen of a reduced calorie diet and increased physical activity throughout the trial. The majority of patients had at least one weight-related complication. The primary efficacy outcomes were percent change in body weight from baseline to week 68 and percentage of patients who achieved ≥ 5% body weight reduction.4
Proportion of patients achieving clinically meaningful improvements in physical functioning defined as a proportion of patients achieving
A1C: glycated hemoglobin; BMI: body mass index; CI: confidence interval; CVD: cardiovascular disease; GLP-1: glucagon-like peptide-1; HDL: high-density lipoprotein; ITT: intent-to-treat; LDL: low-density lipoprotein; LS: least squares; MI analysis: multiple imputation analysis; MI: myocardial infarction; SD: standard deviation. Go with
an improvement in score of at least 3.7 and 14.6 for SF-36v2 and IWQOL-Lite-CT, respectively, (Wegovy® vs. placebo): SF-36v2: 39.8% vs. 24.1%. IWQOL-Lite-CT: 51.8% vs. 28.3%.#
SELECT TRIAL1,5§
• Of 17,604 patients enrolled in SELECT, the mean follow-up time was 39.8 ± 9.4 months.
• The primary endpoint was the time from randomization to the first occurrence of major adverse cardiovascular events (MACE), defined as a composite endpoint consisting of CV death, non-fatal myocardial infarction, or non-fatal stroke.
• A primary cardiovascular endpoint (MACE) event occurred in 569 patients (6.5%) in the Wegovy® group and in 701 patients (8.0%) in the placebo group (HR = 0.80; 95% CI [0.72, 0.90]; p < 0.001).
In adults with established CVD and overweight or obesity taking CV SoC, Wegovy® demonstrated powerful non-fatal MI relative risk reduction vs. placebo (supportive 2° endpoint, both with standard of care).1,5§
relative risk reduction of non-fatal MI HR = 0.72 (95% CI [0.61, 0.85]); supportive 2° endpoint.
Wegovy®: 2.7% (234/8,803 vs. placebo: 3.7% (322/8,801 events, both with standard care.
What is the dosing schedule for Wegovy®?
Wegovy® has a convenient, once-weekly dosing schedule. The 16-week dose escalation helps reduce the likelihood of GI-related AEs.1
Adapted from the Wegovy® Product Monograph.
Data from the in-trial period. Cumulative incidence estimates are based on time from randomisation to first EAC-confirmed non-fatal myocardial infarction with all-cause death modelled as competing risk using the Aalen–Johansen estimator. Subjects without events of interest were censored at the end of their in-trial observation period.
Time from randomization to first MACE, MACE components, and selected secondary confirmatory endpoints.
If your patient does not tolerate the 2.4 mg dose of Wegovy®:
• Temporarily decrease the dose to 1.7 mg weekly, for a maximum of 4 weeks.
• Patients should re-escalate to the 2.4 mg dose.
If your patient misses a dose, instruct them to:
• Take Wegovy® as soon as possible if the next scheduled dose is at least 2 days (48 hours) away.
• Not to take Wegovy® and resume once-weekly dosing as scheduled if the next scheduled dose is less than 2 days (48 hours) away.
For complete dosing information, please refer to the Product Monograph.
How is Wegovy® administered?
Wegovy® comes in a pre-filled FlexTouch® pen designed for ease of use. Wegovy® is injected subcutaneously.
Each Wegovy® package includes:
• 1 multi-use, prefilled FlexTouch® pen containing 4 fixed doses of one Wegovy® strength (either 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, or 2.4 mg)
• 4 NovoFine® needles
A new prescription is required for each dose strength. Each pen strength (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg) has a unique DIN, and therefore requires a separate prescription to be dispensed. Needles are included with every pen (no separate Rx needed).
from the Wegovy® Product Monograph.
Wegovy is not indicated to reduce the risk of MACE, CV death, non-fatal stroke, heart failure, or all-cause death.
Data are from the in-trial period. Time from randomization to each endpoint were analyzed using a Cox proportional hazards model with treatment as categorical fixed factor. Patients without events of interest were censored at the end of their in-trial period. For the primary endpoint the HR and CI were adjusted for the group sequential design using likelihood ratio ordering. Secondary endpoints are not under multiplicity control. CV death includes both cardiovascular death and undetermined causes of death.
# Baseline SF-36v2 physical function scores: 51.0 (Wegovy®) and 50.8 (placebo). Baseline IWQOLLite-CT physical function scores: 65.4 (Wegovy®) and 64.0 (placebo).
§ SELECT study design: A randomized, double-blind, placebo-controlled, event driven trial in 17,604 patients with BMI ≥ 27 kg/m2 and established CVD (prior myocardial infarction, prior stroke, and/or PAD). Patients with a history of diabetes were excluded. Patients were randomized 1:1 to either semaglutide 2.4 mg or placebo in addition to CV SoC. At baseline, 92.0% of patients were receiving CV medication (70.2% beta blockers, 45.0% ACE inhibitors, 29.5% angiotensin receptor blockers and 26.9% calcium-channel blockers); 90.1% were receiving lipidlowering agents (primarily statins [87.6%]); and 86.2% were receiving anti-platelet agents. The primary endpoint was the time from randomization to first occurrence of MACE, defined as a composite of: CV death, non-fatal MI, or non-fatal stroke.1
£ The composite heart failure endpoint was defined as time to the first occurrence of either heart failure hospitalization, urgent heart failure visit, or CV death.
Watch this step-by-step video to help your patients learn how to use and store Wegovy® in a pre-filled FlexTouch® pen.
How is Wegovy® stored?
Before first use: Store in a refrigerator (2 to 8°C).
After first use: Store below 30°C or in a refrigerator (2 to 8°C) for up to 8 weeks.
• Protect from excessive heat and light (keep the pen cap on). Do not freeze.
• Always remove the injection needle after each injection and store the pen without a needle attached.
• After the final dose of Wegovy® the pen should be discarded in accordance with local requirements.
CV: cardiovascular; EAC: event adjudication committee; GI: gastrointestinal; HR: hazard ratio; MACE: major adverse cardiovascular events; IWQOL-Lite-CT: Impact of Weight on Quality of LifeLite for clinical trials; SF-36v2: Short Form Health Survey Version 2; SoC: standard of care.
What is the safety profile for Wegovy®?
STEP 1-3 trials: In three 68-week, placebo controlled trials, Wegovy® established a safety profile in over 2,000 patients in weight-management clinical trials.1
The most frequently reported adverse reactions (occurring in ≥ 10% of Wegovy® patients) were:1
Nausea
Diarrhea
Constipation
Vomiting
Abdominal Pain
Headache
Fatigue
Most GI events were mild or moderate, of short duration, and did not lead to discontinuation.
Permanent discontinuation of treatment due to GI AEs occurred in 4.3% of people treated with Wegovy® vs. 0.7% placebo.
SELECT trial: The safety profile for Wegovy® in the SELECT trial was generally similar to that reported in the weight-management Phase 3a trials with some exceptions (n = 8,803 taking Wegovy®). Please refer to the Product Monograph for more information on such AEs, including fractures of the femoral neck, femur, hip, and pelvis occurring in 1.0% (24/2,488) vs. 0.2% (5/2,424) of female patients treated with Wegovy® vs. placebo, respectively.1 Wegovy® established a safety profile in over 2,000 patients across weight-management clinical trials and over 8,000 patients in the CV outcomes trial.1
Help your patients manage GI side effects with lifestyle tips by encouraging them to:6
• Reduce meal size.
• Stop eating when full or when not hungry.
• Drink more water and eat high-fibre foods.
• Avoid spicy or high-fat foods.
• Drink fewer carbonated or alcoholic beverages.
Is there a patient support program for Wegovy®?
Yes—before your patients fill their first prescription of Wegovy®, encourage them to enrol in the FREE Novo Nordisk Care® for Wegovy® patient support program by visiting wegovy.ca¶ and entering the DIN: 02528509. With Novo Nordisk Care® for Wegovy® your patients will have access to:
• A savings card¥
• Drug coverage navigation support
• Live support with a program educator (RN, RD, or pharmacist)
• Helpful videos
• Informative articles
• Educational weight-management resources
Visit wegovy.ca¶ today to learn more about how the Novo Nordisk Care® for Wegovy® PSP can support your patients taking Wegovy®!
Novo Nordisk Care® for Wegovy® is valid for Canadian residents only. Program availability may change or end at any time at the manufacturer’s discretion. For more details, see the Program terms and conditions. Coverage eligibility is determined by the patient’s insurance provider and/or plan sponsor. Novo Nordisk Canada Inc. cannot guarantee coverage approvals.
Clinical use:
Wegovy® should not be used in combination with any other semaglutide-containing drug (e.g., Ozempic®, Rybelsus®) or any other GLP-1 receptor agonist. Efficacy and safety in combination with other products intended for weight management have not been established. Wegovy® is not indicated in type 1 diabetes mellitus or diabetic ketoacidosis.
Contraindications:
• Personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2).
• Pregnancy or breast-feeding.
Most serious warnings and precautions:
Risk of Thyroid C-Cell Tumours: In both genders of rats and mice, semaglutide causes treatment-dependent thyroid C-cell tumours. Patients should be counselled regarding the risk and symptoms of thyroid tumours.
Other relevant warnings and precautions:
• Cardiovascular effects: heart rate increase, PR interval prolongation, and use in heart failure
• Theoretical risk of dependence, tolerance, and/or abuse
• Risk of hypoglycemia with concomitant use of insulin or an insulin secretagogue (precaution with driving and operating machinery)
• Gastrointestinal events leading to dehydration
• Delayed gastric emptying
• Acute pancreatitis
• Acute gallbladder disease
• Hypersensitivity
• Retinal disorders in patients with type 2 diabetes
• Suicidal behaviour and ideation
• Aspiration in association with general anesthesia or sedation
• Acute kidney injury
• Use with caution in hepatic insufficiency
• Not for use in end-stage renal disease
• Fertility
• Contraception use recommended
For more information:
Please consult the Product Monograph at www.wegovypm-e.ca for more information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling Novo Nordisk at 1-800-465-4334.
AE: adverse event; CV: cardiovascular; DIN: drug identification number; PSP: patient support program; RD: registered dietitian; RN: registered nurse.
¶ The website wegovy.ca is open to the general public.
¥ Exclusions may apply. The user may still be responsible for costs not covered by their Novo Nordisk Care® savings card. Manufacturer reserves all rights to change or stop this program at its discretion.
References:
1. Novo Nordisk Canada Inc. Wegovy® Product Monograph. April 8, 2025.
2. Pedersen S, et al. Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy in Obesity Management. 2020. Available at: https://obesitycanada.ca/guidelines/pharmacotherapy. Retrieved February 1, 2025.
3. Garvey WT, et al. Two-year effects of semaglutide in adults with overweight or obesity: The STEP 5 trial. Nat Med. 2022;28(10):2083-2091.
4. Wilding JPH, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989-1002.
5. Lincoff AM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023;389(24):2221-2232.
6. Wharton S, et al. Canadian Adult Obesity Clinical Practice Guidelines: Obesity in Adults: A Clinical Practice Guideline. 2020. Available at: https://www.cmaj.ca/content/192/31/E875. Retrieved September 10, 2020.
All trademarks and registered trademarks are the property of their respective owners. Wegovy®, Novo Nordisk Care®, FlexTouch®, NovoFine®, Ozempic®, Rybelsus®, and Apis Bull Design® are registered trademarks of Novo Nordisk A/S used under licence by Novo Nordisk Canada Inc.
Novo Nordisk Canada Inc., tel: (905) 629-4222 or 1-800-465-4334. www.novonordisk.ca
Continued from page 27
NOVA SCOTIA
Nova Scotia’s new program supports private family practice clinics that are ready to build teams.
“The 2023 contract included funding for a pilot project available to family physicians who hire an allied healthcare provider (AHCP),” said a Doctors NS spokesperson. “The pilot project intends to incentivize innovation in primary care resulting in improved access and attachment.”
Participating physicians can bill for the services provided by the AHCP to a maximum of $110,000 per year. All services delivered by the AHCP must be within their scope. Only family physicians in their own practice (not in a health authorityoperated facility) may apply to be part of the pilot project.
It’s too early to evaluate how well this is working.
Meanwhile, do we actually know to what degree collaborative care initiatives boost efficiency and free up doctors to take on new patients?
A 2014 Alberta study of four academic FP clinics that employed RNs and LPNs identified, among other things, the importance of clear leadership and defined roles in bringing about improved workflow and patient access.
The number of primary care providers accepting new patients on Alberta Find a Doctor reached a four-year high of 462 at the end of March 2025, after three successive years of decreases, it says. That included a total of 418 family doctors and 44 nurse practitioners taking patients, with 20 in the south zone, 251 in the Calgary area, 38 in central zone, 89 in Edmonton and 64 in the north, the website states.
It’s important to note that a March 2025 report by the Alberta Auditor General warned that the Alberta Department of Health still needs to make some improvements to its datagathering on PCNs.
A UNIQUE APPROACH
to be nimble in the moment, for example by taking charge of patient questions and answers.
He gave the example of a patient calling the clinic for lab test results. If you’re calling in and everything’s normal, in a traditional clinic the person answering the phone would say, “Hold on, I have to go ask somebody,” Dr. Ram said.
“But our patient care co-ordinators have the training and the backing of the physicians to say, ‘yeah, that is all normal’ . . . as opposed to wasting everybody’s time,” he said.
“The biggest thing is that you pick the right team members, and that it is led by a physician who understands how to leverage and use all of their team to the maximum amount that they are capable of doing,” Dr. Ram said. “Part of that for physicians is actually letting go of the care a little bit, and understanding that the team around you is going to be providing safe care—not equal to what a physician does, but safe care and providing what the patient needs in that moment.
“You just need to hire people that are willing to keep learning, keep educating themselves, and keep moving themselves into a level where they’re providing as much of the full scope care that a patient needs in the moment they need it.”
Overall, he is seeing about double the number of patients he used to see in a more traditional set up, and on the day of our interview he had just seen 50.
Drumheller, Alta., family physician Dr. Rithesh Ram will tell you he definitely sees many more patients now through the teamwork he’s established at the clinic he shares with one other doctor. Together, they have a panel of 5,000 patients.
Dr. Ram’s collaborative care set-up ticks all the right boxes: He chooses and trains his own staff. He has a full-time LPN, fully funded by Alberta’s PCN. His team (including the pharmacist) collaborates closely, through a customized EMR.
He is certain that his team saves him a lot of time by taking care of things he does not need to do himself.
The Riverside Clinic has no wait time, Dr. Ram said, with the two physicians and their team available to both booked patients and walk-ins.
“We don’t have MOAs (medical office assistants), because an MOA has a very specific scope of practice, and they’re trained in a very certain way. So we developed what we call patient care co-ordinators,” Dr. Ram explained.
No MOA, no receptionist. Just four patient care coordinators and a fifth who oversees them.
Dr. Ram said this looser structure enables his office staff
Of course, not every doctor wants to see 50 patients a day.
B/dynorphin (KNDy) neuron to modulate neuronal activity in the thermoregulatory center in the hypothalamus.1**
What was the efficacy profile of VEOZAH in the SKYLIGHT 2 clinical trial?
VEOZAH provided clinically meaningful reductions in the frequency of moderate to severe VMS and provided statistically significant reductions in the severity of VMS symptoms vs. placebo at Weeks 4 and 12.1†
about new
Statistically significant difference between VEOZAH vs. placebo was observed at Week 1 for VMS frequency (secondary endpoint).5-7†
Mean (SD) change from baseline in VMS frequency with VEOZAH: 3.91 (4.30) vs. 2.34 (3.34) with placebo.
Baseline (SD) VMS frequency in VEOZAH group 11.8 (8.26) vs. 11.6 (5.02) with placebo. LS mean difference vs. placebo (SE): -1.71 (0.40); 95% CI: -2.51, -0.91; p<0.001, without multiplicity analysis.
Week 52 data5,6†
The duration of this study is longer than that of the efficacy data included in the VEOZAH Product Monograph. Mean change in the frequency and severity of moderate to severe VMS from baseline to each visit in the extension period was an exploratory endpoint. Assessments after the 12-week placebocontrolled period were descriptive only.
SLEEP DISTURBANCES
VEOZAH demonstrated powerful reductions in self-reported sleep disturbances related to VMS, as measured by the PROMIS SD SF 8B (key secondary endpoint). In the management of VMS, VEOZAH improved sleep disturbances vs. placebo at week 12 (p=0.007).5†
* Comparative clinical significance is unknown.
** Clinical significance unknown.
† SKYLIGHT 2: The efficacy of VEOZAH was evaluated in the first 12-week, randomized, placebo-controlled, double-blind portion of the SKYLIGHT 2 phase 3 study. After the first 12 weeks, postmenopausal women on placebo were then re-randomized to VEOZAH for a 40-week extension to evaluate safety for up to 52 weeks of total exposure. The study included post-menopausal women who had a minimum average of 7 moderate to severe VMS per day. Coprimary endpoints were mean change from baseline in moderate to severe VMS frequency and severity at weeks 4 and 12.1
FREQUENCY: Measured as a daily mean and analyzed as weekly average (calculated as the average frequency over nonmissing days from 7 days).5
SEVERITY: Measured as a daily mean and analyzed as weekly average (calculated as the average frequency over nonmissing days from 7 days).5
LS mean: least squares mean estimated from a mixed model for repeated measures analysis of covariance.1
‡ Statistically significantly superior compared to placebo at the 0.05 level with multiplicity adjustment.1
'' Women previously taking placebo were switched to VEOZAH 45 mg.
§ PROMIS SD SF 8b assesses self-reported sleep disturbance during the prior 7 days and includes perceptions of restless sleep; satisfaction with sleep; refreshing sleep; difficulties sleeping, getting to sleep, or staying asleep; amount of sleep; and sleep quality. Responses to the 8 items range from 1 to 5, and the range of possible summed raw scores is 8 to 40. Higher scores on PROMIS SD SF 8b indicate more disturbed sleep.
¶ Two-sided unadjusted p-value.5
What is the safety profile of VEOZAH?
VEOZAH demonstrated a safety and tolerability profile up to 1 year.1
12–week safety profile
Adverse events that occurred in at least 2% in VEOZAH 45 mg and greater than placebo in two trials£
Special populations
Hepatic impairment1
VEOZAH is contraindicated in individuals with cirrhosis.
VEOZAH is not recommended for use in individuals with Child-Pugh Class B (moderate) chronic hepatic impairment.
VEOZAH has not been studied in individuals with Child-Pugh Class C (severe) chronic hepatic impairment and is not recommended in this population.
No dose modification is recommended for individuals with Child-Pugh Class A (mild) chronic hepatic impairment.
Renal impairment1
52–week safety profile
Adverse events that occurred in at least 2% in VEOZAH 45 mg and greater than placebo over 52 weeksϕ
A numerical imbalance was observed in the incidence of other malignancies between VEOZAH and placebo groups in the long-term safety trial SKYLIGHT 4. A causal relationship between VEOZAH and increased risk of malignancies has not been established.1
Please see the VEOZAH Product Monograph for complete adverse events information.
What is the dosing for VEOZAH?
VEOZAH provides convenient once-daily dosing.
The recommended dose of VEOZAH is 45 mg orally once daily, with or without food. Take VEOZAH with liquids at about the same time every day, and swallow whole. Do not cut, crush, or chew tablets.1
Missed dose
If a dose is missed or not taken at the usual time, patients should take the missed dose as soon as possible, unless there is less than 12 hours before the next scheduled dose. Return to the regular schedule the following day.1
VEOZAH is contraindicated in individuals with severe (eGFR < 30 mL/min/1.73 m2) renal impairment.
VEOZAH has not been studied in individuals with end-stage renal disease (eGFR < 15 mL/ min/1.73 m2) and is contraindicated in this population.
No dose modification is recommended for individuals with mild (eGFR 60 to < 90 mL/ min/1.73 m2) or moderate (eGFR 30 to < 60 mL/ min/1.73 m2) renal impairment.
Dosing considerations1
Perform baseline bloodwork to evaluate hepatic function and assess for injury including serum ALT, serum AST, serum ALP, and serum bilirubin (total and direct) before initiating treatment with VEOZAH.
Do not start VEOZAH if ALT or AST is ≥2 x ULN or if the total bilirubin is elevated (≥2 x ULN).
Proceed with caution if ALT or AST is between >1.5 x ULN and <2 x ULN.
While using VEOZAH, perform follow-up evaluations of hepatic transaminase concentration monthly during the first 3 months, at 6 months, and 9 months after the initiation of therapy.
Advise patients to discontinue VEOZAH immediately and seek medical attention including hepatic laboratory tests if they experience signs or symptoms that may suggest liver injury.
Signs or symptoms that may suggest liver injury include new onset fatigue, decreased appetite, nausea, vomiting, pruritus, jaundice, pale feces, dark urine, or abdominal pain.
Discontinue VEOZAH if transaminase elevations are ≥5 x ULN and/or transaminase elevations are ≥3 x ULN and the total bilirubin level is ≥2 x ULN. If transaminase elevations ≥3 x ULN occur, perform more frequent follow-up hepatic laboratory tests until resolution. Exclude alternative causes of hepatic laboratory test elevations.
See the VEOZAH Product Monograph for complete dosing and administration information.
Is there a patient support program for VEOZAH?
Yes—the VEOZAH® Connect Patient Support Program has been designed to help facilitate the treatment journey with VEOZAH. Benefits include an easy enrolment process, financial support, a call centre available 8am-8pm EST, adherence support, and ongoing patient updates and reminders. For more information:
Phone: 1-855-283-6924 (1-855-2VEOZAH)
Fax: 1-877-298-5167
Email: support@veozahconnect.ca
Clinical use:
Pediatrics (<18 years of age): not indicated Geriatrics (≥65 years of age): no data available; therefore, an indication has not been recommended
Contraindications:
Known cirrhosis
Severe renal impairment or end-stage renal disease
Patients using concomitant moderate or strong CYP1A2 inhibitors
Known or suspected pregnancy
Relevant warnings and precautions:
Incidence of other malignancies
Benefit-risk consideration to treat women with previous or known breast cancer or other estrogen-dependent malignancies
Risk of endometrial hyperplasia and endometrial carcinoma
Not recommended in Child-Pugh Class B (moderate) chronic hepatic impairment; not studied in Child-Pugh Class C (severe) chronic hepatic impairment and is not recommended in this population
Risk of hepatic transaminase elevation and hepatotoxicity
Perform baseline bloodwork to evaluate hepatic function and assess for injury (including serum ALT, serum AST, serum ALP, and serum bilirubin [total and direct]) prior to initiating VEOZAH. Perform hepatic laboratory tests monthly for the first 3 months, at 6 months, and 9 months after initiation of therapy
Not recommended in breast-feeding women
For more information:
Consult the Product Monograph at www. veozahmonograph.ca for important information relating to adverse reactions, drug interactions and dosing information. The Product Monograph is also available by calling 1-888-338-1824.
£ SKYLIGHT 1 and 2 were identical phase 3 efficacy and safety studies that were randomized, placebo-controlled, double-blind for 12 weeks, followed by re-randomization of women previously receiving placebo to VEOZAH (women on VEOZAH remained on VEOZAH) for an additional 40 weeks of active treatment.1
# Abdominal pain includes abdominal lower pain, abdominal upper pain, and abdominal tenderness.1
¥ Liver test elevation includes ALT abnormal/increased, AST abnormal/increased, blood ALP abnormal/increased, blood bilirubin increased, gamma-glutamyltransferase increased, hepatic enzyme abnormal/increased, transaminases increased, and liver function test abnormal/increased.1
ϕ SKYLIGHT 4 was a phase 3, 52-week, randomized, placebocontrolled, double-blind, long-term safety study.1
∆ Liver test elevation includes ALT abnormal/increased, AST abnormal/increased, blood ALP increased, blood bilirubin increased, gamma-glutamyltransferase increased, hepatic function abnormal, hepatic enzyme increased, transaminases increased, and liver function test abnormal/increased.1
For people ≥60 years of age, those with chronic health conditions or weakened immune systems, RSV can take a serious, even fatal toll. 1,2 In older adults hospitalized with RSV:
• ~1 in 9 patients ≥65 years of age died within 30 days3*
• ~1 in 7 patients ≥60 years of age demonstrated a loss of independence at discharge 4†‡
Take action by starting the conversation today
Help avoid the unnecessary toll of RSV.
RSV = respiratory syncytial virus.
* All-cause mortality. Retrospective cohort study from Ontario, Canada. Hospitalization data collected from the 2010–11 to 2018–19 respiratory virus seasons.
† 14% diff erence: 40% of patients lived independently pre-hospitalization (n=122/302) vs. 26% at discharge (n=79/302, p <0.01).
‡ 302 adults ≥60 years of age hospitalized with laboratory-confi rmed RSV were enrolled. Living situation was assessed 2 weeks pre-hospitalization, at enrollment, and at hospital discharge.
1. Centers for Disease Control and Prevention. RSV in older adults fact sheet. Available at: https://www.cdc.gov/rsv/older-adults. Accessed March 2025. 2. Government of Canada. Respiratory syncytial virus (RSV): for health professionals. Available at: https://www.canada.ca/en/public-health/services/diseases/respiratory-syncytial-virus-rsv/ health-professionals.html. Accessed March 2025. 3. Hamilton MA, et al. Predictors of all-cause mortality among patients hospitalized with infl uenza, respiratory virus, or SARS-CoV-2. Infl uenza Other Respir Viruses 2022;16:1072–1081. 4. Branche AR, et al. Change in functional status associated with respiratory syncytial virus infection in hospitalized older adults. Infl uenza Other Respir Viruses 2022;16:1151–1160.
MORE OTC QUESTIONS FROM PATIENTS
In our survey doctors were asked: Thinking about your own practice, compared to five years ago, how often are you speaking with patients about OTC products today?
THE VITAL IMPORTANCE OF OTC COUNSELLING
For more than a decade, the Medical Post Survey on OTC Counselling & Recommendations has highlighted the physician’s importance as counsellors, advisors and influencers in the area of nonprescription products. With the participation of clinicians across Canada, this important survey tracks and monitors which OTC products community doctors are recommending when they advise patients–providing helpful insights used by both your fellow doctors and the nonprescription industry. In the charts on the following pages, you can see how you compare to other Canadian physicians in terms of the nonprescription products you recommend to patients.
Thank you to all who participated in the 2025 OTC Counselling & Recommendations Survey.
Survey methodology
The 2025 Survey on OTC Counselling & Recommendations was an online survey fielded between October 2024 and January 2025 by the research division of EnsembleIQ. A total of 802 Canadian doctors responded to the survey for a margin for error of +3.45% at the 95% confidence level.
In total, 30 product categories were presented to the overall sample of physicians. To establish the OTC brand rankings, respondents were first asked an open-ended question: 1) How often do you make recommendations on this product category each month?
Subsequently, respondents were presented with a comprehensive list of brands for each category and were asked to 2) Please indicate which brand(s) you usually recommend.
Important information about the #1 OTC Brand logo
Only the OTC products voted #1 mostrecommended brands by physicians in the Medical Post’s Survey on OTC Counselling & Recommendations may use this logo or claim to be “Physicians’ most recommended brand.”
Doctors’ most-often recommended products
As part of the national Survey on OTC Counselling & Recommendations, we ask doctors how many times each month they make a recommendation on popular nonprescription products. Below you’ll see the ones they recommend most often.
Anti-nauseant
Blood Pressure Monitor
Responses
Laxative
Responses less than 35% not shown; n=635; 79% recommend in category. Results may total >100% due to multiple brand recommendations.
Pediatric Probiotic
Responses
making Ombrelle the #1 recommended sunscreen brand by physicians.
Scar / Stretch Marks Therapy
Vaginal Lubricant
Gynatrof
Vagisil
Astroglide
Responses less than 16% not shown; n=438; 55% recommend in category. Results may total >100% due to multiple brand recommendations.
AVERAGE RECOMMENDATIONS/MONTH
BASE: Make at least 1 recommendation/month
CONTEST
Pharmacy Practice + Business and Profession Santé 2025 Survey on OTC Counselling and Recommendations (re: pharmacists) The Medical Post and Profession Santé 2025 Survey on OTC Counselling and Recommendations (re: physicians)
Caption the cartoon
WHAT WOULD BE A FUNNY LINE FOR A CHARACTER TO SAY HERE? Use your smartphone to scan the QR code above—or go online to https://www. canadianhealthcarenetwork.ca/caption-junes-cartoon-knife—and you can enter your answer on the Medical Post’s online home. If your answer is selected, you’ll receive a $75 Amazon gift card and this cartoon will re-run in the next issue of the Medical Post magazine with your caption! So you get money—and doubtless esteem and accolades from your colleagues!
Caption contest winner
“I take back what I said before. Let’s go with the ‘conservative’ treatment.”
We had a lot of great entries for the caption-the-cartoon contest in the last issue of the magazine, but we thought Dr. Nizaar Lilla’s entry above was the funniest. Dr. Lilla, a psychiatrist in New Westminster, B.C., will receive a $75 Amazon gift card as a prize.
What is Vyepti® indicated for?
Vyepti® (eptinezumab for injection) is indicated for the prevention of migraine in adults who have at least 4 migraine days per month. 2
How is Vyepti® administered?
Recommended dose: 100 mg administered as one 30-minute IV infusion every 12 weeks 2
Vyepti® is given as an intravenous infusion (after dilution) by a healthcare professional.
Infused over approximately 30 minutes.
The treatment benefit should be assessed 3-6 months after initiation of the treatment. Any further decision to continue the treatment should be made on an individual patient basis and determined prior to each dose. 2 See the Vyepti® Product Monograph for complete dosing and administration information.
What are the select pharmacokinetics of Vyepti®?† Absorption
Administered by intravenous infusion which bypasses extravascular absorption and is 100% BIOAVAILABLE 2
Median time to peak concentration was attained at the end of infusion 30 MINUTES2
See the Vyepti® Product Monograph for complete pharmacokinetic information.
What were the efficacy data for Vyepti® in chronic migraine patients in the PROMISE-2 trial?
In PROMISE-2, Vyepti® 100 mg demonstrated significant reductions in mean monthly migraine days (MMDs) during weeks 1-12 vs. placebo in chronic migraine. 2,3‡§
• The mean migraine frequency at baseline was 16.1 migraine days/month and was similar across treatment groups. 2
• 41% of patients were taking concomitant preventive medication for migraine.2
What were the efficacy data for Vyepti® in episodic migraine patients in the PROMISE-1 trial?
In PROMISE-1, Vyepti® 100 mg demonstrated significant reductions in mean MMDs during weeks 1-12 vs. placebo in episodic migraine. 2,4‡¶
• The mean migraine frequency at baseline was 8.6 migraine days/month and was similar across treatment groups. 2
• 96.4% (n=856) of patients were taking at least 1 acute concomitant headache medication and 4.6% (n=41) of patients were taking at least 1 prophylactic headache medication. Regular use (greater than 7 days per month) of other treatments for the prevention of migraine was not allowed.2
What were the efficacy data for Vyepti® in episodic and chronic migraine patients with 2-4 prior migraine preventive treatment failures in the DELIVER trial?
In DELIVER, Vyepti® 100 mg demonstrated greater reductions in MMDs vs. placebo from weeks 1 to 12 and from weeks 13 to 24.
MMDs=monthly migraine days
*Comparative clinical significance is unknown.
† Clinical significance is unknown.
‡ Baseline was the average over the 28-day screening period prior to receiving treatment. The change from baseline in MMDs (weeks 1-12) was analyzed using ANCOVA with baseline MMDs as covariate and treatment and prophylactic medication use (Yes/No) as fixed effects.
¥ Baseline was the average over the 28-day screening period prior to receiving treatment. The change from baseline in MMDs (Week 1-12) was analyzed using ANCOVA with baseline MMDs as covariate and treatment as a fixed effect.
§ PROMISE-2: A parallel-group, double-blind, placebo-controlled global trial to evaluate the efficacy and safety of Vyepti® for the preventive treatment of chronic migraine in adults (defined as ≥15 to ≤26 headache days, of which ≥8 were assessed as migraine days). A total of 1,072 patients were randomized and received placebo (n=366), Vyepti® 100 mg (n=356), or Vyepti® 300 mg (n=350) every 12 weeks for 24 weeks (2 infusions). During the trial, patients were allowed to use acute or preventive medication for migraine or headache on an established stable regimen (except for onabotulinumtoxinA). Patients with a dual diagnosis of chronic migraine and medication overuse headache (associated with the overuse of triptans, ergotamine, or combination analgesics >10 days/month, or acetaminophen, acetylsalicylic acid, or non-steroidal anti-inflammatory drugs ≥15 days/month) were included in the study population. Patients using opioids or butalbital-containing products >4 days/month were excluded.
¶ PROMISE-1: A parallel-group, double-blind, placebo-controlled global trial to evaluate the efficacy and safety of Vyepti® for the preventive treatment of episodic migraine in adults (defined as ≥4 and ≤14 headache days of which at least 4 had to be migraine days during the 28-day screening period) in adults. A total of 888 patients were randomized and received placebo (n=222), Vyepti® 30 mg (n=223), Vyepti® 100 mg (n=221), or Vyepti® 300 mg (n=222) every 12 weeks for 48 weeks (4 infusions). Patients were allowed to use concurrent acute migraine or headache medications, including migraine-specific medications (e.g., triptans, ergotamine derivatives), during the trial. Regular use (greater than 7 days per month) of other treatments for the prevention of migraine was not allowed.
# DELIVER: A parallel-group, double-blind, placebo-controlled efficacy and safety study of Vyepti® for the preventive treatment in episodic migraine (defined as migraine occurring on ≥4 days and headache occurring on ≤14 days) and chronic migraine (defined as migraine occurring on ≥8 days and headache occurring on ≥15 days) in patients with two-to-four prior migraine preventive treatment failures. A total of 892 patients were randomized and efficacy analysis was based on 890 patients (eptinezumab 300 mg n=293, eptinezumab 100 mg n=299, placebo n=298). During the trial, patients were allowed to use acute antimigraine medications. The mean migraine frequency at baseline was 15 migraine days/month and it was similar across treatment groups. The primary efficacy endpoint was the change from baseline in mean MMDs over weeks 1-12. The key secondary endpoints included the proportion of patients with ≥50% and ≥75% reductions from baseline in MMDs over Weeks 1-12 and change from baseline in the number of MMDs over Weeks 13-24.
Vyepti®
• The mean migraine frequency at baseline was 15 migraine days/month and was similar across treatment groups. 2
• 94% of patients were taking concomitant preventive medication for migraine.2
In DELIVER, for patients with prior preventive treatment failure, Vyepti® 100 mg demonstrated ≥75% and ≥50% MMDs reduction from baseline in patients taking Vyepti® vs. placebo (key secondary endpoints). 2,5#
What is the safety profile of Vyepti®?
The safety profile of Vyepti® was evaluated in clinical trials in more than 2,000 patients with episodic and chronic migraine who received at least one dose of Vyepti®, representing more than 1,600 patient-years of exposure; of these, approximately 1,500 patients were exposed to 100 mg or 300 mg. 2
The most common adverse reactions in the placebo-controlled clinical studies (PROMISE 1 and PROMISE 2) for the preventive treatment of migraine were nasopharyngitis and hypersensitivity reactions. 2
Adverse reactions in Vyepti®-treated patients (and more frequently than in patients receiving placebo)2
The following treatment-emergent adverse events were observed in ≥1% of Vyepti® 100 mg patients and equal to or greater than placebo. 2
Treatment-emergent
Exclusion criteria: Both studies excluded patients with a known history of cardiovascular disease (hypertension, ischemic heart disease), neurological disease, cerebrovascular disease, morbid obesity and diabetes, alcohol/ drug abuse, and severe mental disorders. 2
Is there a patient support program for Vyepti®? Yes—staffed by qualified healthcare professionals and reimbursement specialists, the Vyepti TODAY® Patient Support Program is designed to support the patient journey from prescription to infusion.
Ask us to find out if Vyepti® is covered or has public funding in your province (criteria in addition to the indicated condition apply).
Contact us for more information and to get your patients started: Call 1-833-8-VYEPTI (893784) Email support@vyeptitoday.ca Fax 1-833-9-VYEPTI (893784)
Clinical use:
• Vyepti® should be prescribed by healthcare professionals experienced in the diagnosis and treatment of migraine.
• No data are available in the pediatric population (<18 years of age). Therefore, Vyepti® is not authorized for pediatric use.
• The safety and efficacy of Vyepti® has not been established in geriatric patients (≥65 years of age). The clinical study program of Vyepti® did not include sufficient numbers of these patients to determine whether they respond differently from younger patients.
Most serious warnings and precautions:
Hypersensitivity reactions: Serious hypersensitivity reactions, including angioedema, urticaria, rash and anaphylactic reactions have been reported with the CGRP-class products including Vyepti®. These reactions may develop within minutes of the infusion. If a serious hypersensitivity reaction occurs, administration of Vyepti® should be discontinued immediately and appropriate therapy initiated.
Other relevant warnings and precautions:
• Patients with cardiovascular diseases
• Patients with diabetes or morbid obesity
• Patients with hereditary fructose intolerance (HFI)
• Hepatic insufficiency
• Patients with HIV, Hepatitis B and C
• Patients with autoimmune disorder
• Patients with neurological disorder
• Renal Insufficiency
• Fertility
• Pregnancy
• Breastfeeding
For more information:
Please consult the product monograph at https://www.lundbeck.com/content/ dam/lundbeck-com/americas/canada/products/files/vyepti_product_ monograph_english.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 us at 1-800-586-2325.
References:
1. Data on file. Lundbeck Canada Inc. 2. Vyepti® Product Monograph. Lundbeck Canada Inc. 3. Lipton RB, et al. Efficacy and safety of eptinezumab in patients with chronic migraine: PROMISE-2. Neurology. 2020 Mar 31;94(13):e1365-e1377. 4. Ashina M, et al. Eptinezumab in episodic migraine: A randomized, double-blind, placebo-controlled study (PROMISE-1). Cephalalgia. 2020 Mar;40(3):241-254. 5. Ashina M, et al. Safety and efficacy of eptinezumab for migraine prevention in patients with two-to-four previous preventive treatment failures (DELIVER): a multi-arm, randomised, double-blind, placebo-controlled, phase 3b trial. Lancet Neurol. 2022;21:597-607.
Vyepti® is a registered trademark of H. Lundbeck A/S, used under license by Lundbeck Canada Inc.
Vyepti TODAY® is a registered trademark of H. Lundbeck A/S, used under license by Lundbeck Canada Inc.
Vyepti TODAY™ is a trademark of H. Lundbeck A/S, used under license by Lundbeck Canada Inc.
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BY DR. GINEVRA MILLS
I remember a time, not long ago, when it was rare to have time for something like this—not just time in the technical sense, but the mental bandwidth, the energy, the breath it takes to prioritize myself before anything else.
Beyond productivity
What efficiency in medicine should really mean
My alarm clock rings a little earlier than it needs to most mornings. In the spring and summer months, I appreciate the opportunity to take advantage of early morning sunlight to get outside and exercise before the rush of the day begins. Before it’s time to get the kids ready for school and out the door— before I scramble to pack a somewhat healthy lunch and get out the door myself. I lace up my shoes and leave the house while the sun is just beginning to peek over the trees. Everyone is still fast asleep in bed, and I know that when I come back, the peaceful facade of my
morning will have evaporated. The air is crisp, but I head toward the ocean.
The edge of the wind sharpens as the ocean comes into view. The sunlight slants just right through the grey clouds, beckoning me toward the shore. When I arrive, I run along the beach until time reminds me that I must turn around, back toward the world of responsibility. As I turn for home, a gentle rain starts to fall—cool and clean on my skin. Home is always uphill, but my lungs ache in a satisfying, spent kind of way. I feel alive. Grateful. Grounded. All from my short morning run.
Before adjusting my practice, I drove past the water every morning, wishing I had time to run, or even to stop at the beach and sit there for a few minutes to catch my thoughts. But long days charting and evenings preparing for clinic meant I went to bed too late. Nighttime ruminations on difficult patients and worries about medical errors clogged my mind. Even if I had carved out time, I’m not sure it would have had the same grounding effect. I doubt I would have lifted my head from the pavement in front of me to notice the sky, let alone run toward it.
As physicians, we work exceptionally hard to provide the best care for our patients. We seek out methods of becoming more efficient so that we can, purportedly, become better at our jobs. We build templates into our EMRs and implement the use of AI scribes to make accurate documentation easier. We optimize workflows in our clinics to save money and improve patient experience. Maybe, we can see more patients in a day or reduce the non-patient care burden that we carry on behind the scenes.
On paper, we’ve become impressively productive as a profession.
Somewhere along the way, however, it seems that we’ve stopped asking a deeper question about our motivations for making these changes: What do we really
COLUMN
gain by becoming more efficient in our medical practices?
We work in a system where we are the limited resource up against an unlimited demand for medical expertise. It’s no surprise that we equate efficiency with volume—more patients seen, more problems addressed, more boxes checked in less time. But that version of efficiency doesn’t create space. It consumes it. It turns physicians into machines that never quite power down. In this way, efficiency in our medical practices can leave little room for the human aspects of our job—or of ourselves.
From early in our medical education, we are conditioned to accept this narrative of physicianhood. For years, I rarely questioned the exhaustion that came from long, stressful hours. Or the fragmentation of my life into little blocks that fit around my career. Never mind the fact that, in the dark recesses of winter, I could often go whole weeks barely seeing daylight. I believed that was the cost of being good at my job. Until one day, it wasn’t sustainable anymore. While I never intentionally set out to change everything about my approach to practicing medicine, sometimes life redraws the map for us.
As I’ve been building a new practice over the last year, I naturally sought out ways to make this practice as efficient as possible. I was surprised to discover, though, that my understanding of efficiency in medicine began to evolve— not as a reaction to a crisis in my life, but as a question of personal and professional alignment. I began to ask myself some different kinds of questions about efficiency in my life: What kind of life do I want to build for myself with the tools I’ve been handed? And, what kind of person do I want to become in the process?
In any profession, it is easy to confuse efficiency with acceleration. In medicine, if we can move faster, see more patients, do more procedures, document quicker, we can fill more space. But real efficiency—wise efficiency— should create space, not take it away. It should help us spend our time where it matters most: on helping us live happy, wholesome and rewarding lives. The truth is, this type of efficiency doesn’t
“When systems in medicine are built to support presence instead of pressure, we can offer our patients more than quick appointments with rushed decisions and split attention.”
just benefit us—it benefits our patients, as well.
When systems in medicine are built to support presence instead of pressure, we can offer our patients more than quick appointments with rushed decisions and split attention. It can support the quiet moments that allow us to listen to a patient without glancing at the clock, or to sit with the unexpected turns of our days without mentally triaging the next 10 tasks waiting to be finished. It allows us to embrace the values we have in our lives so that we can show up more fully for our patients and return home with enough of ourselves left to live lives of meaning and connection.
Efficiency in medicine shouldn’t only be about enhancing our professional lives without attention to our personhood. It should be the means through which we honour both. None of us went into medicine because we wanted to become more efficient. We entered the field to connect, to serve and to be present for people in moments that matter. But presence takes time—and increasingly, time feels like the one thing we’re never allowed to have as physicians.
There will always be ways that I can improve my productivity and efficiency in my new practice. As it continues to grow, I know that inefficiencies will continue to rear their heads and threaten to upend the work-life integration I’ve come to value most. These days, I try to notice when that balance is present— like in the mornings, when I can run
to the ocean before work. It’s not a big accomplishment, but it marks something important: I had the time, the space and the energy to begin my day with intention. And, I still got to be a mom who got her kids out the door, made it to work on time, and was ready to be fully present to care for my patients.
Overwork and burnout do not have to be an inevitable part of medicine, as if it’s simply the cost of doing good work. We should continue to seek efficiency in our medical practices to improve patient care and alleviate the negative pressures of our professional lives. However, we should seek out efficiency to answer an ever important question: How can we do this work well and still have something left for ourselves?
The answer isn’t working harder. It’s working wiser.
It’s redefining efficiency not as a way to push ourselves further, but as a way to keep ourselves whole.
DR.
GINEVRA MILLS is a reproductive endocrinologist and infertility specialist based in Victoria.
Submissions
Doctor: Got a story to tell or a view for which you’d like to make a case?
Send it to Canadian Healthcare Network Editor Martha Porado at mporado@ensembleiq.com Items run in our Doctor Daily newsletter.
Learn about DAYVIGO® and considerations for use
Do your patients have trouble falling asleep or staying asleep?
DAYVIGO (lemborexant) is indicated for the treatment of insomnia, characterized by difficulties with sleep onset and/or sleep maintenance1
UNDERSTANDING THE SLEEP CYCLE
• The sleep cycle is divided into 4 stages: Non-rapid eye movement (NREM) sleep stages N1–N3 and the rapid eye movement (REM) sleep stage. 2,3
• Most people experience 4 to 6 sleep cycles a night. 2,3
• The sleep stages are based on analysis of brain activity during sleep, which demonstrates distinct characteristics. 2,3
The Stages of Sleep2,3
1
EEG recording: theta waves - low voltage. The lightest stage of sleep. Muscle tone is present in the skeletal muscle, and breathing occurs regularly.
EEG recording: beta waves - similar to brain waves during wakefulness. REM is associated with dreaming and not considered restful. Rapid eye movements. Breathing rate is erratic and irregular.
DAYVIGO (lemborexant) is indicated for the treatment of insomnia, characterized by difficulties with sleep onset and/or sleep maintenance.1
DAYVIGO’S MECHANISM OF ACTION*
DAYVIGO is a hypnotic. It belongs to the pharmacologic class of dual orexin receptor antagonists.1 Orexins are neuropeptides that studies suggest play an important role in the maintenance and regulation of wakefulness.4
• Orexin Types: Orexin A and Orexin B.4
• Orexin Receptor Types: The actions of orexins are mediated by 2 receptors: Orexin Receptor Type 1 (OX1R) and Type 2 (OX2R).4
DAYVIGO is a competitive antagonist of both orexin receptors, OX1R and OX2R, with a higher affinity for OX2R.1
• The orexin neuropeptide signaling system is a central promoter of wakefulness.1
• Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R is thought to suppress wake drive.1
2
EEG recording: sleep spindles and K complexes. A deeper sleep than Stage 1. Heart rate and body temperature drops.
Each cycle lasts about 90 minutes.
EEG recording: delta waves - lowest frequency, highest amplitude. Also known as slow-wave sleep (SWS). The deepest stage of sleep. Most difficult to waken from.
Explaining how DAYVIGO works to your patients
DAYVIGO belongs to a group of medicines called “dual orexin receptor antagonists”. Orexins are chemicals that bind to certain receptors in your brain to keep you awake. DAYVIGO temporarily blocks the orexin receptors. This may help you fall asleep faster and stay asleep longer.1
• In the daytime, orexins help us stay awake.
• At night, DAYVIGO temporarily blocks orexin receptors and this may help you fall asleep and stay asleep.
PHARMACODYNAMICS: SLEEP
ARCHITECTURE
In patients with insomnia, DAYVIGO led to increases in both non-REM and REM sleep as assessed by polysomnography. The increases in REM sleep were statistically significantly greater for both doses of DAYVIGO compared to placebo at both the beginning (Days 1 and 2) and end (Days 29 and 30) of treatment.1
EFFECTIVE AS QUICKLY AS NIGHTS 1,2 (calculated as the mean of nights 1 and 2)1† DAYVIGO 5 mg and 10 mg were superior to placebo in time to sleep onset at Nights 1,2. The primary efficacy endpoint was the mean change in latency to persistent sleep (LPS) from baseline to end of treatment, as measured objectively by polysomnography. LPS was defined as the number of minutes from lights off to the first 10 consecutive minutes of non-wakefulness.
• Each of the 4 to 6 sleep cycles a night lasts about 90 minutes; however, the length of a sleep cycle can vary throughout the night. 2,3
• During the first half of the night, most of the time is spent in deep sleep—the N3 stage commonly lasts 20 to 40 minutes. As the night progresses, however, more time gets spent in REM sleep and less in deep sleep. 2,3
Sleep Architecture: The analysis of the different cycles and stages of sleep is commonly referred to as sleep architecture. It provides information about factors that can alter sleep architecture, such as sleep disorders. 2
Mean change from baseline in LPS at Nights 1,2: DAYVIGO 5 mg: -17 minutes ( p<0.01) DAYVIGO 10 mg: -19 minutes ( p<0.001) placebo: -6 minutes
Significant reduction in wake after sleep onset1† DAYVIGO 5 mg and 10 mg were superior to placebo in reducing time spent awake after sleep onset (WASO) at Nights 1,2. The secondary efficacy endpoint was the mean change from baseline to end of treatment in wake after sleep onset (WASO) measured objectively by polysomnography. WASO was defined as the minutes of wake from the onset of sleep until wake time.
Mean change from baseline in WASO at Nights 1,2: DAYVIGO 5 mg: -51 minutes ( p<0.001) DAYVIGO 10 mg: -60 minutes ( p<0.001) placebo: -18 minutes
DAYVIGO 5 mg achieved clinical significance vs. placebo
In two studies, DAYVIGO 5 mg achieved clinical significance vs. placebo for both sleep latency and time spent awake after sleep onset as assessed both subjectively by the patient and objectively by polysomnography.1†‡
12-MONTH EFFICACY DATA
DAYVIGO demonstrated sustained improvements in sleep over 12 months of treatment.1
* Clinical significance unknown.
† A 1-month multicentre, randomized, double-blind, placebo-controlled, parallel-group Phase III study in 1006 patients (263 patients were randomized to active comparator), 55 years and older with insomnia disorder, using both polysomnography and patient sleep diaries.
‡ A long-term, randomized, double-blind, placebo-controlled, multi-center trial in adult patients aged 18 or older who met DSM5 criteria for insomnia disorder. The study had 2 periods: a 6month placebo-controlled treatment period (Period 1), followed by a 6-month period (Period 2) where patients who previously received placebo were re-randomized in a double-blind fashion to receive only active treatment: DAYVIGO 5 mg or DAYVIGO 10 mg.
The orexin neuropeptide signaling system is a central promoter of wakefulness.
Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R is thought to suppress wake drive.
Orexin Orexin Receptor DAYVIGO
SAFETY INFORMATION
Somnolence was the most common adverse event
In clinical trials of patients with insomnia treated with DAYVIGO 5 mg or 10 mg, the most common adverse reaction (reported in 5% or more of patients treated with DAYVIGO and at a higher rate than placebo) was somnolence (DAYVIGO 5 mg 7%, DAYVIGO 10 mg 11%, placebo 2%). DAYVIGO was associated with a doserelated increase in somnolence.1
Percentage of patients with treatment-emergent adverse events1
(Incidence ≥ 1% in any DAYVIGO treatment group where the incidence in the DAYVIGO group was more than placebo from Sunrise 1 and Sunrise 2 studies.)
Tips for using DAYVIGO1
• Take right before bed: Take DAYVIGO once a day within a few minutes of going to bed.
• Give it time: Only take DAYVIGO when you can get at least 7 hours of sleep.
• Avoid eating close to taking: Time to sleep onset may be delayed if taken with or soon after a meal.
• Don’t mix: Do not take DAYVIGO with alcohol, sedatives, or other medicines that make you sleepy.
• Use as your doctor prescribed: Talk to your doctor if after 7 to 10 days your sleep problems do not get better or get worse; this may mean there is another condition causing your sleep problems.
• Take a missed dose only if you have time to sleep for 7 hours. If you miss a dose and you do have time to sleep for at least 7 hours before you must wake up again, take your dose as usual. If you do not have time to sleep for at least 7 hours before you must wake up again, do not take your dose. Take it the next night when you can ensure at least 7 hours before you must wake up.
Most common adverse event resulting in discontinuation of treatment
Somnolence was the most common adverse reaction leading to discontinuation, with an incidence similar to placebo: 1% for DAYVIGO 5 mg, 2% for DAYVIGO 10 mg, and 1% for placebo.1
Long-term safety
Over 12 months of continuous treatment, adverse reactions were consistent with those observed during the first month of treatment.1
Physical dependence and withdrawal profile
In completed clinical trials with DAYVIGO, there was no clear evidence of physical dependence or withdrawal symptoms upon discontinuation of prolonged use of DAYVIGO as assessed by the Tyrer Benzodiazepine Withdrawal Symptom Questionnaire.1
Caution should be exercised when prescribing DAYVIGO to individuals with a history of substance use disorder, including addiction to, or abuse of, alcohol and other sedative drugs due to risk of misuse or abuse.1
COUNSELLING FOR YOUR PATIENTS TAKING DAYVIGO
Dosing
See the Product Monograph for complete dosing and administration information.
DAYVIGO is covered by most Canadian private insurance plans.¶
Clinical use:
DAYVIGO is not recommended for patients under the age of 18 years.
DAYVIGO is not recommended in patients with severe hepaticimpairment.
Contraindications:
• Hypersensitivity to this drug or to any ingredient in the formulation, including any non-medicinal ingredient, or component of the container.
• Patients with narcolepsy.
Relevant warnings and precautions:
• Abnormal thinking and behavioural changes
5 mg and 10 mg doses
Start with the lowest effective dose for the patient.1
•The recommended dose of DAYVIGO is one 5 mg tablet taken no more than once per night, within a few minutes before going to bed, with at least 7 hours remaining before the planned time of awakening.1
•T he dose may be increased to the maximum recommended dose of 10 mg based on clinical response and tolerability.1
•Response should be evaluated after 7 to 10 days. If symptoms fail to remit after 7 to 10 days, alternative primary psychiatric or medical illness should be considered.1
D ose adjustments1
• CNS depressant effects (including alcohol) and daytime impairment and risk of falls
• Complex sleep behaviours
• Sleep paralysis, hypnagogic/hypnopompic hallucinations, and cataplexy-like symptoms
• Worsening of depression/suicidal ideation
• Drug interactions - inhibitors and inducers of CYP3A
• Patients with galactose intolerance
• Driving and operating machinery
• Patients with dependence/tolerance and abuse liability
• Rebound insomnia
• Patients with hepatic impairment
• Patients with compromised respiratory function
• Pregnant or breastfeeding women
For more information:
Please see the Product Monograph at https://ca.eisai.com/ en-CA/our-products for important information on adverse reactions, drug interactions, and dosing not discussed in this piece. The Product Monograph is also available by calling 1-877-873-4724.
¶ Data on file, Eisai Limited.
References:
1. DAYVIGO Product Monograph, Eisai Limited, January 30, 2025.
2. Suni E. Stages of Sleep: What happens in a Sleep Cycle. The Sleep Foundation 2023. www.sleepfoundation.org/stages-of-sleep (accessed March 10, 2025).
3. Patel AK, et al. Physiology, Sleep Stages. NIH, National Library of Medicine https://www.ncbi.nlm.nih.gov/books/NBK526132/ (accessed March 28, 2025).
4. Mieda, M. The roles of orexins in sleep/wake regulation. Neuroscience Research 2017;118:56–65.
DAYVIGO® is a registered trademark of Eisai R&D Management Co., Ltd. and is licensed to Eisai Inc. Eisai Limited, 6925 Century Avenue, Suite 701, Mississauga, Ontario L5N 7K2
COLUMN
Nothing stays the same
An
avid hiker faces a fall, a fever and the unpredictable
course of sickness
It’s the last day of a wet and humid long weekend. I’ve been in the ER all three days and it’s been quiet. Often, it picks up on the final day of a long weekend, so it seems we’re overstaffed.
My first patient is a middle-aged woman with three days of lower abdominal pain. She’ll have diverticulitis. My second patient is also middle aged, and a month ago, he was diagnosed with paroxysmal atrial fibrillation. Twice, he’s had a cardioversion, but he still has several episodes of atrial fibrillation daily, and wants to get fast-tracked to his ablation. So he’s in the ER, despite having excellent rate-control and a followup scheduled with his cardiologist in the morning. “What if,” he said, “I refuse to leave this hospital until I have my ablation.”
“Listen,” I say. “If I could do it for you right now, I would. And if there’s any other way I can help you, I will.”
I’m not even an hour into my shift when I’m paged to resuscitation room B.
Rhonda Brown (not her real name) is in her late 60s. She’s an avid hiker, and she was here yesterday. She’d been hiking one of the many local forested trails when she slipped and tumbled 4.5 metres down a steep embankment. Because of the humidity, she and her companion had decided to bypass a segment of the trail.
The ground was wet and muddy and her foot slid forward with her first step. She tumbled through jagged edges jutting from the ground, fallen tree branches and weeds before finally coming to a stop in a wet patch. An ambulance was called and by the time she was seen by my colleague yesterday, the nurses had undressed her and cleansed most of her wounds.
Pain everywhere
Her only medications are a blood thinner for atrial fibrillation and an antihypertensive. After the fall, she had pain everywhere so she was pan-scanned by my colleague. Her blood tests were normal, as were CT scans of her head,
BY DR. RAJ WAGHMARE
chest abdomen and pelvis. Her arms, legs and forehead were covered in cuts and scratches, but X-rays were negative for fractures. Only one wound, on her right shin, required suturing.
“Such a nice lady,” my colleague later told me, “while I was stitching her, she was telling me that she looks after her grandkids and that she plays pickleball and golf at least three times a week.”
When I ask what brings her in today, her husband, at the bedside, gives me a quick run-down of the day before. I listen, and then tell him that I’ve reviewed her notes, the scans and the blood tests.
“I don’t want to blame anyone,” Rhonda’s husband said. “But the nurse who came today took one look at her and said that she should have never been sent home.”
I’ve been called over because Rhonda is sick. Very sick. She has a fever of almost 40 C, her heart rate is 130 and her blood pressure is terribly low. She’s septic. In fact, although she’s alert, conversing with her family, and able to answer my questions, she’s clearly in septic shock. The wound-care nurse my colleague arranged found Rhonda weak and bed-ridden. She was OK in the morning, but progressively worsened throughout the day.
Rhonda says since the fall, she’s had pain everywhere—her head, her neck, her chest, her arms and her legs. That being said, no specific area is particularly painful. Regarding the fever, she hasn’t had a sore throat, cough, flu-like symptoms, no urinary nor gastro-intestinal symptoms. Her heart sounds are normal, just fast, and her lungs are clear. She’s pale, with a normal neurological exam, but when she answers some questions, she stutters. Her adult son, who arrived at the
bedside shortly after I did, speaks. “My mom doesn’t normally talk like this.”
I examine her wounds. There are many scrapes and scratches, but none appear to be particularly bad or infected. The only thing I find is that her right leg, just above the ankle, is very, very tender. It may be slightly warm, but it isn’t red. Also, although it’s on the same extremity on which she received sutures, the wound is quite a distance from the area that’s tender.
I tell her family that Rhonda is septic. I tell them that I’m not sure why, and that we’re going to treat her with aggressive re-hydration, broad spectrum antibiotics and run some tests.
I see a few more patients—a 78-yearold with palpitations, a one-year-old who’s been vomiting, and an 82-yearold who fell two days ago. He’ll have a broken neck. It wasn’t like this a decade ago. It seems now that every second patient is old. And sick. My phone rings.
“Can you come back to resus?”
Rhonda’s had two litres of saline and her blood pressure is still in the 70s. The nurse asks if I want to start norepinephrine, but I put my fingers on Rhonda’s wrist and the pulse seems strong. I cycle the blood pressure cuff. She’s at 105 systolic now. “I think we can hold off,” I say.
Ten minutes later, the nurse calls me back. I look at the monitor. Rhonda’s blood pressure is back in the 70s.
“How did that happen,” I say. “She was just at 100.”
“OK,” the nurse said. “I didn’t tell you, but I’d actually started the norepinephrine before I asked you, so that’s why her blood pressure went up.”
I nod. “Yeah, go ahead, start it.” I’ll talk to the ICU.
I page the ICU doctor and tell him the story. He has many questions, and asks several of them twice. I understand—it’s a strange story, and it’s shocking she’s come back so sick. He says he’ll come see her as soon as he can. Meanwhile, Rhonda’s family asks me to assess her again. She’s communicating with them, and she answers my questions, but her speech is becoming slower. Her son repeats what he told me before: “Something’s wrong. She doesn’t
normally talk like this.”
She’s getting the maximum amount of norepinephrine and fluids are still infusing. I throw on more antibiotics and give her a few pulse doses of phenylephrine. Her blood pressure barely moves.
Later that night
Later that night, Rhonda is transferred to the ICU. Although she’s on three vasopressors, her blood pressure remains low. Meropenem, vancomycin and clindamycin are given to combat sepsis. Her kidneys begin to fail and she stops making urine.
By morning, things aren’t getting better. Her level of awareness decreases, so the morning doctor discusses intubation and ventilation with her. She consents.
Her right lower leg remains the only suspicious source of infection, so a plastic surgeon infiltrates the leg with local anesthetic and cuts deep into her tissues to look for necrotizing fasciitis. The tissues appear normal. There are no signs of necrotizing infection; there isn’t even pus. A portable chest X-ray shows new interstitial markings; early acute respiratory distress syndrome is suspected.
By evening, Rhonda’s clinical picture is that of mixed septic and cardiogenic shock. Her doctors doubt that her leg alone could have caused such severe illness. Perhaps, it is thought, she had some undiagnosed underlying illness and her fall, along with her infected wound set off a cascade that ended with heart failure.
Overnight, Rhonda continues to worsen, until the following morning, her family asks doctors to withdraw care.
Afterword
I thought back to what Rhonda’s husband had said early on: “I don’t want to blame anyone. But the nurse who came today took one look at her and said they never should have sent her home.”
I discussed the case with my colleague who had seen her the day before. He was shocked and saddened.
“What could you have done differently,” I said. “The woman I saw on
Monday night was a completely different patient than the one you saw 24 hours later.” This is the nature of medicine, and it’s the nature of life. Everything changes. Constantly. This is what I’d told her husband. When Rhonda walked out of the hospital, she had normal vital signs, and no fever. “One of her wounds became infected, even though they were washed out, cleansed and dressed. And somehow, she became critically ill.”
“Maybe I could have put her on antibiotics,” he said.
I told him about the 90-year-old I’d seen at a rural hospital in the first year of my career. He had a massive heart attack, and was turning blue right in front of me. I crossed my fingers and gave him a thrombolytic. “You’ve got balls,” the specialist at the regional cardiac centre said, as I prepared him for transfer.
“Yeah,” I said, “Trust me, I’m still shocked he didn’t bleed to death after the infusion.”
He spent a week at a tertiary care centre before being transferred back to our rural hospital for one night. The next day, as he was preparing to go home, he told me that his hand was sore where the IV had been inserted. It was a little red and a little warm. I gave him a seven-day course of antibiotics.
He survived the heart attack and the thrombolytics, but several days later, he returned with Clostridium difficile from the antibiotics. He was dead within days.
“We see a dozen cuts and scrapes every day,” I told my colleague. “We can’t be giving them all antibiotics. Her case was one in 10,000.”
It was the same when I explained it to Rhonda’s husband. He understood immediately that the patient that walked out of the hospital the first night was entirely different from the one who returned the next day. I went one step further when discussing the case with my colleague. Had we kept her, against her will, in the hospital, and watched her minute by minute for any sign of complication from her fall, it is more than likely that she still would have died.
DR. RAJ WAGHMARE is an ER physician. He blogs at theoverheadpage.com. His stories come from 25 years of practice.
CLINIC
Tech for people with diabetes
Who benefits most from glucose monitors and insulin pumps, and how do you troubleshoot problems?
BY KYLIE TAGGART
More and more patients with diabetes are taking advantage of technology that helps maintain appropriate blood glucose levels and lessens the burden of calculations and finger pricks needed to achieve them. What is the role of the non-endocrinologist physician in helping these patients?
Two experts provided advice: Dr. Ilana Halperin, a staff endocrinologist
at Sunnybrook Health Sciences Centre in Toronto and associate professor at the University of Toronto, and Dr. Bikrampal Sidhu, an endocrinologist at Kingston Health Sciences Centre and assistant professor at Queen’s University in Kingston, Ont.
The right tech
Type 1 and type 2 diabetes are very different diseases when it comes to what
technology is appropriate, Dr. Sidhu said. Knowing who should be on what type of technology is key.
For people with type 1 diabetes who take insulin, glucose monitoring can help reach blood glucose targets with a lower risk of hypoglycemic events. This can be as simple as a wearable sensor sending information to a reader or cell phone about blood glucose measures. There’s the choice of flash (or intermittent) monitoring or real-time, continuous monitoring.
People with type 2 diabetes can benefit from continuous glucose monitoring (CGM), particularly if they’re on insulin. While not necessary or helpful for most patients not on insulin, getting the data from a device might help some who are struggling to maintain their blood sugar levels. Dr. Halperin recently offered a patient a sample of a CGM sensor and it made him realize what foods were spiking his blood sugar levels. While he might not qualify for funding for CGM, he may pay for one every couple of months to make sure he’s on track with diet and exercise.
Traditional insulin pumps provide a steady infusion of insulin and require the user to input information about meals or exercise. Now, people with type 1 diabetes can use closed-loop systems, where continuous glucose monitors interact with insulin pumps to provide automated insulin delivery (AID) when needed. “It’s totally changed the experience for people with diabetes, not only in terms of better glucose management, but also improving quality of life,” Dr. Halperin said. Patients sleep better and have less diabetes-related stress, among other positive outcomes.
An AID system is the preferred treatment option for patients with type 1 diabetes, states the 2025 Diabetes Canada clinical practice guideline on glycemic management in people with type 1 diabetes. If AID is not possible or not the patient’s choice, the next best choice is CGM in combination with an insulin pump or basal bolus injection, the guidelines note.
Most people with type 2 diabetes will not need AID systems, although there have been studies on AID systems in
people with type 2 diabetes who take insulin. One was published in the New England Journal of Medicine in March 2025. Patients using the AID system had a significantly greater reduction in glucose blood levels than those using CGM alone.
“Unsurprisingly, they work really well,” Dr. Halperin said. People with type 2 diabetes who use them, “are still encouraged to announce their meals but a lot of the heavy lifting is done by the algorithm.”
The main trend remains that all patients with diabetes treated with insulin can benefit from CGM, but it’s patients with type 1 diabetes who really benefit from AID systems.
Costs and coverage
The biggest barrier to using diabetes technology is the cost. All jurisdictions in Canada have coverage for glucose monitoring and AID systems for people with type 1 diabetes, provided certain conditions are met. Coverage for people with type 2 diabetes who take insulin varies depending on jurisdiction. An overview of public insurance coverage is available on the website of Breakthrough T1D Canada, formerly the Juvenile Diabetes Research Foundation (JDRF).
For AID systems, the pump can cost up to $7,000, with a cost of supplies ($300 to $400 a month) and cost of glucose monitor sensors ($300 to $400 a month). “I think it will be a while before we see widespread adoption of these systems for type 2,” Dr. Halperin said. If a patient with type 2 diabetes can shoulder the cost and is struggling to manage their blood sugar, it may be appropriate to refer them.
Troubleshooting
Luckily, all commercially available technologies have phone numbers to call for tech support and websites with resources on how to use the technologies. Physicians should remind patients using CGM that, “If the number doesn’t match their symptoms, they should do an old-fashioned capillary blood glucose or finger poke check,” Dr. Halperin said. There are times when the sensor is not accurate, especially on the first or last
day of the 10-to-14-day long wear of the sensor, she said. If the patient is going to make a dosing decision to treat a high- or low-blood sugar reading at this time, it’s a good idea to do a finger poke test first. Some patients with type 1 diabetes may choose a do-it-yourself AID system, where they update the system using open-source code. Patients first adopted these systems when fewer commercial AID systems were available and when coverage was not as comprehensive. Dr. Halperin co-authored a 2023 paper published in the Canadian Journal of Diabetes on how physicians can support patients who use these systems. “Any system that helps patients feel better should be supported by their clinicians,” Dr. Halperin said. Uptake for DIY systems was only 30% in her clinic. It’s a lot of work to build the app, update it, manage the technology as well as the disease, with no easy telephone number to call for help. Still, physicians should understand the basics, she said. “Whatever system my patient chooses, I should be educated enough to know how to adjust insulin settings to optimize glycemic control.”
Adhesion and irritation
Skin irritation can occur with wearable sensors. For some people the sensor doesn’t stick properly, or the glue comes off. Patients can buy skin glue and/or use products like Skin Tac to make sure their skin is tackier and stickier in the area where they’ll wear the sensor. Patients can also put on bandages or patches to hold the sensor in place, Dr. Sidhu said.
If a patient has itchy skin around the sensor area, Dr. Sidhu recommended using an asthma inhaler or a nasal spray like Flonase or Flovent. Spray a bit directly on the skin where the sensor will go before putting the sensor on. “It acts as a little anti-inflammatory right under the sensor. That can actually prevent those reactions,” he said. It works better than a cream.
Technology in pregnancy
Not all glucose monitoring technology is approved for use in pregnancy by Health Canada, “But we offer it to almost everybody in my pregnancy
clinic,” Dr. Sidhu said. “It’s a lot easier to measure your sugars on a sensor than off.” Thousands of Canadian patients have gone through pregnancy using glucose monitoring technology without concern and there’s evidence of benefit of real-time CGM in patients with type 1 diabetes who are pregnant.
With AID systems, “Targets are higher than what we would consider acceptable in pregnancy. For that reason, they’re not approved,” Dr. Sidhu said. “Most endocrinologists would say it’s still better than we could do without those pumps.” There’s mounting evidence showing the benefits of patients using AID systems in pregnancy, and patients should not be taken off AID systems if they’re pregnant.
“Pregnancy is not a reason to not be on technology,” Dr. Sidhu said.
Other specialists
AID systems should be supported by an endocrinology or diabetes management team. If a patient with type 1 diabetes isn’t connected to a team, make a referral, Dr. Sidhu said. Even the most wellinformed primary care physician or other specialist might not know about some of the recent developments in the area.
Once a patient has decided on a system, learn about it from the company’s website. There’s information on how to access the data and how to assess the device. Physicians can also access resources on technology at type1better.com, a program run out of McGill University and through clinical resources offered by Diabetes Canada.
“I would encourage all family doctors to get comfortable with putting in continuous glucose monitors themselves. Do it once or twice. They’re very simple things to do,” Dr. Sidhu advised. “When you can show your patient, they’re much more likely to use it and get the benefit out of it.”
Finally, recognize that patients are the experts. They’re often active on various online forums about diabetes technology. Dr. Sidhu recently learned from a patient about the best waterproof bag to protect an AID system when scuba diving or surfing in salt water, a fact he can now share with other patients.
LAW
The means justify the end
Ontario court rejects a negligence claim after man on a motorcycle was attacked by a bear
Doctors are not judged on the result. They are judged on what they do to get there, regardless of how bad the result may be. This wellsettled principle arose in a recent Ontario case involving a patient who was riding his motorcycle at midnight when he was attacked by a bear. He was thrown from the bike and landed a metre away, sustaining serious injuries including a broken forearm, a burst vertebra and an open fracture of the tibia.
Urgent surgery was performed to repair the forearm, vertebra and tibia. The patient was then transferred to an orthopedic rehabilitation facility. It was there that the alleged negligence took place: The patient claimed the rehab physician failed to diagnose osteomyelitis, an infection of the bone,
which resulted in delayed recovery.
The claim was dismissed. “A negative outcome does not equate to negligence,” said the judge, “and the fact that the risk of a procedure materializes does not necessarily mean that liability attaches. The standard of care expected of a physician should not be measured by the result.”
On the contrary, the proper question to ask is whether the doctor, “acted according to the professional rules of art in the treatment of the patient.” In other words, doctors are expected to bring to their tasks, “the degree of care and skill which could reasonably be expected of a normal, prudent practitioner of the same experience and standing.” As the Supreme Court of Canada put it several decades ago, “doctors have an obligation of means, not an obligation of result.”
BY BILL ROGERS
And while exercising the same care and skill of a normal, prudent practitioner of the same experience and standing, doctors are, of course, not expected to be perfect or infallible. Errors in judgment occur, and they do not constitute negligence so long as the judgment is exercised “honestly” and “intelligently.”
In this case, the result the patient complained of was certainly unfortunate, but it was not egregiously bad. He complained that, because of the osteomyelitis, the recovery of his tibial fracture was delayed. But he did recover. Accordingly the trial was done in “simplified” form, which meant the maximum possible damages would have been $200,000.
First sign of trouble
The first sign of trouble appeared when the patient’s tibial wound developed a lump and later became infected. Local irrigation at bedside was done, which was not effective enough, so debridement surgery was eventually performed. The tibial fracture ultimately healed.
One of the patient’s expert witnesses was an infectious disease and internal medicine physician, but was nevertheless allowed by the judge to give his opinion on the standard of care expected of the defendant doctor, who was a family physician/hospitalist. The expert’s opinion was limited in scope, such that he was not permitted to impose his specialist’s knowledge on the standard of care of a family physician/hospitalist. His opinion was that the standard of care of a family physician/hospitalist was to suspect infection upon first seeing the lump, and to arrange for laboratory work and imaging analysis, including ultrasound and CT scan, immediately. Rejecting this, the judge preferred
the testimony of the defendant’s expert, who said that in over 40 years as a family practitioner and hospitalist, he had never had occasion to order a CT scan in such circumstances.
The judge noted that it is not the law in Ontario that a physician should eliminate the most serious potential ailment first, as opposed to treating the most probable diagnosis. This principle has been expressed many times, and the judge cited a 2015 decision involving a 22-year-old man who went to emergency with severe chest and back pain. The doctor diagnosed a musculoskeletal injury and discharged the man the following morning. Less than a week later he died of an aortic dissection.
The doctor was held blameless. “The likelihood of a healthy 22-year-old male having an aortic dissection is almost zero,” the court found. “While the patient’s death is tragic, his history and presentation were entirely consistent with a soft tissue injury. It is not the standard of care of an emergency room physician to diagnose a rare condition, such as an aortic dissection, in these circumstances. The doctor met the standard of care despite the tragic outcome.” The court went on to say that, “With respect to the law on differential diagnosis, a physician will not be held to a standard of practice in which he or she is required to anticipate a worst case but most unlikely scenario. Unfortunately for this patient, this is exactly what tragically occurred. He succumbed to both the worst case and most unlikely scenario.”
Here, the defendant doctor met the standard of care by, “closely and appropriately monitoring and managing the tibial wound.” He was aware of the lump, but there were no symptoms or indices of infection present: no erythema, no induration, no obvious discharge, no inflammatory markers and the white blood count was normal. He therefore appropriately opted for conservative treatment. He also took comfort in the fact that an orthopedic surgeon visited the rehab facility every two weeks, and would be coming in three days. And when this visit occurred, the orthopedic surgeon saw the patient and agreed that warm compresses and conservative
management should continue. “It was reasonable,” noted the judge, “for the defendant doctor to rely on that.”
The patient’s theory
The patient’s theory was that the osteomyelitis was caused by a “retained suture,” a stitch that was not properly removed after the surgical procedure and was left behind in the body. A nurse had found it—a piece of blue suture—in the wound after taking off the packed gauze. It was safely removed. The patient asked
“With respect to the law on differential diagnosis, a physician will not be held to a standard of practice in which he or she is required to anticipate a worst case but most unlikely scenario.”
if he could keep it, so the nurse gave it to him. He put it in a plastic bag and took it home. It was never tested, and it was not produced at trial.
The judge rejected the theory that the retained suture caused osteomyelitis, noting that, according to the defence expert, this idea was founded on, “three very rare occurrences which would have had to happen together,” namely: 1) bacteria from the blood would have had to somehow spread to the suture; 2) the bacteria would have had to survive two weeks of antibiotics treatment; and 3) the bacteria would have had to get from the suture into the bone, even though the suture was distinct from the bone, and not contiguous to it, or embedded in it. The expert said he had never seen, heard or read of such a scenario. The patient’s
own expert said he had never seen, heard or read of such a scenario either. This was quite remarkable, given that it was his theory.
In fact, ruled the judge, the osteomyelitis was already established by the time the plaintiff was transferred to the rehab facility. Moreover, the treatment that the patient received, namely surgical debridement and antibiotics, would have occurred regardless of the timing of the diagnosis. The judge also noted that the surgical debridement and antibiotic treatment were delayed due to the fact that the plaintiff did not want to proceed with debridement surgery, but opted for a more conservative treatment, despite the fact that he was advised this could delay recovery.
The patient, a lawyer, represented himself at trial. He argued that he did not represent himself, as he was being represented by his law firm. “Nevertheless,” said the judge, “he was intimately involved with this case, given that he was the plaintiff.”
The patient said that he had worked exclusively on the case for at least the last two years. This may have clouded his objectivity. “He was wedded to his case and the correctness of it,” the judge observed. Where his evidence differed from that of the medical practitioners, and the medical records, he maintained that they were wrong, including the medical notes and records from the rehab facility, including the doctors’ and nurses’ notes. He insisted that his evidence was correct.
Remarkably, the patient maintained that the visiting orthopedic specialist never examined him, even though the nursing notes indicated that he was indeed seen by the visiting orthopedic specialist, in the company of the defendant doctor. “Nevertheless he was insistent on the correctness of his case, becoming argumentative and defensive in advancing it,” said the judge. “I found his evidence to be problematic and, in some instances, unreliable and not credible.”
BILL ROGERS is a Toronto lawyer and writer covering medical and pharmaceutical issues.
Keeping your corporation tax efficient
Doctors who rely solely on advisors risk missing out
Most physicians who incorporate do so for the tax planning benefits. However, a corporation is not always the most tax efficient way to pay yourself or invest. They require attention to planning to realize the benefits. A common mistake is for physicians to assume that their accountant or financial advisor will just make that happen. Corporate efficiency straddles both the accountant and investment advisor domains. It also depends on your personal spending. So, you must have basic knowledge to bridge the gap and work with your advisors to get the best result.
Corporate vs. registered
One common mistake is for incorporated professionals to focus on investing through their corporations while neglecting their RRSP, tax-free
savings account (TFSA) and/or first home savings account (FHSA). A corporation has the advantage of partial tax deferral. Paying the low corporate tax on active income leaves more to invest than if you took the income personally. You pay the rest of the tax when you pay out dividends in the future. In contrast, RRSPs and FHSAs have full tax deferral. Plus, interest or dividends received by a corporation are taxed annually while they can be reinvested tax-free within a registered account.
So, it makes sense that using available RRSP or FHSA room should beat leaving that money invested in the corporation. Empiric models of that dilemma by portfolio manager Ben Felix and personal finance expert Jamie Golombek have also demonstrated that.
A TFSA does not have tax deferral. So, there is an upfront tax hit to taking
BY DR. MARK SOTH
extra money from a corporation to fund it. However, the subsequent taxfree growth can allow it to pull ahead of a corporation over time—usually under 10 years with reasonable returns. Fortunately, the investment horizon with a TFSA is often your lifespan, hopefully, many decades.
The possible exception when a corporation may outperform registered accounts is if you have a capital gainsonly investment strategy. However, that requires making compromises in cost, risk and diversification. The models I mentioned also assume that the corporate investment income is managed tax efficiently. That becomes more difficult when the corporate passive income becomes high. Redirecting money to grow in registered accounts instead of the corporation helps to delay that problem.
Salary vs. dividend
Corporate owners can choose to pay themselves using salary or dividends. The most tax efficient way is usually a mix. Tax integration generally favours salary compared to the combined corporate and personal dividend tax rates. A salary also has the benefit of providing valuable RRSP contribution room. However, there are situations when using dividends is more efficient than salary. Dividend-splitting with a lower income spouse was a common example but is more difficult to do now. Another common situation favouring dividends is when paying a dividend releases refundable dividend tax on hand (RDTOH) to the corporation. When the corporation receives passive income from its investments, it is taxed at a rate approximating the highest personal tax rate. A portion of the tax paid is recorded as RDTOH. When
the corporation pays out a dividend, and personal tax is paid, the RDTOH is refunded to the corporation. This can lead to inefficiency if not enough dividends are paid for the corporation to get the tax refund. The impact worsens over time because the real value of RDTOH is eroded by inflation.
So, talk to your accountant about whether you have an RDTOH balance and anticipate what it will be for each corporate tax year. Keep the net corporate tax lower by paying dividends to release it. That is efficient when you need that money personally to spend but is more complicated if you do not. You might decide to reduce your salary if it exceeds your needs once the dividend is factored in. However, if there is still unreleased RDTOH, no salary used, and you do not need the money, the investment income is being taxed at a high rate without the refund until you do move the money out.
Capital dividends
Another important thing to ask your accountant about is whether you have a positive capital dividend account (CDA) balance. Like RDTOH, the CDA only exists on paper for tax purposes. However, it represents a way to move real money out of a corporation taxfree. When the corporation realizes a capital gain, the non-taxable “excluded” half of the gain is added to the CDA. Conversely, half of a realized capital loss subtracts from it. As a bonus, if you donate a security with a capital gain to a registered charity, the full capital gain adds to the CDA.
When there is a positive CDA balance, your corporation may elect to pay out a tax-free capital dividend. Your accountant will usually charge a fee for doing the paperwork (filing a special election). However, the benefit of moving money out of the corporation tax-free is significant.
You could use that money to repay personal debt, catch up on registered accounts or fund a planned splurge. Alternatively, you could reduce the amount of salary or dividends you need and leave more to grow in the corporation. If you or a spouse have a
low personal tax rate, it could make sense to invest personally. There are many options. You should discuss them with your accountant if you have a positive CDA balance. Again, do not delay excessively. The buying power of that CDA balance will erode with inflation.
Income smoothing
A corporation can make your income tax efficient by smoothing it. Instead of paying tax at high marginal tax rates during high-income years, the corporation can retain earnings to pay the money out during a lower-income year. The corporate tax paid up front is usually less than personal rates. Plus,
“A corporation is not always the most tax efficient way to pay yourself or invest. They require attention to planning to realize the benefits”
the dividend tax credit mostly accounts for that tax when the retained earnings are paid out personally. Smoothing the rate of personal income taken each year keeps you in lower tax brackets overall.
In the short-term, that can smooth income fluctuations from personal leaves or business disruptions. If you foresee that coming, talk to your accountant to plan for smoothing your income to cover it.
How much you need to fund your lifestyle and personal investment accounts drives how much you draw from your corporation each year. So, if you foresee a spending splurge coming up, speak to your accountant. They can help you plan how to fund it by moving money out of your corporation more efficiently—perhaps, by taking a little more income now to smooth that out.
It is also a good opportunity to consider whether realizing capital gains to use the CDA may help. You can smooth income slightly on short notice using shareholder loans. However, coupling that to other efficient ways of moving money out of the corporation is even better.
Long term, a corporation shifts some income from your working years to help fund retirement. That is greatly beneficial if your retirement income and spending will be lower than during your working years. Estimating your retirement income, spending and opportunities to income-split during retirement is complex. However, it is important. Understanding it and considering how to smooth your income and lifestyle consumption over your life span is not only more tax efficient, it also helps you to enjoy the fruits of your labour along the way.
Time & tax efficient
Corporate taxes and financial planning are complex. Your accountant and/ or financial planner can make dealing with that time efficient. However, you must still play a role. Discuss how much dividend you should use to keep corporate passive income tax efficient. Salary is efficient to cover the gap between the dividends paid out and your spending needs. Factor using your registered accounts into that requirement. If you plan to have a major income or spending change, discuss that in advance to plan for it tax efficiently.
DR. MARK SOTH is a practising academic intensivist in Hamilton and writes the Loonie Doctor blog.
More finance advice
Our physician finance advice columns offer trusted, practical guidance tailored to the unique financial challenges and opportunities faced by Canadian doctors. Go online here: CanadianHealthcareNetwork.ca/ finance
PRACTICE MANAGEMENT
No more revolving door
How to stop MOA turnover at your clinic’s front desk
BY ABIGAIL CUKIER
Medical office assistant and receptionist turnover is a significant issue in healthcare. In fact, one U.S. poll revealed that 58% of medical practices identified staffing as their primary challenge. High turnover can be a major headache for physicians— it costs money, your schedule gets disrupted, patients wait longer and the remaining staff must pick up the slack.
So, what can a physician do to stop the revolving door of clinic administrative staff?
The Ontario Medical Association says improving staff retention starts when you hire them. Its guide, “Managing Your Medical Office Staff,” says to establish and clearly communicate the conditions under which employees will be hired. “If the conditions do not match expectations,
and the job is not as described, you may lose candidates or staff and be forced to repeat the hiring process.”
Job descriptions should accurately represent actual duties and responsibilities, as well as job specifications.
During the interview process, ask a consistent set of questions to each candidate to create a basis for comparison—and be sure to focus on cultural fit, not just technical skills.
“You want to find someone who is teachable,” said Margy Yu, founder of Vancouver-based Clinic Core Essentials. “You also want someone who can handle being inundated with phone calls and email alerts and lineups. If not, they can come off to patients as annoyed, irritated or hostile. So it’s important to look for those soft skills.
The front desk is such an integral part of the patient experience, she noted, that “you should invest the time to find the right candidate and communicate about the position.”
Yu says equipping staff with adequate support and resources so they can do their jobs is a major piece in achieving retention. She knows what can happen when this is missing. While working at the front desk of a wellness clinic, Yu experienced poor management and overwork. This led to her leaving the clinic. When she became a manager at another clinic, she did not receive a lot of support and was left to figure out most tasks on her own. “The company kept growing without enough staff and since I was the most competent one there, they just kept rewarding me with more work,” she said.
Yu left that position. “When I was ready to go back into the workforce, I felt sick to my stomach thinking about going to a similar environment. I just kept seeing different clinics with similar problems. I figured, if I worked in a string of clinics that had similar patterns, I’m sure that there are a lot of clinics that are also flying by the seat of their pants. ‘How can I remedy this?’”
Yu founded Clinic Core Essentials, which provides front-desk training, virtual assistants and receptionists and helps set up front desk operations for new clinics, primarily in the chiropractic, physiotherapy and wellness areas.
She says clinics should ensure processes are documented and not all in one employee’s head. “Once that person leaves, all the workflows and little nuances go right out the window and the remaining or new staff are left not being able to meet that standard and it ends up being this revolving door.” She advises clinic managers to create written standard operating procedures or document processes on video, so new hires can learn from them.
The OMA recommends developing a policy and procedure manual to train staff, ensure that the office runs efficiently and maintain productive and clear working relationships. Policies and procedures can cover topics including the length of a probationary period, work hours, absenteeism, code of conduct, dress code and how to complete specific tasks. The association also recommends training all staff to perform every task and to work with each physician, so staff can cover for each other.
The OMA also stresses that motivated and engaged employees are more likely to stay. They suggest communicating your goals and your staff’s role in achieving them. “With a clear understanding of how they contribute to the success of the practice, staff feel a greater sense of accomplishment,” the OMA HR handbook states.
It also recommends discussing important decisions in advance and holding regular staff meetings to keep everyone informed about developments in the office. “Encourage staff to express their views on processes, job satisfaction,
morale, etc. It is important for employees to feel that their opinions are welcome,” the guidebook reads.
And some of this feedback can help doctors learn about employee satisfaction. For example, through no-name surveys that ask questions like, “What annoys you about working here?” or “What keeps you here?” Doctors of BC says “stay
“You want someone who can handle being inundated with phone calls and email alerts and lineups.”
interviews” can help you understand how your team feels about the work environment and support retention. They are a conversation with individual employees aimed at understanding what makes them want to stay and what may cause them to leave.
Employees should receive regular feedback, including through formal reviews and day-to-day interactions, including praise for good performance and constructive criticism for areas that need improvement. Performance reviews can include setting goals for each employee to help them remain motivated
VIRTUAL RECEPTIONIST SOLUTIONS
One strategy to help with medical receptionist and office assistant retention is easing their workload through off-site medical reception and assistant
and feel they have opportunities for development.
If a staff member is underperforming, the OMA suggests first ensuring the job itself is not the problem and then trying to rectify the issue with the employee, which is much less costly than turnover. If termination is necessary, move quickly with input from a lawyer.
Rewards and incentives are a great motivator for employees. Salary is important, and the OMA recommends setting the pay scale to be in the top 25% for similar jobs. But other rewards are also important, such as flexible working conditions, team-building events, training or a chance for advancement and special projects. Tennessee-based Doctors Management suggests providing financial bonuses tied to staying at the job for certain periods or hitting certain goals, like reducing patient wait times.
Make their jobs easier
Providing tools to make the job easier can also help ensure employees want to stay. Consider new technologies like patient self-check-in, which eliminates a significant chunk of workload from your front desk. Supply easy-to-use software and AI tools.
Virtual assistants can also help, Yu says. They can handle tasks the frontoffice staff can’t get to due to other demands. This could include handling billing or entering new patients into the system. Virtual receptionists can handle overflow calls or assist with outgoing calls.
“Sometimes the front desk job or receptionist is such a thankless job,” Yu said. “But it’s such a huge part of the clinic. This team is just as important as anyone else who is hired and that deserves better recognition.”
staffing agencies, which are increasingly cropping up. Companies like Torontobased MD Agility and ClinicLine handle incoming calls, appointment scheduling, refilling prescriptions, emails, faxes, referral management, recalls and reminder calls. They work with a clinic’s
existing EMR and comply with all health privacy laws. ClinicLine, which provides dedicated off-shore medical assistants full time, part time or hourly, says it saves clinics 30% to 40% in overhead costs from recruiting, hiring and training, replacing staff, and handling staff wages.
Internal Medicine (General and Subspecialist), Pediatrician, Surgeon in busy outpatient clinic in Mississauga Angela (647)606-4399 www.torontooutpatients.com
Join the health care evolution with Enhanced Care Clinic, where doctors thrive. Set your own schedule/number of visits per hour or per day. Efficient medical admin and backend support (billing, scheduling, call back). Collegial environment with experienced peers. EMR on-site with remote access. Over a decade of practice support experience. Attractive compensation.
For location details: visit: yournewclinic.ca | call: (647) 254-5578 supportyourpractice@enhancedcare.ca
Established Urogynecology Clinic – Calgary
Rare opportunity for possible partnership in growing pelvic floor clinic. Revenue is 90% private and no Alberta Health position is required. If you’re looking to establish yourself in Calgary, this is a unique opportunity without being dependent on Provincial, institutional or academic positions.
The clinic specializes in urogynecology and also offers cosmetic procedures. The most suitable partner would be:
1. A fellowship-trained urogynecologist
2. An OBGYN with a strong interest in pelvic floor/ urogynecology
3. A family physician with an interest in pelvic floor medicine and cosmetics
A business-minded approach, a willingness to grow a private-pay practice/business and interest in laser medicine and cosmetic gynecology are essential.
The clinic currently offers private surgery for prolapse and cosmetic gynecology, with existing private OR access and established connections with a private surgical facility. This presents a possible opportunity for an appropriately trained surgeon who is not in an academic position but still wishes to perform surgery outside the Medicare system.
Additional Considerations:
The true value of this clinic lies in:
1. A large, loyal patient base with recurring revenue from ongoing maintenance treatments.
2. Strong brand recognition and an established online presence driving patient demand.
How does an ER doc stop comments about looking too young for the job?
In the blink of an eye
I think the underlying issue is that the young physician feels undermined for their skills and this can be translated to patients not trusting or respecting the young physician as much as someone older. I experienced the same issue . . . and still do. As a young female physician, I tried wearing a white coat, dressing more professionally and using less makeup/earrings/anything else that would make me look younger. I still get the same comment. Now that I’m mid-30s and seven years in practice, I’m starting to appreciate these comments knowing that I’ll be 40 in the blink of an eye. Now I joke with the patients that it’s my good genes/good skin care, because after many years in practice, I’m confident in my medical skills and these comments are viewed as compliments rather than annoyances.
—DR. LINDA YI-CHAN SUN
Grow facial hair
I had the same problem when I started practice 55 years ago. My solution was to grow a full beard (they were not in fashion back then) and the comments stopped immediately. Twelve years later when I shaved it off the remarks were more along the line of how youthful I looked for an old guy. I’m afraid this approach would not work for my female colleagues.
—DR. GLENN GIBSON
Humour and boundaries
I’ve been in this position before: Patients think I’m a nurse because I’m female; colleagues think I’m a resident or medical student because I look young. While often these comments are not intended to bother us, they can sometimes lead to feelings of frustration, inferiority or resentment. When I hear, “You look like a teenager/too young,” I usually smile and follow it with a reply such as, “Thanks, I hope my age doesn’t catch up to me, I’ve been studying forever!” This adds humour but also reiterates the tireless work and dedication it takes to become a physician. It shows confidence and maturity. However, if someone is constantly downplaying our skills or expertise because of the way we look or our gender (or beliefs, etc.), it is important to set boundaries and to ensure they understand their comments are hurtful or unwelcome: “I am sure you don’t mean to make me feel this way, but when you comment on how young I look, I feel that you don’t value my role as your colleague/physician. I would appreciate it if you stopped making comments about my appearance in the future.”
—DR. MARINA MALAK
Don’t wish it away
When you are young you look young, enjoy that time in your career and
life. Our first impressions when meeting new people are unfortunately always based on appearance. But that quickly and more permanently changes once we open our mouths. What comes out will determine how people see you and formulate opinions on you. Colleagues will quickly get past your youthful appearance. As people age, the way they see youthfulness ages too. A 70-year-old sees a 50-year-old as youthful. You have to go through that life experience to fully understand it. Hopefully you have many years to enjoy the “compliments.” Never wish your youthfulness to go away, it will do that far too fast in your medical career and won’t come back again.
—DR. BRENT BUKOVY
Next Problem
“I get really frustrated with patients who are nonadherent—a very allergic asthmatic patient who continues to keep cats, for example, a diabetes patient who can’t adhere to lifestyle recommendations. How do I continue to treat them?”
Send solutions (and new questions!) at about 100 words to lleger@ ensembleIQ.com by Aug. 5. Get a $25 gift card if your answer is chosen.
DR. LINDA YI-CHAN SUN
A family physician and surgical assistant in St. Catharines, Ont.
DR. GLENN GIBSON
A retired GP/anesthetist, Campbellford, Ont.
DR. MARINA MALAK
A family physician in Mississauga, Ont.
DR. BRENT BUKOVY
A family physician in Thunder Bay, Ont.
NOW ALSO AVAILABLE IN A NEW ORODISPERSIBLE FILM (ODF) FORMULATION.
Indications and Clinical Use:
Convenient and discreet1
Can be taken with or without water2
Dissolves on the tongue2
Available in cartons of 4 individually wrapped films2
VIAGRA (sildenafil citrate) is indicated for the treatment of erectile dysfunction, which is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance
Contraindications:
• Patients taking any type of nitrate drug therapy, or who utilize short-acting nitrate-containing medications, due to the risk of developing potentially life-threatening hypotension
• Use of organic nitrates, either regularly and/or intermittently, in any form (e.g., oral, sublingual, transdermal, by inhalation)
• In men for whom sexual activity is inadvisable
• In patients with erectile dysfunction with previous episode of non-arteritic anterior ischaemic optic neuropathy (NAION)
• Co-administration with guanylate cyclase stimulators
• Patients with a known hypersensitivity to any component of the tablet or film
Relevant Warnings and Precautions:
• The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment.
• History of cardiovascular disease including hypertension (BP >140/90 mm Hg)
• Patients who have suffered a myocardial infarction, stroke, or life-threatening arrhythmia within the last 6 months.
• Patients with resting hypotension (BP < 90/50 mm Hg at rest) or hypertension (BP > 170/110 mm Hg at rest).
• Patients with cardiac failure or coronary artery disease causing unstable angina.
• Patients taking an alpha-blocker
• Underlying conditions that could be inversely affected by the vasodilatory effects of VIAGRA
• Combination with sodium nitroprusside (a nitric oxide donor) or heparin
• Patients with bleeding disorders or active peptic ulceration
• Consider starting dose reduction in patients with hepatic and/or severe renal impairment and/or elderly patients
• Patients should stop taking PDE5 inhibitors, including VIAGRA, and consult their health professional immediately if they experience a decrease in, or sudden loss of, vision in one or both eyes.
• Increased risk of NAION recurrence.
• Patients with retinitis pigmentosa (minority have genetic disorders of retinal phosphodiesterases)
• Visual effects (e.g., impairment of colour discrimination, increased perception to light, blurred vision, eye pain, ocular redness). The patient should not operate a motor vehicle or any heavy machinery until the adverse effects disappear.
• Sudden decrease or loss of hearing, which may be accompanied by tinnitus and dizziness
• Priapism
• Use in combination with other PDE5 inhibitors, other pulmonary arterial hypertension (PAH) treatments containing sildenafil, or other agents for the treatment of ED
• Caution in patients with anatomical deformation of the penis
• Stevens-Johnson’s Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
For more information:
Please consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/index-eng.jsp for important information about conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions, and dosing which have not been discussed in this piece. The Product Monograph is also available by calling 1-844-596-9526.
References: 1. Shaw A, Lawrence TE, Yan T, et al. Bioequivalence studies of sildenafil citrate orodispersible film administered with and without water vs VIAGRA® film-coated tablets in healthy male volunteers. Curr Ther Res Clin Exp, 99(2023), Article 100708. 2. VIAGRA Product Monograph, https://health-products.canada.ca/dpd-bdpp/index-eng.jsp
The first and only PDE4i indicated in the topical treatment of seborrheic dermatitis* ONCE-DAILY STEROID-FREE* PDE4i
ZORYVE is indicated for topical treatment of seborrheic dermatitis in patients 9 years of age and older.
Designed for simple administration
FOR SEBORRHEIC DERMATITIS
• Can be used on all affected areas of skin, including the face, body, and/or scalp†
• Once-daily topical application
Please consult the Product Monograph at www.arcutis.ca/zoryve-pm-hcp for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling us at 1-844-692-6729.
PDE4i: phosphodiesterase 4 inhibitor
*Comparative clinical significance has not been established.
†When they are not wet.
‡Subject to restrictions. For program terms and conditions, go to www.zoryveassist.ca and click “Terms and Conditions”.
Reference: 1. ZORYVE® Product Monograph. Arcutis Canada, Inc. October 2024.
ZORYVE AssistTM Patient Assistance Program is designed to provide financial support to eligible patients receiving a ZORYVE prescription.‡
