Issuu

SCOPE Winter 2017 vol 1 issue 1

MAGAZINE

SPECIA LI PUBLIS HED BY NAUG THE VI CTORIA URAL DIVISIO E N OF FA DITIO MILY P RACTIC N E

An inside view of family medicine in Victoria

RE-WIRING

OUR BRAINS Patients in Victoria are learning skills

to manage their own anxiety and depression through eight-week cognitive behavioural therapy groups

SCOPE Winter 2017

vol 1 issue 1

Publisher Victoria Division of Family Practice Victoria Division of Family Practice Board of Directors: front (l–r) Dr. Katharine McKeen, Dr. Valerie Ehasoo, Dr. Steve Goodchild, Dr. Kathy Dabrus, Dr. Tim Troughton. back (l–r) Dr. Ian Bekker, Dr. Bill Bullock, Dr. Lisa Veres, Dr. Geoff Inman DODD’S EYE MEDIA PHOTOGRAPH

Message from the Board Welcome to the first issue of Scope Magazine! Over the past five years, the Victoria Division of Family Practice has grown and developed, and we are launching this magazine to connect with you: Division members, patients, partners in the health system, and the community at large. We are excited to have a place where we can tell you more about the work we do to improve access to primary care, and to build a healthy community. We are also excited about having a new way for you to talk to us: to offer your thoughts in letters to the editor, guest articles, feature stories and interviews, and more. We welcome a dialogue that helps us all to learn about each other, to share ideas, and to envision new possibilities. Scope will enrich our current relationships and help us to build new ones. We hope there is something in these pages to excite you, inform you, and inspire you to offer your own contributions for coming editions. Enjoy!

EDITORIAL Managing Editor Alisa Harrison Editorial Board Member Dr. Ian Bekker Editor-in-Chief Crystal Sawyer Contributors Dr. Joanna Cheek, Dr. Wanda Crouse, Alisa Harrison, Isabel (Annie) Moore, Crystal Sawyer, Dr. Tim Troughton, Dr. Robert Shepherd, Natalia Zapotoczny ART Art Director/Designer Crystal Sawyer Photographers Quinton Gordon, Dodd’s Eye Media, Kurt Knock, Audrey Bai, Alisa Harrison, Crystal Sawyer Illustrator Polina Isakharova Circulation Nicole Dehoop, Tyler Michaels Webmaster Tyler Michaels Published by Victoria Division of Family Practice PO Box 8418 Victoria Main Victoria, B.C. CANADA V8W 3S1 Tel: 1.877.790.8492 Fax: 778.265.0298 Editorial: victoriaeditorial@divisionsbc.ca vdfpmagazine.ca COVER Illustrator Polina Isakharova Cover Design Crystal Sawyer

Your 2016–17 Board Victoria Division of Family Practice Victoria

Winter Edition 2017 Scope Magazine is published semiannually by the Victoria Division of Family Practice. Submit story ideas, articles, letters to the editor, and high resolution images or illustrations using the upload link at vdfpmagazine.ca. Articles will be edited for clarity, brevity, accuracy, space, and taste. Scope Magazine maintains first serial rights to material; contributors may republish their work in another medium, or package their work in a book. Republished pieces must note that the article was first published in Scope Magazine and include a link to the magazine’s web site. © 2017. No part of this magazine may be reproduced in whole or in part, in print or electronic form, without written permission from the Publisher. Printed in Canada using recycled paper.

contents

FEATURES

2 Hip to Keep Cool 6 Slaying the Dragon 8 Forging New Pathways 12 Lighting the TORCH 14 Got You Covered 20 Room 109

SHORTS 11 Emergency Planning Picks up PACE 17 Look Whoâ€™s Walking: Walk-in Clinic Survey Results 18 First Person: Hooked on Collaboration 19 Fear Factor: The first in a Series of CBT skills 22 Behind the Scenes 23 The Role of the Chronicler 23 MOA Temp Pool Roster Launch 24 From Patient to Partner 25 Gallery 25 Letter to the Editor

Scope Magazine | Winter 2017

HIP TO KEEP COOL

More than 800 people throughout Greater Victoria have taken part in the eightweek, MSPfunded CBT skills group training sessions in the past year, with hundreds more slated for early 2017.

BY DR. JOANNA CHEEK | Psychiatrist, Assistant Clinical Professor

New CBT groups arming patients with skills to self-manage anxiety and depression Meara, a local retail store manager, has faced symptoms of anxiety and depression for more than a decade. AJ is on disability after struggling with chronic pain (and its associated anxiety and depression) for 22 years. Retired teacher ‘Elizabeth’ (who prefers not to use her real name), has experienced anxiety and depression for her entire life. When these three diverse strangers arrived for their first cognitive behavioural skills group training session, they discovered the thread that binds them together: the struggle of being human.

s humans, pain is an inevitable part of our lives. symptoms, and asked my GP about a referral to a We crave security and certainty, but the world psychiatrist. But because my symptoms were not is constantly changing and unknown. No matter severe enough, the psychiatrist referrals were not how courageous or competent we are, we can’t accepted.” escape feeling failure, losing loved ones, getting sick, This hard reality brought a group of local or being hurt. And at times, our emotions, habits, psychiatrists and family doctors together over the thoughts, and behaviours can lead us astray, feed us past year to be a part of the solution. Thanks to new the wrong information, or drive us to react in ways initiatives supported by the Shared Care Committee that perpetuate anxiety and depression. (a collaborative partnership of the B.C. Ministry of So it’s not surprising that—according to the Health and Doctors of B.C.), and leadership from B.C. Ministry of Health—30 per cent of Victorians the Victoria Division of Family Practice, the group experience depression, and 36 per cent experience launched physician-run group medical visits, anxiety or mood disorders bringing together 15 people during their lifetime. If we for an eight-week series of Out of every 100 people 90-minute sessions. In these included stress, burnout, anger, in Greater Victoria, chronic pain, and addiction, cognitive behavioural therapy that number would easily climb (CBT) skills groups, doctors 30 are diagnosed with to include the majority of our teach the participants skills depression, and 36 are population. to manage their own difficult diagnosed with anxiety But seeking help isn’t easy. emotions, thoughts, and or mood disorders, at Most people find the stigma unhelpful habits that can trigger some point in their lives. and intensify stress, anxiety, and of mental health challenges to be more debilitating than the depression. B.C. Ministry of Health Chronic Disease Registry symptoms of the conditions The purpose of the themselves. Stigma silences, group format is not to cut and silence builds walls between us. So rather than costs (although the numbers speak proudly: each our shared vulnerabilities bridging us together, we person receives 12 hours of instruction in a group suffer alone. Even if we are brave enough to ask at the same cost to the system as four 20-minute for help, mental health services are overburdened counselling visits with their family doctors). Rather, by the magnitude of so many people struggling the group itself is therapeutic. alongside us. “There’s so much stigma surrounding mental AJ was close to being lost in that system. “I illness,” states ‘Sue’, who asked to use a pseudonym. saw psychologists who were unable to treat me on “I still find it nerve-wracking to tell someone I have an ongoing basis, due to the enormous backlog of mental health issues because it’s a gamble: are they patients requiring their help,” she remembers. “Being going to ‘get it’, or not? At the CBT skills group, we all on disability, I was unable to afford such assistance ‘get it’, because we’re all there for the same reasons.” privately. I still found myself unable to manage my Meara didn’t seek help until she had become Scope Magazine | Winter 2017

succeeded at applying the strategies each week,” a heavy alcoholic, and had lost interest in her work she says. “We shared a lot of laughter.” Known for and other things she enjoyed. Although initially her playful enthusiasm, psychiatrist and group group therapy sounded intimidating, she explains, facilitator Dr. Wanda Crouse doesn’t find laughter “I was nervous about going at first (hello, anxiety!), incompatible with talking about but after the first session, it difficult topics. “I’m having a lot of became something I looked fun teaching both the participants, forward to every week.” and the family physicians,” she says. AJ comments, “I really Psychiatrists in the project considered myself to be a wear two hats. First, they act as colossal failure, because co-facilitators, teaching participants I couldn’t even manage AJ, CBT Skills Group Participant strategies to support wellness. many simple things. So to Second, they mentor family hear that other people in physicians to enhance their skills in order that they the group could identify with the things that can lead groups on their own. I considered particularly damaged about myself With studies showing that 80 per cent really helped to lessen my feelings of self-failure. of people receive help for their mental health For the first time in more than a decade, I didn’t feel challenges within primary care, the goal is to teach so alone.” family doctors how to support their patients within Elizabeth, who had used CBT strategies to the same system where they are already seeking support her own wellness and had taught these services. Dr. Crouse explains, “I know how hard skills to her students, decided she needed more family physicians work trying to provide quality care help after a chain of stressful life events caused to their patients, and the frustrations of not being her anxiety to able to get help for those patients when it’s needed.” resurface. Family physician Dr. Oona Hayes had been “I enjoyed offering brief CBT skills listening to to support her patients how others individually in her clinic. However, at times she felt

“For the first time in more than a decade, I didn’t feel so alone.”

Scope Magazine | Winter 2017

her patients needed something more. “I found it hard because some patients needed much more background information and understanding about the way the mind works,” she says. “Also, I see so many people who struggle with their mental health that I felt I was always repeating myself. When I was approached about this project, I was excited about the opportunity to teach skills that helped patients to manage their inner experiences, and to live fulfilling lives.” Facilitating groups is often a new skill for family doctors, who are typically trained to work one-onone with patients. Dr. Hayes reflects, “Doing group visits has been a learning curve, and has taken me out of my comfort zone. I was able to apply the CBT skills personally when I started feeling fears about how I would do as a group facilitator.” But physician anxiety is not something they hide in the groups. Rather, they often teach with examples from their own lives, illustrating that we all share in the struggles of the mind, and that no one is immune. It’s been just under one year since the first CBT skills group rolled out in Victoria. In 2016 alone, more than 800 people completed the training, with several hundred more slated for the early part of 2017. In that time, evaluations have shown that participant wellness scores improve on par with medication and individual CBT therapy—both considered gold standard treatments for depression and anxiety. Meara explains, “The course helped me to recognize certain obstacles that I was facing when trying to deal with my issues, and how to overcome them myself. I also learned about how the brain and body interact, and how to use that knowledge to my advantage when I’m in an extreme emotional state.” She continues, “Honestly, I have been so happy with what this group has done for me that I talk about it all the time. I have spoken with my family, friends, and staff about various aspects of it, because I feel that the information taught in this course can be beneficial for anyone—not just for those suffering with anxiety and depression. It really changed my life. I feel so much more confident in my ability to deal with any obstacles that come my way.” “I learned some very practical strategies. I love that it’s science-based, and solidly researched,” Elizabeth adds. Sue states, “I left the last session feeling proud of myself, and feeling empowered. I wish everyone fighting anxiety and depression could be offered these classes.” And indeed, that is the goal. Psychiatrists are continuing to train new facilitators, and communities across the province, and nationwide, are interested in adopting a similar program. Patients who wish to take part should visit their family physician and ask for a referral.

98% of participants in 2016 reported that they use their CBT workbook on a regular basis, often taking it with them to the workplace to help them manage day-to-day challenges. A completely revamped and revised workbook that incorporates suggestions from participants, psychiatrists, and family physicians is due out in early Spring. For more information about the CBT Skills training groups in Victoria, visit divisionsbc.ca/victoria/cbtskillsgroup or email cbtskills@divisionsbc.ca

“I feel that the information taught in this course can be beneficial for anyone—not just for those suffering with anxiety and depression. It really changed my life.” Meara, CBT Skills Group Participant

Scope Magazine | Winter 2017

SLAYING THE DRAGON SUBOXONE NAMED NEW ALLY IN THE OPIOID CRISIS Family doctors are being equipped with education, certification, and emergency phone support as opioid addiction skyrockets, and they begin to shoulder an expanded role in addiction treatment monitoring. But one thing is clear: opioid addiction doesn’t discriminate. Sinners and saints, it’s touching the lives of people everywhere, all around us. BY CRYSTAL SAWYER

ictoria has appeared on a lot of best lists over the years, with other drugs and medications. Still one of the most including world’s friendliest and world’s most romantic commonly used maintenance therapy drugs, Methadone is city. But taking one of the top three spots in the province— extremely potent, interacts negatively with more than 1000 according to a B.C. Coroner’s report—where fatal illicit drug other medications (meaning side effects are likely if combined overdoses occurred is hardly the badge it’s looking for. With with any of these other drugs), and carries a significant risk of 75 illicit drug overdose deaths in the South Island alone last respiratory suppression and accidental death. Although still year, Island Health is reporting a 238% per cent spike over an opioid, Suboxone, by contrast, is a much safer drug that is 2015. But fentanyl, and its even more potent cousin carfentanil, far less likely to cause respiratory suppression. aren’t the only problems: opioid addiction, from heroin, to According to Bullock, the role of family doctors will expand hydromorphone, to oxycodone and other prescription drugs, as they begin to see more patients who have been initiated with is rattling all walks of life. Suboxone treatment. One of only a handful of practitioners in Dr. Bill Bullock, co-chair of the Victoria Victoria experienced in starting people Division of Family Practice’s Mental Health on Suboxone in detox, Bullock says the and Substance Use Steering Committee and two established local methadone clinics family physician who holds one of the staff have also been initiating treatment. A positions at Victoria Community Detox, says rapid access addiction clinic is scheduled opioid addiction is far more prevalent than to open in Victoria to respond to the most people realize. “When a physician is accelerated need, and emergency room informed that a patient has been admitted doctors may also begin to administer to detox for heroin, the doctor is often the drug. “Family doctors will begin to astounded. This is not a condition that only see a spike in their patients who are on affects homeless people. Heroin is being the program. We want to ensure that widely used, and opioid use disorder is they have enough training and increased common in young people, school children, comfort so that they can follow and high school students, and everyone from monitor their patients who have begun veterinary assistants to office workers, treatment,” he says. Monitoring patients to those who work in the physical trades would involve regular appointments every like construction. It is literally affecting two to four weeks (including periodic urine everyone across the board. We are also drug testing to ensure compliance with seeing a lot of people who are abusing the medication, and to look for the use prescription opioids.” of other drugs), and ongoing outpatient Now, the Victoria Division of Family addiction and mental health services such Practice is rolling out an expanded strategy, as counselling. including education, skills training, and Suboxone is a relatively new therapy emergency phone support, to give family that is not familiar to most family doctors. physicians more tools in the wake of the “We want to support and educate them Dr. Bill Bullock, GP, Victoria Community Detox because, although it has been around escalating crisis. An event slated for March and Co-Chair, VDFP Mental Health 7th will gather experts to begin educating for awhile, it is new in the community,” & Substance use Steering Committee doctors in the use of Suboxone to treat explains Bullock, who says most doctors opioid addiction. will have had limited education or Treatment guidelines produced by experience in dealing directly with the Vancouver Coastal Health and the B.C. Centre on Substance Use drug. “It is somewhat tricky to get people started on, which is summarize evidence overwhelmingly in favour of Suboxone as why at this time, it is initially administered by those who have a first-line treatment for opioid use disorder. Up until recently, experience in a specialized clinic setting. Once the patient the mainstay of assisted treatment was Methodone, which, is on a stable dose, it is relatively easy to use. Suboxone is although similar to Suboxone in some ways, is a drug that is an extremely safe drug—side effects are mostly limited to associated with more side effects and negative interaction drowsiness and some gastrointestinal symptoms. One of the

“Heroin is being widely used, and opioid use disorder is common in school children, high school students, and everyone from veterinary assistants to office workers, to those who work in the physical trades like construction. It is literally affecting everyone across the board.”

Scope Magazine | Winter 2017

goals in our education strategy is to have family doctors become comfortable in at least maintaining their patients who are already undergoing Suboxone treatment. This is only one very small part in our response to the crisis.” Studies have shown that in most cases, encouraging an abstinence strategy does not work: in those detoxing from opioids without medication assisted treatment (opioid agonist therapy or OAT), there is a high risk of relapse, and therefore increased risk of overdose or the transmission of HIV and Hepititis C. Bullock says that from a treatment perspective, it’s important to differentiate between addiction and dependence. “With the use of any opioid for a prolonged period of time, people will become physically dependent, meaning they will have withdrawal symptoms when they stop. The difference between someone taking a street drug like heroin and a pharmaceutical medication like Suboxone is that Bullock Suboxone is longacting, is taken once a day, and is prescribed, therefore administration of it is controlled. The majority of people are taking [agonist therapy drugs] under conditions where they are witnessed at a pharmacy, and are urine tested to monitor for the use of other drugs,” he explains. “Addiction, by contrast, is a diagnosis that involves a pattern of continued use despite negative consequences, using more than intended, increasing amounts used over time, increased tolerance, and repeated unsuccessful attempts to stop.” “In some cases, people have been able to taper off the drug very slowly over time, but the main goal is to help them get back to a healthy connection with their family, work, school, and other things that are important to them, and we have many examples of people who have been able to do just that,” he says. “In most people, the idea of being on Suboxone for a very short length of time is not very realistic, and they will not normally be successful in reaching their goals.

“The main goal is to help them get back to a healthy connection with their family, work, school, and other things that are important to them, and we have many examples of people who have been able to do just that.”

out a new, addiction-specific RACE (Rapid Access to Consultative Expertise) telephone support line for Victoria’s doctors early in 2017. “Some of these things are already being done in other jurisdictions,” says Bullock. “It is relatively common in the States, and there is a program in Ontario. We are just working to get us in line with things that are going on in other parts of North America.”

T As for fentanyl and carfentanil, Bullock says they have flooded the market because they are easier to smuggle and to produce in labs. “Heroin must be produced using the opium poppy. Fentanyl and carfentanil are extremely potent, so they can be sent through the mail in very small quantities,” he says. “Although it seems counterintuitive, the dealers are not actually intending to kill their clients. They are mixing it in with other things, but it is very hard to distribute evenly, so in any batch there can be hot spots that are deadly. We are seeing it show up in urine tests all the time, and often people are not aware they have taken it. They may have thought they were taking ecstasy, or say they have only been smoking marijuana, and fentanyl is showing up. Then, there are others who are using fentanyl as their drug of choice.” Family doctors will also have access to online certification via training modules, and the Division is rolling Scope Magazine | Winter 2017

he Victoria Division of Family Practice will hold a special educational event for member physicians about Suboxone treatment on Tuesday, March 7th 2017. Family Physicians & the Opioid Crisis: You Have a Role to Play will feature speakers Dr. Ramm Hering of the Pandora Clinic and Dr. Anne Nguyen of Cool Aid Community Health Services, both leaders in the field of managing addiction in the opioid crisis. A patient who has been undergoing Suboxone treatment for several months will share her experience, followed by a one-hour presentation, questions, and small group table discussions. Each table will include a facilitator who is experienced in the treatment of opioid use disorder. Family physicians may visit the Victoria Division event calendar for emerging details and to register.

Forging new BY CRYSTAL SAWYER

PATHWAYS

DODD’S EYE MEDIA PHOTOGRAPH

Database to streamline GP–specialist referrals rolling out province-wide

here was a time when spotting a polar bear in a snowstorm Pathways Steering Committee) also committed, the foursome might have been easier than finding the right specialist to turned the Warneboldt dining room into their war room, where treat a patient’s unique needs. How were family doctors possibly they met for the next four years to create an entirely local able to keep track of new specialists in town, countless subversion of Pathways. Ever the optimist, Monk says she pushed specialties, those who had retired, different referral forms, hard to have many aspects (including wait times) incorporated, varying wait times, and specific pre-visit instructions? That and together they determined which of those were feasible. question topped every list when the Divisions of Family Practice “My role was more of the project lunatic,” she laughs. “When formed and surveyed their memberships about their priorities. everyone else was putting on the brakes, I was pedal to the And on launch night for the Fraser Northwest Division, it was metal. It’s good they pushed back, and we didn’t end up Christchurch’s Dr. Dee Mangin who shared her own wisdom, including all of the ideas.” from the land of the long white cloud. One idea that did stick, though, was a commitment Dr. Mangin took to the podium to talk to distributed data acquisition, a.k.a. about something she called Pathways—an crowdsourcing. In order for a project indispensable website doctors in New of this magnitude to be sustainable, users Zealand were using to fill these exact themselves would need the power to needs, and more. She left her audience update it with ease, with central oversight with two critical pieces of advice: separate in place to vet suggestions. Specialists any online database from the EMRs; and, would each have their own access key, create a nimble, responsive system that which would allow them to update their could be updated easily by users, in real own wait times, areas of focus, and other time, and that included both patient and profile information in real time—even daily physician resources. At that time, Dr. Tracy if need be. Dr. Ron Warneboldt Monk (who now chairs the Pathways Monk was also impassioned with the Pathways Provincial Lead Physician Provincial User Group) says her Division concept of distributed governance. “We was eager to dive in. “We thought, ‘Let’s do needed to be building campfires in all it.’ Every other Division had identified the same kind of needs, communities involved, where doctors and specialists would get and we had the particular luck of this connection with New to know each other better,” she says. Specialists were particularly Zealand, with these valuable lessons that many jurisdictions had keen to see that Pathways would include a tab labelled, not yet learned,” she explains. Set up initially as a local project, ‘Improving Referrals’, where groups of specialists could offer Pathways received approval and was funded by the GPSC. It was specific guidelines for family physicians and their patients. a mammoth proposition that, from seed to start, would end up The team’s initial developer had established Pathways on taking Monk and a team of colleagues just 18 months to launch. a Ruby on Rails framework, and had set it up on Heroku—the Monk enlisted the help of physician Dr. Ron Warneboldt, platform that later would allow Fraser Northwest to scale with who had been teaching and filling locum positions since ease throughout the province. A RFP allowed the quartet to hire retirement. “Ron is a meticulous, diligent, respected pillar Dr. Warneboldt’s son, Russell, who had worked at Electronic Arts of the community, and a completer,” says Monk. “He could be and Pixar Studios. “Russell is a brilliant analytical thinker and an diplomatic and approach the specialists. I knew, if we didn’t get incredibly gifted programmer, who is able to make complicated Ron to lead this project, it wouldn’t succeed.” With tech-savvy things look clean, with an easy user interface. He was really Dr. John Yap of the Fraser Northwest Pathways Operational good at deciphering what we actually needed from our crazed Team, and Dr. Kathleen Ross (now Chair of the Provincial rantings about what we thought we wanted. With the father–

“We make less referrals and get the right referral the first time now, so the system is much more efficient.”

Scope Magazine | Winter 2017

(left) Immediately following the Pathways demo for Victoria’s family physicians in November 2016, the database garnered the fastest and most widespread uptake of any Division initiative since its inception.

son relationship, he was comfortable disagreeing in a way that an external consultant might not be,” says Monk. The team decided to limit Pathways to specialists, clinic offices, forms, and physician and patient resources. Local MOAs had been hired to survey each specialist MOA for current data—a task that also promoted the strengthening of local relationships. The initial target radius included specialists from Burnaby to Langley, and from Maple Ridge to Whiterock. “We kept it quite focused, surveyed specialty by specialty, and by the Summer of 2012 we had the major specialties on board,” says Warneboldt. The database is designed so that doctors can have it running in the background for the entire workweek, without having to re-login; having no personal patient information on the site eliminates the need for regular time-outs. Doctors flip between Pathways and their EMR to identify specialists, to email resources to patients, and to access up-to-date doctor handouts, succinct and accurate scripts, and decision aids. The homepage lists the latest specialist and clinic updates in a particular Division, so MOAs can track any new specialists, changing specialties, or specialists who are retiring. The development team wasn’t entirely certain whether physicians would have the time or interest to adopt Pathways as an essential tool. But from the moment Fraser Northwest held its official Pathways launch in September 2012, the site began to generate 400 page views per day, every day. “At the beginning, we were setting up training sessions, and people just got irritable with us,” Monk remembers with a grin. “They were basically saying, ‘Leave us alone...it’s so intuitive, we don’t need you to teach us how to use this website.’” “The funny thing was, after about two months of being live, we had one day where our service provider went down,” Warneboldt recalls. “You wouldn’t believe the emails we got saying, ‘I can’t practice without this, I can’t run my office without it.’ People really caught on to it.” Since that day, the server and backups have been fortified and Pathways has not suffered any further significant downtime. In the common situation where a patient has two issues (such as a shoulder and a knee problem), previously she would see two different sub-specialists—a time consuming duplication of investigations. “It’s so much easier to find the ‘two-for-one’s’ now,” says Warneboldt. “With the filtering system in Pathways, you can find the orthopedic surgeon who sees both shoulders and knees. We make less referrals and get the right referral the first time now, so the system is much more efficient.” Pathways also makes it easy to expand a search beyond a particular geographic region if a local specialist isn’t available. Beyond connecting to specialists, embedded into the site are hundreds of peer-reviewed patient resources that can be

used, and emailed directly, to educate patients about their health issues. “Our criteria is that we need to be able to use it during a patient visit within 20 seconds,” says Monk. “It’s practical, and it’s the best we could find of anything that exists from a reputable source.” Each of the resources must satisfy eight criteria before getting the green light. Doctors are finding that at times, these patient resources can even replace the need for a specialist referral altogether—one aspect that alone has the potential to positively impact wait times and overall pressure on the health care system.

DODD’S EYE MEDIA PHOTOGRAPH

Early in 2014, the GPSC approved a trial expansion of Pathways to all of Fraser Health from Burnaby to Hope, to Vancouver, and to the rural Division of Kootenay–Boundary. Dr. Ross was instrumental in giving the platform the legs it needed to spread to other Divisions. “We’d made Pathways as a gift, with the intention that it could be a provincially-scalable platform,” says Monk. “GPSC has, of course, been wonderful in supporting that spread, and Dr. Ross played a key role in opening the path to share it widely in the way we’d always intended.” A monthly working group was established to review IT processes, privacy, and security. “We set up our political system, and established a number of policies and protocols we thought would work for later expansion,” says Warneboldt. The trial expansion went well, user numbers continued to grow, and page views have been a straight-line increase ever since. By the Summer of 2015, Fraser Northwest executive director Mary Miller had completed a report that set out recommendations for expansion to the rest of the province in a step-wise fashion, starting with the major referral areas. “From our expansion to Kootenay–Boundary, we learned that it was fine to add a rural Division, but unless we first added the centre to which it refers [in this case, Kelowna], it wasn’t as much help as it might have been,” Warneboldt explains. With that in mind, major referral centres like Victoria, Kelowna, Kamloops, and Prince George became the team’s priority.

Scope Magazine | Winter 2017

FORGING NEW PATHWAYS continued from page 9

work in the office,” says Warneboldt. In Victoria, Pathways launched with “From the very beginning, we built in this a detailed demonstration to an eager tremendously important feedback system, audience during the VDFP’s annual general so that every entry on every page can meeting in November, 2016. “Dr. Ian Bekker generate instant feedback for showed great leadership and diligence. He improvement.” The inclusion of wait times understood it backwards and forwards and and geographic data also allows patients just ran with it,” says Monk, who saw page to have more input in the referral process. views spike from approximately 19,000 to “Now, we can tell a patient that there are more than 27,500 per week province-wide Dr. Kathy Dabrus Victoria Pathways Physician Lead three specialists with wait times between after Victoria’s launch. four and eight months, and ask them what Dr. Kathy Dabrus, Victoria Pathways is most important to them,” he says. Physician Lead, is now working with her Specialists are now onside and see Pathways as a win–win. team to contact any physician who has not yet logged on to “There were times I had to go and camp out in a specialist’s Pathways, to offer them phone or in-person training. “One thing office and wait until I could give the head MOA or specialist family doctors would love to have is more time for patient a demonstration,” remembers Warneboldt. “I always told them, education,” she says. “On a day-to-day basis, I find the data bank ‘Look, I can get all the data I need from you in three minutes.’ of vetted patient information to be one of the most helpful We’d start the stopwatch, and I could always do it in that time aspects. Now, we can email our patients with information that frame.” Specialist MOAs report that referrals are more is peer-reviewed, scientifically sound, and understandable by appropriate, documentation is better, and phone calls have a lay person, all from a secure and confidential Pathways email decreased dramatically. “They don’t get people calling anymore address.” Dabrus also appreciates the wealth of current about wait times, or to ask if the specialist sees a certain issue,” physician resources now at her fingertips. “There was a time he says. Overall, there has been a balancing of wait times among when we carried notebooks with calculations and assessment specialties, with longer wait times decreasing and shorter wait tools, and algorithms for managing everything from pain to times lengthening. Staff in specialist offices can now focus more osteoporosis. Now, they are all alphabetical, and are updated of their time on work that is valuable to the practice. as soon as new information comes in.” A presentation about Pathways at a Canadian Medical “Where I see it’s greatest value is actually for physicians who Association forum garnered keen interest from others about are new to a community, to understand who the specialists are spreading its geographic reach. “Pretty much every province has in their area, what their wait times are, and what are their areas asked if they can have Pathways,” says Monk. “We want to focus of practice,” says Dabrus. “It makes it so much easier for someone on spreading it across B.C., but there has to consider opening a family practice. New been interest repeatedly from other specialists are also able to introduce provinces.” Beyond a dedicated themselves right on the homepage of the administrator for each area to ensure data site.” As well, family doctors can identify maintains its accuracy, solid relationships favourite resources and specialists who and local governance will be key factors for tend to match their practice and patient other locales to thrive. profile—both invaluable when locums are Monk now chairs a provincial user coming on board. “One of my favourite group that meets every six weeks to review statistics is that the average GP user takes and approve suggestions from users— just 18 seconds to find what they want,” change requests that are displayed she says. transparently in the administrator By now, Pathways has been adopted component of the site. “It looks like such by 80 per cent of Divisions throughout the a finished project already, but our meetings province, with approximately 3000 are packed with decision items about specialists listed. Each Division has hired, further changes to how the site works,” she or shares, a Pathways administrator. says, adding that they are reviewing how forms are displayed, Training manuals are in place to walk them through the and are beginning to tag content to search more effectively. maintenance and updating processes, with a benchmark “It has definitely exceeded our vision,” says Monk. “There are to update each specialist’s profile every six months. other things we are thinking about doing as well, and I would “I think it worked is because it’s actually collaborative,” say, stay tuned.” reflects Monk, who says the success of any large-scale technical Warneboldt adds that the team is keeping a tight reign on project is due more to relationships than to technology. “It adding any features that can’t be updated easily. He says, “It is doesn’t thrive because of one or two people, it thrives because essential that the data presented in Pathways stays accurate for everybody who works on it enjoys and cares about it.” it to continue being such a useful and trusted resource.” “It was made by GPs, for GPs, because we knew what would

“One of my favourite statistics is that the average GP user takes just 18 seconds to find what they want.”

Provincial page views spiked from 19,000 to more than 27,500 per week after the Victoria launch. Now, 3000+ specialists are listed, and 80 per cent of the province has come online.

Scope Magazine | Winter 2017

BREAKING NEWS banners offer lifeline in emergency

athways developers took another lesson from colleagues in New Zealand when they embedded the ability to run Breaking News banners across the site’s homepage. During 2011’s 6.3-magnitude earthquake that killed 185 people in Christchurch, that city’s Pathways system had remained operational, thanks in no small part to its servers being located elsewhere. “They were able to disseminate information to physicians about where clinics were being set up, and where to go to provide emergency services,” explains Dr. Tracy Monk, Chair, Provincial Pathways User Group. Doctors used the system to communicate with colleagues, to request and offer assistance, and to redirect emergency teams. For family physicians involved in emergency preparation and resiliency efforts here in Victoria, it’s the stuff that dreams are made of.

Victoria’s Pathways Physician Lead Dr. Kathy Dabrus recalls challenges with obtaining timely medical information during H1N1 outbreaks in Victoria. Although the province’s medical health officer communicated the current situation continuously, including recommendations for testing and treatment, many family doctors would receive this information via fax at delayed intervals. “In fact, I would watch CBC every morning to learn about the latest take on the virus,” says Dabrus. “It was consistent with information from the medical health officer, which would arrive a day or two later.” Breaking News banners now provide the medical health officer with a resource to reach family practitioners immediately, either across the province or in specific locales. “We’ve never had anything like this,” says Dabrus. “The capacity to spread news quickly and efficiently is amazing, and it absolutely can be integrated with PACE.”

BY CRYSTAL SAWYER n Maya Angelou’s Caged Bird autobiography, she speaks of hoping for the best while preparing for the worst. The Victoria Division’s PACE initiative (Preserving Access to Care in an Emergency) takes that adage to heart. This team of doctors dedicated to building resiliency in a community emergency or natural disaster has released two new tools get the city’s GPs prepared and operational again as quickly as possible. The Practice Continuity Guide and Workbook are tandem booklets that describe various scenarios, such as an earthquake, office flood, snowstorm, or prolonged GP illness, then walk family practitioners through the steps to create their own emergency plans. The Workbook is designed to consolidate customized, step-by-step instructions for what to do in an emergency, including situation-specific office procedures and checklists for creating different types of emergency kits. It integrates staff contact lists and phone tree systems, insurance information, critical records inventories and backups, and details regarding suppliers, vendors, and infrastructure, all into one succinct place. “It’s important that GPs and their staff schedule the time to go through the booklets together, to practice office procedures, and to create their own plans,” says PACE Physician Lead Dr. Ian Bekker, adding that each plan should be updated annually. “We are looking at Printed versions of the Practice Continuity Guide and Workbook are strategies to coach and mentor people available from the VDFP, or can be so we can be confident that each of our downloaded from divisionsbc.ca/ community GPs has a completed plan.” victoria/emergencyresponse PACE has also unveiled P–DOC Brightly-coloured magnets (Physician Department of Operations), displaying the P–DOC Disaster which is an emergency line and Help Line for Physicians will be communication system for physicians distributed soon. to coordinate a health response to a

disaster. Physicians can call in to report a situation, request more supplies or backup, or offer resources to other doctors. PACE conducted the first test of P-DOC on October 20th during ShakeOut B.C. “It did well for the first test run,” says Bekker. “All communication lines worked, and we identified ways to improve the receipt and transfer of critical information.” Dr. Paul Kachan would have appreciated these tools in 2013, when a car crashed through the bus shelter outside of his office, hit two women, damaged a natural gas main, and triggered a building evacuation. Kachan, three other doctors, and two gas station mechanics were the first responders on the chaotic scene, where they discovered one woman trapped under the vehicle. Fearing a natural gas explosion, the group moved the victim to safety and evacuated the building. “Tools like this give us some structure, and provide a framework for the steps we should take,” says Kachan. “Having that connectivity—not trying to do things in isolation in an emergency event— is very important.”

Scope Magazine | Winter 2017

POLINA ISAKHAROVA ILLUSTRATION

Emergency planning picks up PACE

Lessons in lighting the

TORCH

Team-based care model driving new innovations for patients in residence

BY CRYSTAL SAWYER

Early in 2017, The Heights at Mt. View said goodbye to beloved resident Esther McKenzie (better known as Maxie), who died peacefully in her sleep at the age of 93. Maxie was one of 260 residents at The Heights, the Saanich residential care unit that adopted the newly launched TORCH (Towards Optimal Residential Care Health) model when it opened its doors two years ago. Her daughter-in-law, Brenda McKenzie, says TORCH made all the difference to the final phase of Maxie’s life.

ith severe dementia paired with heart and lung conditions, Maxie had begun to need complex care, so was shifted to The Heights from another care facility in mid-December 2015. “Until then, she didn’t have annual checkups with her doctor,” says McKenzie. “She would just rely on hospital care, rather than on a physician’s care.” Although her doctor was excellent and would visit Maxie in hospital, she would have arrived to emergency via ambulance and returned to her care home via MediVan—a situation that can be both upsetting to a resident, and taxing on the health system. TORCH, which began as a prototype, is one of several new models of care being implemented throughout the 37 residential care facilities in the Victoria and South Island region that serve more than 3,300 residents. The new models of care aim to improve consistency and efficiency for residents, physicians and facility staff, while building resilience in the residential care system overall. Reduced barriers to regular resident visits, more support from facility teams, and closer connections to peers are just some of the benefits being reported by physicians who work within the TORCH model. The TORCH project assigned a small group of physicians to a concentrated cohort of residents at each facility, and asked them to visit their facility for one half-day each week. Each physician maintains a consistent resident load, and covers the other GPs at that facility for urgent needs and holidays.

Schedules were arranged to ensure 24/7 care. The Heights, Glengarry, and Kiwanis Pavilion ran the initial TORCH pilot. Upon signing Maxie in to The Heights, McKenzie read about the TORCH project, and was delighted to learn that Maxie was eligible. Although Maxie had persistent hemorrhoids and swollen legs (a symptom of edema brought on by her heart condition), family members saw astounding results within just one month of TORCH physician Dr. Margaret Manville taking her on. “She had had that swelling forever,” recalls McKenzie. “But Dr. Manville was patient, and she tried different things. Seeing Maxie often, rather than going to the hospital when her health became an emergency, made all the difference. The swelling in her legs completely disappeared, and she never complained about her hemorrhoids anymore because they were looked after. When you have somebody checking on you, seeing your progress, and adjusting your medication, it’s a completely different type of care.” Manville, a family practitioner and geriatric medicine consultant who sees about 20 residents each at two of the TORCH facilities, says the model makes good use of a physician’s time. “I like the team-based care model that really is part of the TORCH philosophy,” she says. “I like going to fewer places to see a cohort of residents, spending the mornings, and giving people a good amount of time and care.” McKenzie says that where previously a disconnect had existed between Maxie’s community physician, caregivers, and

Scope Magazine | Winter 2017

Before & After:

Changes in TORCH key indicators

Hospitalization and ER transfers decreased by 43%

The average number of days between admission and the first GP visit decreased from 25 to 5 days

The percentage of patients who had a physician visit once per 90 days increased from 37% to 97%

Patients who had completed Advance Care Plans signed by a physician increased from 53% to 90%

The percentage of patients who had their first GP visit within seven days of admission increased from 45% to 85%

93% of GPs indicated that they always or often work with nursing staff to prioritize care

Patients, family caregivers, physicians, and facility care staff all reported high levels of satisfaction with the model

regular scheduling, expectations, and being the go-betweens. nurses, suddenly they were all on the same page. “The TORCH It never would have happened without Division support, I’m program changed that disconnect in our minds. The care was sure of that.” cohesive. I just can’t say enough about the program.” “Residential care facilities are so happy to have physicians And perhaps nothing speaks more clearly about TORCH’s come and support their work, and their residents. That’s really impact on residents than Maxie’s connection with Manville. the bottom line,” says Manville. “This group of residents is more With her level of dementia, Maxie often confused her son for complex than it ever has been. They need her husband or brother, but recognized more support from physicians. As long as Manville consistently as her doctor. people can be seen in a timely fashion and “Dr. Manville, she always knew. She’d get good care, they’re quite happy.” walk by, and Maxie would say, ‘That’s my TORCH project manager Juna Cizman doctor,’” recalls McKenzie, adding that says the lessons learned from TORCH Maxie’s anxiety levels dropped and, for the now inform the work of the Residential first time in her life, she began to embrace Care Initiative (RCI)—a joint partnership sleep. “She was more at peace with what between the Victoria and South Island was happening to her. With the TORCH Divisions of Family Practice. “Everything program, doctors aren’t just prescribing we’ve learned from TORCH is enriching and something and walking away. They are influencing practice innovation for other immersed in a facility, they see how those residential care facilities in the region,” she changes to medication are working, and says. “We’re taking what we’ve learned to they are able to make adjustments. For us, improve care for all residents. It may be that change was huge.” another form of practice innovation, but The TORCH Prototype Evaluation Report that collaborative care, regular proactive concludes that, with the knowledge that visits, and being a part of the team...these each physician makes weekly facility visits, are critical to care.” peace of mind has increased for both With the shared goal of caring for residents and families. “Even if they aren’t our elders on their terms, more change is seen every week, they like that there’s a ahead in residential care. Fundamental to doctor around who is easy to reach, either Brenda McKenzie consistent, quality care for residents is teamon the phone or in person,” says Manville. Family member of a TORCH patient based care, and having fewer physicians “If you don’t have a physician who can visiting one location regularly to manage a come in a timely fashion, the resident higher number of residents. While some care facilities will adopt either suffers unnecessarily, or gets sent to the emergency TORCH, others will move toward other innovative models of care room, which puts unnecessary load on the ER.” that will enrich more traditional offerings. Manville says the transition to the TORCH model has been as seamless as a new initiative can be. “It’s been well embraced To learn more about TORCH, another innovative practice by the residential care facilities. They love it,” she says. “The model, physician opportunities, and more, contact support of the Division has really helped the physicians. They’ve VictoriaSouthIsland.RCI@divisionsbc.ca done so much work behind the scenes, with logistical problems,

“With the TORCH program, doctors aren’t just prescribing something and walking away. They are immersed in a facility, they see how those changes to medication are working, and they are able to make adjustments. For us, that change was huge.”

Scope Magazine | Winter 2017

Jenny Dagg heads up the new VDFP–Umbrella Society pilot project to accept direct referrals from GPs for patients needing extra help managing addictions. Like Dagg, all Umbrella peer outreach workers have struggled—or have watched a loved one struggle—with addiction. They draw on their experience to offer an empathetic ear, and help to connect clients with critical support and resources.

BY CRYSTAL SAWYER

Doctors partner with Umbrella Society outreach workers for one-to-one addiction support

t’s 2:57 p.m. on a bone-chilling afternoon at the edge of Victoria’s Chinatown. In an overstuffed chair, Jenny Dagg is backdropped by an exposed brick wall in the far corner of a high-ceilinged, timber-framed café. She’s making a few notes while awaiting the arrival of her fifth and last client of the day: a 17-year old girl referred by her doctor because she’s been smoking heroin after class for the past several months. For Dagg — who becomes almost like a friend to those who have an addiction problem, but who need extra support getting on the right track—no day is typical. Already on this wintry Wednesday, she has connected a client to a healthier housing situation, driven a woman to the Food Bank, accompanied another woman to an Alcoholics Anonymous meeting, and referred a young man to CBT skills and men’s trauma groups. When

a pretty redhead comes toward her from the entrance, an alltoo-common thought moves through Dagg’s head: “This could be my niece.” More and more often, her clients look nothing like what we envisioned as addicts two decades ago, at the threeminute mark of Trainspotting. Dagg is one of five peer outreach workers at the Umbrella Society, whose staff (other than the family counsellor and the hub receptionist) draws on its own experience with addiction to help others. They meet with clients at coffee shops, libraries, or other safe places, and connect them with services to support their recovery journey. Since March 2016, Dagg has been leading a pilot project—funded by the Victoria Division of Family Practice and the Victoria Foundation—that allows family physicians to refer addicted patients directly to her. The

Scope Magazine | Winter 2017

GOT YOU

COVERED QUINTON GORDON PHOTOGRAPH

pilot is the longtime vision of Gordon Harper, who founded the Umbrella Society as executive director 16 years ago. “Gordon worked hard to make inroads with the doctors, and was instrumental in getting this on track, securing the funding, and making relationships with the Division,” says Dagg. “It really is Gordon’s insight as to what needs to happen in the world of recovery and addiction in Victoria.” Umbrella Society workers are well connected to both public and private addiction and counselling resources throughout the city. “We refer to everybody in the community: outpatient services, detox and stabilization, treatment centres, housing, skill groups, volunteer opportunities, and lots of other things. Whatever the person needs, we’re going to help them to get there,” Dagg explains. “This pilot project gives doctors a point of entry into the whole system of addiction and recovery. The cure for addiction is connection, and we do whatever we can to make the connections these people need.” Although normally a wait list exists to see an Umbrella worker, those with a family doctor can now jump the queue. “Through the family doctor route, clients are able to see me within a couple of days.” Doctors simply call Dagg directly to

book an appointment for their patient, then the patient signs a release of information to allow the two caregivers to discuss the case. “Obviously, everything a client tells me is strictly confidential, so I can never divulge any of those details, but sometimes it’s important for me to know if a patient has an underlying mental illness, or a history of anxiety or depression.” Especially with opioids, Dagg says people are coming to recovery sooner—usually within a year or two of starting to use—and at a far younger age. “A lot of people were on prescription painkillers but were unaware they would become addicted, then end up on heroin. It’s a dangerous trajectory. The drugs are far stronger now, and the users are crashing fast. But thankfully, the stigma is being lifted, so far more young people are open to exploring recovery,” she says. Another common combination Dagg is seeing is alcohol and cocaine. “It’s the same pattern. They drink to have fun, then they start to go down, so they get some cocaine and stay up for the entire weekend.” So far, approximately 30 doctors have referred to Dagg, either directly or indirectly. “If it’s a direct referral, the doctor will provide me with some brief information about what the

Scope Magazine | Winter 2017

GOT YOU COVERED continued from page 15

substance use looks like, and I’ll take over from there.” As a part situation.’ It can seem overwhelming when they’re in the midst of the pilot, if someone calls the Umbrella Society asking for help, of something that they don’t see a way out of. Even if they’re not the Umbrella hub receptionist will now ask if they have a family quite ready to start on recovery, they’ve made that connection doctor they are willing to work alongside. If the client agrees, with me and they know someone is there.” Umbrella will send a note to the physician to inform them of the Dagg says she is always very gentle, and never tells a client relationship, and the client will jump the wait list. In some cases, what to do. “I let them know what is available to them, and what clients do have a family doctor, but don’t want their doctor to they might wish to try,” she says. “I’m always happy to take them know about an addiction. “They might tell me, ‘My doctor has to appointments and meetings if they want.” known me since I was six...I can’t tell him I’m doing cocaine every Quick to emphasize that they are not counsellors, she says, weekend’,” says Dagg. “We totally get and respect that.” “Every outreach worker at Umbrella has lived experience. That Dr. Virginia (Tuz) Gooderham sits on the pilot project’s means we are in recovery programs of our own. That’s what working group and has referred several patients to Dagg. we bring to the table, having walked the walk.” Dagg’s own “I’ve found it to be a really helpful resource battle with alcoholism plateaued in her thirties, for my patients,” says Gooderham. “It’s and she’s been in recovery for almost nine years. been instrumental for people to have a Now that the pilot project with Umbrella contact person that they can meet with in is listed on Pathways, Dagg is starting to see an a safe environment, who will support them increase of referrals. She is committed to seeing exactly where they are in their recovery each client for as long as they need her. “Success journey.” means something different to each person,” says Gooderham continues, “Jenny Dagg. “It might be that they’ve gone from drinking is amazing. My patients feel really hand sanitizer to drinking vodka. But in the words comfortable with her, and I’m seeing a lot of Gordon Harper, how we really measure success of positive changes in their relationship is if they make a next appointment.” with substances. She’s a very good teacher Dagg’s encapsulated wisdom, cultivated in helping them to learn about addiction through her combined years as an alcoholic and and specifically their own addiction, and an outreach worker? “Listen...don’t judge. Addiction to notice certain behaviours, feelings, knows no postal code, it’s not who you think it is, or thoughts behind why they use the and it’s across the board,” she says. “These people substance. Their awareness is increasing, are hurting, and they feel badly enough about and therefore they are able to make some themselves. A little kindness goes a long way, and choices or changes.” people will open up and ask for help. But if someone The best thing for Gooderham has tells you they have an addiction, cancel your been seeing the positive changes in her next appointment and listen to them at that very patients when they return to her office. “You moment. If they are told to come back another day, Dr. Virginia (Tuz) Gooderham, see they are actually getting somewhere,” they may never come back.” Victoria Health Cooperative she says. “They’re making small changes,

“They’re making small changes, dropping certain substances, forming new habits, and the substances are starting to dwindle. I can see it affecting their mental health in a positive way.”

dropping certain substances, forming new habits, and the substances are starting to dwindle. I can see it affecting their mental health in a positive way. There’s a lot more healing that can happen without the substances on board, so it’s really great to watch.” Gooderham keeps Dagg’s phone number saved on her mobile phone, and will connect the outreach worker with patients while they are in her office. “I just pass my phone to the patient,” she says. “You instantly hook them up, and you know you’ve got somebody who can start to see them right away. That way, they’re not nervous to talk to her and make the next move. It’s really an extremely valuable resource.” Dagg agrees, “If I’m the first person in this journey of recovery, we’ve gotten them off to a good start. I’m a friendly face, I’m not going to judge them. I’m just going to accept them and go from there.” Dagg says during her meetings with clients, she often observes them cross an emotional ravine from worry and fear to hope and relaxation. “They realize, ‘It’s not just me, I’m not alone, I’m not a bad person, and this is a workable 16

Scope Magazine | Winter 2017

LOOK WHO’S WALKING BY KRISTIN ATWOOD, Ph.D | TRANSITIONS IN CARE PROJECT MANAGER

Walk-in clinic survey reveals importance to patients

hat do we really know about walk-in clinic patients? To boost its understanding of patient needs and choices, the Victoria Division of Family Practice wanted to find out, so in 2016 it collaborated with researchers at the University of Victoria to survey more than 900 patients at 11 walk-in clinics throughout Greater Victoria. Participants completed a comprehensive survey that included 23 questions about their experience with the clinics, the reasons they chose to visit, the frequency of visits, and demographic indicators. Researchers also conducted a series of individual interviews with volunteers. The Walk-in Clinic Project learned that more than half of walk-in clinic patients are unattached, meaning they don’t have a family doctor. One responded noted, “Thank God for walk-in clinics. I have lost my family physician of 15+ years. The government should have planned for this; it’s no surprise that so many doctors have retired, or will retire soon.” Interestingly, most unattached patients consider the walk-in-clinic to be their primary care provider. Another patient commented, “I have used this walk-in clinic for approximately seven years. We lost our daughter to cancer, and [the doctor] helped us during and after. We cannot find a family doctor, so we use this walk-in clinic as our own family doctor.” One-third of walk-in clinic users live in poverty. A significant proportion visit a walk-in clinic for non-acute needs. Analyses of the survey are preliminary, and more results are scheduled later this year.

For more information about the Walk-in Clinic Project, email katwood@divisionsbc.ca Preliminary results. Only statistically significant findings are presented.

WHO

uses walkin clinics?

are non-white:

15% 6% Asian

45% are attached 88%

3% Indigenous

of unattached patients would like a family doctor

household 27% have incomes <$25,000*

46 average age

66% are women

*unattached patients are more likely to be living in poverty

WHAT

do patients say about walk-in clinic care?

WHY

do patients use walk-in clinics?

satisfied or very satisfied with 84% are the care they receive at walk-in clinics

arrive with an illness, injury, or sudden onset of symptoms

56% unattached: more likely to arrive with a chronic health issue,

prescription renewal, or to fill a form, and more likely to have visited a walk-in clinic seven+ times in past year

attached patients: 31%

WHERE would patients go if there were no walk-in clinics?

Scope Magazine | Winter 2017

family doctor wait times are too long

attached patients: 41%

see their family doctor

32% go to the ER 18% stay home

doctor’s 25% family office closed clinic 22% walk-in more convenient

unattached patients: 54% go to the ER

“Wait.”

18% stay home

“Panic!”

12% look for help online

In August 2015, Dr. Tim Troughton made the shift from the Kootenays to set up his practice in Victoria, continuing his focus in geriatric care. This Fall, he became one of the Victoria Division’s new Board members, and is committed to partnering with other doctors to improve health care in Victoria.

HOOKED ON COLLABORATION DODD’S EYE MEDIA PHOTOGRAPH

FIRST PERSON BY DR. TIM TROUGHTON | FAMILY PRACTITIONER

ur first visit to Victoria was in 2009 for a short vacation. We were enamoured by the vibrant atmosphere, architecture, and people, and had fun exploring the streets and restaurants. After growing up near the sea in Northern Ireland, there was something magical about being so close to it again. Work back in the Kootenay Valley was full service; the local ER department and ward involved frequent and demanding out-of-hours shifts. It was a great place to raise young children, but as they grew into teenagers more opportunities became desirable. It was time to take another look at the coast. Thanks to the excellent recruitment personnel of both the South Island and Victoria Divisions of Family Practice, I was able to assess several work opportunities, and eventually settled on a location downtown. In August 2015, we made the move: a small U-Haul convoy that included our son (who had passed his driver’s test just one day before) as one of the drivers. After some months of renting, we eventually purchased a place to call home. Having serviced an older demographic in Creston, I chose to open a practice focusing on elderly patients. The joint provincial government–Doctors of B.C. initiative A GP for Me (negotiations chaired by Dr. Lorne Verhulst) was a timely blessing, permitting both quantity and quality time with orphaned senior patients. I will never forget the visit from one very spirited centenarian lady, for whom the billing could not be applied! As the weeks went by, more calls arrived from MOAs, and from patients orphaned by their family doctor’s retirement. It brought into sharp focus the supply and demand equation in primary care, and the need for robust solutions from university to residency levels.

At the office, we decided to invest in the world of EMR (electronic medical record)—a disquieting experience more endured than enjoyed, but in the long run worth the transition from scribbles to screen. After conversations with several colleagues and the VDFP, and a well-organized presentation from EMR vendors, we were able to make an informed decision. We prioritized ease of use, a clear one-screen summary of relevant medical history, low running costs, and reliable scheduling and accounts. If the ‘happy wife, happy life’ adage is correct, then ‘happy MOA, happy Dr. Tim Troughton, Family Physician office’ must be a close second. To be honest, during this whole transition period I struggled with some melancholia. Challenges and change are not always hurdled easily. Having a loving spouse, applying the truths of mindfulness (we can choose our thoughts), and close friends who helped adjust my perception to see the big picture, all conspired to carry me through. There is a saying in Africa that goes, “If you want to go fast, go alone. If you want to go far, go together.” The Victoria Division of Family Practice’s mission statement echoes the latter sentiment. It’s about partnering together to make a difference to the health of a city. In 2017, let’s partner together to do just that.

Scope Magazine | Winter 2017

“It brought into sharp focus the supply and demand equation in primary care, and the need for robust solutions from university to residency levels.”

CBT SKILLS: THE FIRST IN A SERIES BY DR. WANDA CROUSE | PSYCHIATRIST

FEAR FACTOR In each issue of Scope, we present one of the many skills taught to participants in the eight-week Cognitive Behavioural Skills group training program. In this edition we tackle overcoming fear. This April, facilitator Dr. Wanda Crouse will even usher in her own lifelong fear of spiders as a teaching tool.

arly in the eight-week course Cognitive Behavioural Skills training program, facilitators broach the topic of the False Promise of Avoidance with participants: in other words, running away from something that produces a strong emotional response can reduce unpleasant sensations. Unfortunately, that reaction typically increases the likelihood of responding the same way each time the situation is encountered, and often with increasing intensity. American psychologist Dr. Susan Jeffers wrote a great little book entitled, Feel the Fear and Do it Anyway. Often, I tell participants that they don’t even have to read her book to experience the benefits; just place it somewhere that it will be seen, and follow the advice of the title. The idea behind this proposal is that if one is able to remain in an uncomfortable emotional state, its intensity will decrease in a very short length of time. We call this strategy Riding the Wave: learning to endure the discomfort in order to learn that it does decrease, and that although it may be uncomfortable, anxiety will not hurt you. By running away, we send ourselves the message that the threat is overwhelming, and that we cannot tolerate the experience. Of course, as we all know, it is easier said than done. I’ve been afraid of spiders since childhood. It doesn’t really help that I understand how the fear started. It doesn’t seem to help that I KNOW better than to shriek and jump up on a chair. The visceral response—racing heart, sweating, light-headedness, and rapid, shallow breathing—is immediate and intense. I am, indeed, on Autopilot: not thinking, examining, then deciding how to respond, but rather simply reacting. During the past decade, I’ve worked hard to modify this reaction, and can now catch myself as I begin to react. I no longer scream for my husband to come and kill the monster. Recently, I was able to put a spider into a container and deliver it outside. Astounding progress, without a doubt. However, my concern lingers that there may come a time when a spider appears, and my habitual response kicks in and creates real problems. I fear that if something like this were to occur on the Malahat, I would be a real danger to myself, and to others. Is this an example of Catastrophic Thinking (allowing myself to imagine a worst-case scenario, and exaggerating the possibility of its occurrence, and the magnitude of the consequences)? Taking the time to examine the situation, I can ask, “How likely is this outcome to occur?” and, “If it did occur, what might be the outcome?”. My feared scenario is not entirely

unlikely, and, if it did happen and I responded with panic, the outcome could, indeed, be quite negative. So, I can conclude that it is a somewhat reasonable proposition. So, there you have it: full disclosure. Now, considering that I am one of the facilitators helping folks to overcome symptoms of anxiety, I feel a sense of responsibility to be a role model for approaching one’s fears in a way that increases one’s probability of a successful outcome. With this duty in mind, in April, I will attempt to model the concept of graduated exposure for dealing with fear. Graduated exposure is just that: taking small, manageable steps towards one’s goal. The idea is not the Sink or Swim model, but rather acknowledging that a big step—one that produces overwhelming distress—will potentially decrease the possibility of success while triggering a return to avoidance. I have asked Claudia Copley, Entomology Collection Manager & Researcher at the Royal B.C. Museum, to act as my expert. She will provide factual information to counter any unrealistic thoughts or beliefs I may have about spiders in this part of the world. In CBT Skills Groups, we encourage people to Pause in their emotional reactivity to examine the facts of the situation in order to determine the appropriateness of their response. Ms. Copley will also act as the handler of spiders she will bring for us to use in this activity. I will try to model the ideas of Baby Steps, or graduated exposure. People with specific phobias, like spiders, could be afraid to varying degrees. Some cannot read about, look at pictures of, or tolerate even the idea of being in the same building with a spider. The current level of anxiety I experience means that I can begin with being beside a spider in a closed container, but I experience symptoms of anxiety at the thought of anything requiring greater closeness. With that in mind, Ms. Copley and I will work with the ideas of proximity, size, and actual contact for varying periods of time. I will use a variety of techniques like Abdominal Breathing, One Breath, and Visualization to better manage my physical sensations. I’ll make a point of establishing reasonable Goals for the exercise (based on SMART goal setting), which may increase my sense of success. I’ll make a point of giving myself credit with Good For Me’s, and congratulating myself for steps taken and for the hard work this exercise has required. And, ultimately, I hope that I will be able to feel the fear and do it anyway! All CBT Skills group participants will be invited to attend. You’re invited as well.

Scope Magazine | Winter 2017

What’s happening in

ROOM 109?

school, or may have difficulty completing school. Others saw tudents today are dealing with an dizzying cocktail of this step as necessary as well, and the school was ready.” physical and mental health issues, but getting them to The school—home to approximately 650 students in actually see a physician, nurse, or counsellor can be equally grades eight to 12—is located in Harewood, which despite high challenging. That’s where the John Barsby Wellness Centre need does not have a primary care clinic. With a population of (JBWC), which opened its doors in the Fall of 2015 at a South about 12,000 (12 per cent being of visible minority), Harewood Nanaimo high school, comes in. has a young demographic whose families The JBWC at John Barsby Community earn 23.78% less than other Nanaimo School is the culmination of 10 years households, and 31.45% less than the of vision and hard work by Nanaimo average household in British Columbia. pediatrician and B.C. Pediatric Society Consequently, many of Harewood’s youth Advocacy Chair Dr. Wilma Arruda. Arruda are in crisis. brought together stakeholders from the Clinic co-medical director (with school, school district, Ministries of Health, Arruda) Dr. Sandy Barlow says key to this Education, and Child and Family Services, equation is that doctors are able to rely on Island Health, Discovery Youth and Family a sessional funding model through Island Services, indigenous services, addiction Health, which allows them to build critical services, and the Nanaimo Division of relationships with the students to uncover Family Practice, which helped the clinic to underlying issues. “These kids carry a big secure infrastructure funding via the A GP burden, and even if it’s something classic for Me initiative. like strep throat, there’s usually something “I realized that I was disconnected beneath in their stories,” she says. from the schools, where issues are “Somebody comes in complaining about happening and where students are knee pain, or stomach pain, or headaches, often identified as having difficulty. For a and often issues about mental health or pediatrician, being connected to schools safety at home are divulged. A big part of it is really crucial,” says Arruda. “The A GP for is just being able to build that relationship Me initiative allowed family physicians to where kids feel safe, and this is a safe get involved, allowed for the hierarchy Dr. Wilma Arruda environment for them.” of support required, and allowed for a Pediatrician & JBWC Co-Medical Director Arruda agrees, “Youth are connecting comprehensive team of people to create to address things that sometimes have some formality and structure.” less to do with health and more to do with Arruda had been doing work something else in their lives that needs support...housing, food, through the Tillicum Lelum Aboriginal Friendship Centre with or safety from someone in the family who is harming them. marginalized populations at Bayview Elementary, which is Some of the scenarios we’ve heard are quite alarming, but we’ve a feeder school for John Barsby. “This area of Nanaimo has a been able to help them. In some cases they wouldn’t have higher aboriginal population, more marginalized families, and a received help any in other way, and the situation could have lower socio-economic status,” she says. “There are clear concerns escalated to a crisis, hospitalization, or something much worse.” that young people in this area may not be quite as prepared for

“Some of the scenarios we’ve heard are quite alarming, but we’ve been able to help them. In some cases they wouldn’t have received help any in other way, and the situation could have escalated to a crisis, hospitalization, or something much worse.”

Scope Magazine | Winter 2017

What began as a wellness centre at a south Nanaimo high school has become a safe space for kids, and a safety net for students at risk BY CRYSTAL SAWYER

Barlow says her time as a resident working with the Victoria Youth Clinic and learning about youth-friendly care has served her well in helping to set up the holistic, welcoming clinic. The JBWC feels like a comfy lounge, complete with couches, music, complimentary beverages, snacks, fruit, and a microwave. Practitioners are smiling, open, and non-judgmental. The team-based care clinic is open four days a week and is staffed by three public health nurses on rotation, who attend to many issues up front. One of six family physicians is available twice per week, Discovery Youth substance services are available on Tuesdays, and a Registered Clinical Counsellor from Aboriginal Child and Mental Health, Kathryn Atkinson, spends half-days there each Wednesday. Staff at the clinic confirms that Atkinson is always fully booked, and that they wish she were able to be there full time. Barlow says having the ability to offer counselling services to students without parental involvement has been a game changer. “We find that some parents are resistant to counselling, so students can get support in a safe environment without ever having to divulge that to parents if they don’t want to.” Although the centre has been open for less than two school years, Barlow says evaluations indicate that it is reaching the kids who need it most. “We’re getting a lot of kids accessing the clinic with mental health issues, depression, anxiety, substance use, sexual health needs, and the ones with more risky behaviours who don’t normally access primary care,” she says, adding that between five and 15 students come through the door each day. “Certainly, the underpinning for most kids is a lot of mental health concerns.” Those issues are often stemming from troubles on the home front, or from cyberbullying, which centre staff says is rampant. Centre evaluations have shown that even students who have a family doctor prefer the JBWC because of its accessibility and confidentiality. “Parents and neighbours don’t go there, you don’t have to miss class or get a ride, and you don’t have to tell your parents,” says Arruda. Whereas in the first year of operation, staff saw a lot of cases that had already escalated to the point of crisis, this year

Co-Medical Director Dr. Sandy Barlow (pictured left with her newborn son), GP Dr. Randal Mason, Clinical Counsellor Kathryn Atkinson, and Public Health Nurse Maria Devesa at the John Barsby Wellness Centre, a holistic clinic that’s been established inside John Barsby Community School. According to the Centre’s evaluation, the entire staff loves working there—which students feel, and which impacts positively on the clinic’s effectiveness.

they are able to conduct more preventative care. Dr. Randal Mason, who is actually a John Barsby alumnus, worked at the clinic during his residency and is a favourite among students during his Wednesday shifts. In his downtime, he and a public health nurse visit classrooms to boost health literacy, often answering a host of anonymous sexual health questions that have been submitted by the students. Mason and the team say other specialized educational events are on the horizon. “We’re hoping to be able to evaluate these kids five years down the road, once they do graduate, to see if we’ve made any impact to their health and success as adults,” says Barlow. Although funding, establishing a sustainable framework, and having all agencies working together are essential, Dr. Arruda’s intention is to expand—even with satellite clinics— to all of Nanaimo’s high schools over time. This year, the group launched a satellite clinic at Nanaimo District Secondary School, and the South Island Division of Family Practice and Local Action Team worked with Belmont Secondary School in Langford to embed a customized clinic into its architectural plans. Other Divisions in B.C. have expressed interest in exploring the schoolbased model, and Barlow confirms that administrators haven’t lost sight of opportunities to serve the elementary school population as well. “Although much American data exists in support of schoolbased clinics, we have little Canadian data. Experiences at the JBWC have shown us clear value of this model,” says Arruda. “The centre is established, and it’s not going away, which is helping students to trust and use the system. Even if we help one youth avoid having serious mental or physical health problems, it’s worth it. But we’re not seeing one youth, we are seeing many.”

Scope Magazine | Winter 2017

BEHIND THE SCENES WITH NICOLE DEHOOP | VDFP OPERATIONS COORDINATOR

Coffee, chocolate, and a whole lot of kindness BY CRYSTAL SAWYER

hen Alisa Harrison joined the Division five years ago as Executive Director, she knew that finding a solid assistant would be essential in building the organization from the ground up. In a twist of fate, her search came to an end just 35 metres west of her Cowichan Bay home office. Neighbour Nicole Dehoop was considering a return to the workforce after a decade of raising children, so agreed to step in and create the GP member database. A little data entry quickly mushroomed into a part-time administrative assistant role, which became fulltime within months. “It exploded from there,” recalls Dehoop, whose five-year stint as Administrative Coordinator role shifted to Operations Coordinator in mid-January. “Because Alisa and I were here right from the beginning, I know where everything is, and who everybody is.” Married with three teenage daughters, Dehoop has seen her role continue to expand. Along with being assistant to Harrison and to the Board, she is in charge of the administrative support team, and works with the Collaborative Services Committee, the Dine and Learn and Transitions in Care teams, the executive, the joint executive, and Island Health. Her new title will see her conducting more member outreach and project-related work. Despite the heavy workload, Dehoop loves her job, and the flexibility of working from home is just the cherry on top. “It’s pretty amazing to be a part of something so new, and to see it grow into what it is now,” she says. “When I look at this year’s Annual Report, it’s just amazing to see how far we’ve come, and the work that we’ve done. I think that explains the commitment for everybody on the team. We all have that feeling that we’ve started a new project, and it’s our baby.” “It’s inspiring to work with Alisa and the others on the team, and to support—directly or indirectly—projects like the CBT skill groups and TORCH,” continues Dehoop. “Everyone is on the same page, we all have each other’s backs, and we’re all working together well as a team,” she says. Dehoop, who spent the majority of her life in Alberta and worked as an elementary school teacher, originally thought she would become a nurse. “Now at my age, I wish I would have become a nurse. I feel more comfortable with the medical world; I think that was my calling.” That said, lessons from her teaching career often come in handy. “I’ve conducted some training with staff, so I’ve definitely transferred some of those skills from the classroom, even though I’m not teaching little kids anymore.” Most days, Dehoop heads down to her basement at 9am—coffee in hand—to tackle her inbox, logistics for the day’s meeting roster, and a very long to-do list. Her cell phone, her tablet or laptop, chocolate, and a healthy dose of focus are always in her toolkit. When she does get a little break, she can

be found hiking or camping with her family, sweating it out in a jazzercise class, getting pampered at the spa, or cheering for her daughters on the soccer field. The great-great granddaughter of the Manitoba Cree Nation’s Reverend James Settee (the second Indigenous person ever to be ordained as an Anglican priest), Dehoop also has some Danish and Italian blood. She and husband John Dehoop—an engineering technologist who is Construction Coordinator for the Municipality of North Cowichan—fell in love with the island after his parents moved here. “We kept visiting because we just loved the outdoors so much. We finally followed when John got a job here.” “My husband tells me that I’m attentive, responsible, adaptable, confident, capable, and caring,” says Dehoop, who has tried to model those values for her daughters. “I also tell myself that nobody is going to die if something doesn’t get done.” On her wish list? A photographic memory, the opportunity to travel outside of North America, and a lifetime of fresh crab dinners. Lee Iacocca has a famous quote that begins, “Start with good people.” Luckily for the Division, they didn’t have to go far to strike gold.

KURT KNOCK PHOTOGRAPH

Scope Magazine | Winter 2017

THE ROLE OF THE CLINICAL

CHRONICLER:

a symbiotic relationship BY NATALIA ZAPOTOCZNY | MOA, Myo Clinic

s the Clinical Chronicler, my role is similar to a court stenographer: I am an objective observer who records everything that occurs during the patient visit. I consolidate details of each encounter into an accurate report in a manner that, if left to his or her own memory, the physician may be unable to replicate. This system allows the physician more time to spend with the patient, and decreases their risk of burnout as I can cover some of this scut work. I prepare letters, complete forms, and submit claims. Not only do I enable the physician to focus on medicine, I gain experience in the inner workings of a clinic and its EMR. The result of our paired relationship is a sophisticated approach to patient care.

MOA Temp Pool Launches A new pilot project is enabling family physicians in Victoria to access to a roster of medical office assistants who are available on a temporary basis to fill absences, to assist with backlog and special projects, and to cover human resource gaps. MOAs who indicate their interest in this pilot project will have their contact information included on a list that can be sent to physicians and fellow MOAs if they contact the Victoria Division of Family Practice seeking temporary coverage. It is the responsibility of the physicianâ€™s office to contact shortlisted temporary MOAs regarding interviews and employment agreements. MOAs may remove their names from the roster at any time. For more information about the MOA Temp Pool pilot project, call 1-877-790-8492 ext. 3

Scope Magazine | Winter 2017

FROM

PATIENT TO PARTNER BY ISABEL (ANNIE) MOORE | RESEARCH EDUCATION & GRANT FACILITATOR, ISLAND HEALTH

SPOR initiative engages patients in research projects, focuses on patient-identified priorities

SPOR is the Strategy for Patient-Oriented Researchâ€”a national initiative led by the Canadian Institutes of Health Research. SPOR is intended to improve health outcomes and enhance patient experience by engaging patients as partners, and by focusing on patient-identified priorities. This strategy presents an important opportunity to make research more responsive, and to integrate evidence at all levels in the health system. What does it mean for British Columbia? The B.C. SUPPORT Unit (one of several units established across Canada as a part of SPOR) launched in November to provide training in patient-oriented research, patient engagement, knowledge translation, and research methods support. The Unit is currently testing B.C. Data Scout, a service that allows clinicians and researchers to discover whether sufficient Ministry of Health data exists to test their ideas. What does it mean for Vancouver Island? Together, Island Health and the University of Victoria form the BC SUPPORT Unit Vancouver Island Centreâ€”one of four across B.C. that will offer regional services and supports. Locally, centre staff and researchers from the University of Victoria are collaborating with the VDFP, the Umbrella Society, and the Society of Living Illicit Drug Users (SOLID) on a patient-oriented research project that seeks to reduce the stigma of substance use in primary care. Visit bcsupportunit.ca or email Rebecca.Barnes@viha.ca to learn more, discuss your ideas, or book a presentation about the SUPPORT Unit.

Scope Magazine | Winter 2017

ALISA HARRISON PHOTOGRAPH

GALLERY

LETTER TO THE EDITOR Inconsistencies highlighted between breast and colon cancer screenings in need for requisitions

AUDREY BAI PHOTOGRAPH

DODD’S EYE MEDIA PHOTOGRAPH

1+2 Dr. Caitlin Harmon and her daughter, and the son of Dr. Divya Chawla, enjoy the VDFP Family Holiday Social, December 4th at Windsor Park Pavilion. 30+ members, staff and their families enjoyed face painting by Susi Sunshine, Lego creations with Lego Guy Joseph Williams, cookie decorating, and crafts. 3 Health Match B.C., provincial health authorities, and several Divisions of Family Practice collaborated on the booth that won the Innovation Award at the 2016 Family Medicine Forum 4 Victoria’s GPs practice one of the CBT skills at the VDFP’s Annual General Meeting, November 16th 2016. 5 Jon Schmid, Director of Access and Transitions at Island Health, and Kristin Atwood, Transitions in Care project manager, celebrate getting access to centralized fax numbers for community information coming to Royal Jubilee and Victoria General Hospitals. Scope Magazine | Winter 2017

P’s are expected to promote screening for asymptomatic treatable conditions. The B.C. Cancer Agency supports screening for breast cancer and for colon cancer. A woman can have a screening mammogram without a requisition from the doctor, if she says she has a doctor. A patient has to get a requisition from the doctor to get the fecal immunochemical test (FIT) with follow-up by the Colon Screening Program. The possible adverse effects of screening mammography are not given much attention. Briefly, most women undergoing mammography will not have their lives lengthened as a result of treatment for breast cancer. A positive mammogram can cause anxiety and lead to further testing including a biopsy. Biller-Andoro and Jueni, in the New England Journal of Medicine, suggested that women be better informed about the risks and benefits of screening mammography. There is a four per cent chance that a person with a positive fecal immunochemical test has colon cancer. Early treatment of colon cancer can put the patient into long term remission. Why can a woman get a mammogram without a requisition from the doctor, while a person has to have a requisition to get the FIT? FROM DR. ROBERT SHEPHERD

Send your Letter to the Editor to victoriaeditorial@divisionsbc.ca with the subject line ‘Letter to the Editor’. 25

Call for Contributions Scope Magazine needs writers, photographers, and artists!

Write an article, or submit a story idea, photograph, illustration, satirical cartoon, or letter to the editor. Stuck for ideas? You’ll find a brainstorming list on our website.

Deadline for story ideas for the next issue: Friday, July 7th 2017 We are seeking contributions from member GPs, specialists, resident doctors, medical students, MOAs, partnering organizations, and patients. For information and to subscribe for your digital and print editions, visit

vdfpmagazine.ca

This Edition’s Poll: Should there be a governmentfunded program to cover the cost of basic medications? Email your response by March 3rd to victoriaeditorial@divisionsbc.ca

On the pulse of Victoria’s health.

The Victoria Division of Family Practice (VDFP) represents family physicians in Victoria. Together, our 400+ member physicians are working hard to improve our health care system. All of our work aims to enhance patient care, foster healthy communities, and ensure that people can access a family physician when they need one. We are working on a wide variety of innovative initiatives to improve patients’ and physicians’ experiences across the system of care. Some of our priorities include mental health and substance use care, care of the elderly, residential care, physician recruitment and retention, and transitions between hospital and community. You’ll find some of those stories, and more, in each edition of Scope Magazine — the quarterly magazine published by the VDFP. We are making progress. Since 2013, we have helped 18,200 patients find a family doctor, and more than 55,000 patients have developed stronger relationships with their GPs. Meanwhile, 22 family doctors have returned or relocated to practice in Victoria. We continue to recruit more GPs to the city, and we are helping those nearing retirement to adjust their practice so they can see patients longer while maintaining their own health and well-being. For more information, visit divisionsbc.ca/victoria Victoria