July-August 2014 | Volume 39 | Number 4

Rising to the challenge

100 years ago

DIGEST

Running strong! The AMA Youth Run Club crosses the finish line of a successful year

Going social Challenges and safeguards for

the online doctor

Alberta Doctors'

What do you think about our website?

Earlier this year, we asked all of our members to fill in a survey about our website

Patients First®

World War I and medicine in Alberta

AMA MISSIoN STATEMENT

The AMA stands as an advocate for its physician members, providing leadership and support for their role in the provision of quality health care.

CoVER PhoTo: Dr. Allan C. Rankin ( provided by University of Alberta Archives)

6 Rising to the challenge 100 years ago World War I and medicine in Alberta

12 Going social Challenges and safeguards for the online doctor

17 A brighter future for medical oncology 2014 scholarship winner sets his sights on better care

18 Running strong! The AMA Youth Run Club crosses the finish line of a successful year

25 What do you think about our website? Earlier this year, we asked all of our members to fill in a survey about our website

27 What you need to know about privacy agreements Some tools to help you as custodian of personal and health information

Patients First® is a registered trademark of the Alberta Medical Association.

Alberta Doctors’ Digest is published six times annually by the Alberta Medical Association for its members.

Editor: Dennis W. Jirsch, MD, PhD

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP

Editor-in-Chief: Marvin Polis

President: Allan S. Garbutt, PhD, MD, CCFP

President-Elect: Richard G.R. Johnston, MD, MBA, FRCPC

Immediate Past President: R. Michael Giuffre, MD, MBA, FRCP, FRCPC, FACC, FAAC

Alberta Medical Association 12230 106 Ave NW Edmonton AB T5N 3Z1 T 780.482.2626 TF 1.800.272.9680 F 780.482.5445 amamail@albertadoctors.org www.albertadoctors.org

September-October issue deadline: August 15

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor.

The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.

© 2014 by the Alberta Medical Association

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CoNTENTS

FEATURES

DEPARTMENTS 4 From the Editor

10 Health Law Update

14 Mind Your Own Business

16 Insurance Insights

21 Dr. Gadget

23 PFSP Perspectives

29 In a Different Vein

32 Classified Advertisements

July - August 2014

3

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AMA - AlbertA Doctors’ Digest

In medical school I learned that denial is a common psychological

defence mechanism. Some years later, with the popularity of Elisabeth Kubler-Ross’ work on grief, I learned that it

is a stage we may go through in coming to terms with death. Lately though, I’ve been hearing that denial ¬ our ability to forego rational thinking, especially in the face of anything unpleasant ¬ is characteristic of our larger, communal lives, is a phenomenon that blinkers us and is one with which we must contend.

Michael Specter, science writer for The New Yorker has written a book with a provocative title: Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives.1 According to Specter, denialism ¬ by which is meant denial writ large, our all-too-common and irrational refusal to accept established fact ¬ pertains to the irrational ideological commitments we make as well as our mistrust of authority.

MMR vaccine and autism and even the mercury contained in the once-used vaccine preservative thimerosal has not been associated with harm.

The seeds of doubt had been planted, though. The combination of an early, menacing report and public mistrust has led to renascent measles as parents forego recommended vaccination for their children and as “herd immunity” suffers. We’re doing ourselves no favors. With the exception of improved sanitation and clean drinking water, no public health measure has saved us from more ill health and mortality than widespread vaccination.

We’re similarly irrational about our foodstuffs. Organic farming has become a lucrative and expanding enterprise, once again seemingly fuelled by our suspicion of big industry as well as nostalgia for earlier, less complicated times. We’re uncertain of exactly what the term organic means but generally use the term as a synonym for “natural,” by which we generally mean good, or safe, or wholesome. Lest we think that natural is synonymous with good, however, we might best remember that mercury, lead, and asbestos occur naturally, as do viruses, E. coli and salmonella.

Food grown “organically” is assumed to be better for us than food grown by conventional means. Though there’s likely benefit in buying locally grown produce and supporting regional economies, the big questions remain. Is organic food any better for us than that containing genetically modified ingredients, even when it is harvested by remote controlled combines rather than human hands? Are organic fertilizers and pesticides somehow more beneficent than those made with synthetic chemicals? The answer is not an unambiguous “yes,” as we recall recent salmonella outbreaks associated with bean sprouts and the spate of diseases associated with consumption of raw milk. Once again we disdain available evidence. The National Academy of Sciences and the United Kingdom’s Genetically Modified Science Review Panel have repeatedly concluded that the process of adding genes to our foodstuffs through genetic engineering is as safe as conventional plant breeding.

The larger imperative is that with over seven billion of us on the planet, we are running out of arable land,

FRoM ThE EDiToR4

Dennis W. Jirsch, MD, PhD | EDITOR

On one hand we’re capable of sophisticated reasoning. On the other hand we have an extraordinary ability to deny reality.

Deny, deny, deny

>

An obvious example of denialism has to do with our mistrust of childhood vaccination accompanied by recent outbreaks of measles in Canada and the United States of America (USA). An “epidemic of doubt” was triggered in Britain when The Lancet published a 1998 study connecting symptoms of autism to the measles, mumps and rubella (MMR) vaccine. This alarming study was seriously flawed, roundly discredited and subsequently retracted by both the magazine and its authors. Rigorous examination by the USA National Academy of Sciences through the Institute of Medicine has rejected any causal relationship between the

July - August 2014

5as seen so readily in sub-Saharan Africa, and we have critical need for crops that are both drought and disease resistant. Several hundreds of thousands of the world’s people enter the middle class each day and ¬ you guessed it ¬ want more meat in their diets. As we look to feed our burgeoning numbers, the impossibility of providing adequate foodstuffs without the benefit of food science is apparent, as too is the interdependent tangle of environmental degradation, climate change, water scarcity and agricultural productivity.

The most perfect example of our denialism ¬ our irrationality ¬ must be our enthusiasm for alternative medicine and its melange of new age mysticism, unfounded claims and out-and-out quackery. In this truly alternative world, belief trumps effectiveness and no one has to prove what is safe or what works and what doesn’t. And so complete is our abandonment of evidence that we all have favored nostrums to ward off colds, at the same time that coffee enemas and laetrile are propounded as cancer cures, and a host of other exotic plants and potions promise weight loss, better hair and renewed vigor.

> argue that unless something else was at play here, this awareness would be accompanied by a terror-filled realization of our mortality that would be incapacitating. As such, it would represent both a psychological and an evolutionary dead-end constraining that thought and action necessary for survival and reproduction. The only way our cognition and our awareness of ourselves could develop successfully, the authors argue, is if we simultaneously developed mechanisms that would permit us to deny our mortality at the same time as our cognitive capacity grew.

That we deny our mortality is commonplace. We are only too willing to go to war, indulge in dangerous activities, smoke, eat to excess, avoid planning for retirement and so on. We embrace the appearance of youthfulness, and at end our funerals are short, packaged events. And what is it that we say so commonly to reassure ourselves? “Life goes on.”

If Varki and Brower are correct, we’ve been presented with a two-sided coin. On one hand we’re capable of sophisticated reasoning. On the other hand we have an extraordinary ability to deny reality and, perhaps accordingly, have overpopulated our planet beyond its carrying capacity even as we neglect the climatic disruptions that have become commonplace.

It’s an interesting notion that we’ve gotten as far as we have, not only because we’re more intelligent and savvy than, say, our Neanderthal cousins but, too, because we deny information we don’t care for, especially as it reminds us of our general puniness and fallibility. It’s not a big jump beyond this to expect that we’re capable of believing whatever unsupported dogma serves us best. Whatever, as they say, floats our boats.

Bottom line, once again, it would seem best to acknowledge that we’re inherently irrational and error-prone. That said, our greatest, most valuable tool must stem from the work of Francis Bacon and others, with its emphasis on verifiable evidence, hypotheses and facts. We know this best, perhaps, as the Scientific Method.

It’s the best means we have of discerning truth, or as Carl Sagan put it some years ago ¬ it’s our “candle in the dark.”3

References

1. Specter M. Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives (The Penguin Press, 304 pages, November 2009).

2. Varki A, Brower D. Denial: Self-Deception, False Beliefs, and the Origins of the Human Mind. Twelve (Grand Central Publishing), 2013.

3. Sagan C. The Demon-Haunted World: Science as a Candle in the Dark. Random House, 2011.

The most perfect example of our denialism – our irrationality – must be our enthusiasm for alternative medicine and its melange of new age mysticism, unfounded claims and out-and-out quackery.

There may be an explanation for our loose attachment to reason and it may relate to our humanness and our evolution as a species.

Dr. Ajit Varki, a physician trained in internal medicine, had a remarkable conversation some years ago with Danny Brower, chair of the molecular and cell biology department at the University of Arizona at Tucson and it culminated in a provocative text. Why is it, Varki and Brower wonder in Denial: Self-Deception, False Beliefs, and the Origins of the Human Mind,2 that in a world filled with a number of other highly intelligent animals ¬ chimps, orangutans, elephants, dolphins, and so on ¬ that others haven’t developed human-like mental abilities, even though they’ve had millions of years to do so?

Varki and Brower find an answer in the conjunction of modern man’s cognitive abilities with his capacity for self-awareness and his understanding that others are self-aware too. Though developing such perception of self and others was itself a signal event, Varki and Brower

AMA - AlbertA Doctors’ Digest

One hundred years ago, on August 4, 1914, the assassination of Archduke Franz Ferdinand of Austria plunged the world into World War I

(WWI). As a British Dominion, Canada was constitutionally obligated to defend Britain. The unanswered question was how much would we contribute. The British asked for a division. Canada sent 32,000 troops and horses on 33 ships by October, for an anticipated six-month war.

Canada had a population of eight million. Nine-year-old Alberta had 500,000 residents.

Health care institutions were being initiated in Alberta. There were about 400 doctors in the province. Twenty-six students had completed their premed at the new medical school in Edmonton. The Strathcona (later University) Hospital was one-year old.

Alberta’s enlistment norms would exceed those of the rest of Canada, particularly in medicine. It left the province under-doctored and so under-bedded that when the Spanish flu epidemic hit, schools, churches and community buildings were turned into isolation hospitals. As Albertans rose to the wartime challenge, they never anticipated such a post-war dividend in return.

The Canadian Army Medical Corps (CAMC) had been organized in 1896 by the Minister of the Militia, Dr. Frederick Borden. The CAMC was ill-prepared for war in 1914, with just 20 doctors, five registered nurses (RNs), and 102 bearers/caregivers. That figure would rise to almost 20,000 through volunteers by 1918. Physician conscription was never required.

Of the 49,000 Alberta troops, 6,140 died, while 60,000 were admitted to a hospital because of disease or battlefield injuries (some were admitted more than once).

The first unanticipated troop call came following the chlorine gas attack during the Battle of Ypres in April 1915. The gas cloud was diagnosed by future dean Dr. Allan C. Rankin and Lieutenant Colonel Dr. George G. Nasmith. The anticipated increase in casualties led to the formation of the Military Hospitals Commission (MHC) >

6 CovER FEATURE

Rising to the challenge 100 years agoWorld War i and medicine in Alberta

Dr. Allan C. Rankin was awarded the highest honor of any Alberta physician during World War I and was named the first dean of the U of A Faculty of Medicine. ( provided by University of Alberta Archives.)

A small field operating room overseas. ( provided by Selby Collection, University of Calgary Archives)

Stretcher-bearing during a gas attack. ( provided by Selby Collection, University of Calgary Archives)

J. Robert Lampard, MD

under Senator James Lougheed, which eventually created or controlled over 12,000 beds, 918 in Alberta.

University of Alberta (U of A) President Dr. Henry M. Tory offered to provide a 1,040 bed hospital in 1915. The Canadian government declined, but the MHC took over the Strathcona Hospital in 1916 and kept it for six years.

Of the estimated 200-plus physicians who enlisted, 40% remained in Canada and 60% went overseas. At home, medical care focused on recruitment examinations, rehabilitation and return-to-work programs. Overseas, Alberta’s physicians focused on

July - August 2014

7> the treatment of diseases as they arose and battlefield injuries that came in waves. Physicians were responsible for a gamut of services from supervising ambulance trains and ships, acting as battalion medical officers, triaging at field ambulance units, staffing and operating casualty clearing centers, stationary hospitals, general hospitals and supervising the specialty hospitals that evolved in England. Hygiene was a major focus as deaths from diseases dropped 25-fold from the Boer War.

One Field Ambulance (FA) (the 8th from Calgary) and one-third of the 11th (western universities) Field Ambulance were formed in 1915. Two of the four U of A faculty enlisted (Dr. Heber H. Moshier and Dr. Rankin). The faculty was saved by the arrival in 1915 of Professor James B. Collip, MD, and the part-timers. At least three died, including two Lieutenant Colonels (Dr. Moshier and Dr. Hewetson) and one Captain (Dr. Monkman). Several were gassed (Hepburn, Cooper-Johnson, Mason) but survived and many more were injured.

Alberta’s enlistment norms would exceed those of the rest of Canada, particularly in medicine.

The most exceptional record was that of Dr. Rankin. After helping treat the encephalitis outbreak amongst the first contingent of arriving troops, he was transferred to France as part of a mobile laboratory. Dr. Rankin supervised the typhoid vaccination of the Belgians to prevent a recurrence amongst the troops, diagnosed malaria amongst the Indian troops, was the first to describe the trench fever syndrome, and conducted research on the best gas mask design. He returned to France as a CO of a Field Ambulance before supervising the Matlock Officer’s Hospital at war end. He was awarded the highest honor of any Alberta physician (CMG - Companion of the Order of St. Michael and St. Geo) and was named the first dean of the U of A Faculty of Medicine months later by President Tory. In WW II he was immediately called upon to head the Hygiene and Sanitation (laboratory) Service of the army at the same rank, Lieutenant Colonel.

Dr. Hepburn introduced some novel techniques, including boiling sea water to use for IVs and irrigating solutions, wearing five pairs of gloves and stripping one pair off after each operation and giving universal or O negative blood using the direct transfusion method. He also wrote three articles for the medical literature, as did Dr. Rankin, and earned two fellowships after the war in the Khaki University program that Dr. Tory organized.

The highest ranking Alberta officer was Dr. John S. Stewart, a dentist from Lethbridge, who joined the artillery in 1907. Sent overseas, he became the Brigadier General in charge of all the artillery batteries of the third division.

About 150 Alberta nurses enlisted in the 2,293 RN positions that were created. Most nursing positions were filled by eastern grads (to the chagrin of the westerners). Roberta MacAdam was a dietician who enlisted and succeeded in getting elected in the 1917 Alberta election from overseas. She was a strong supporter of creating a veterans’ department, developing programs for returning soldiers, improving their access to health care, improving school curricula and organizing the normal schools.

Although the Spanish flu may have shortened the war, causing 150,000 deaths on each of the German and allied sides, it became more virulent after it crossed the ocean to North America. Of the 40,000 Albertans affected, 3,000-4,000 died. The number included the Minister of Health Alexander G. MacKay, who died of flu complications in 1920.

In preparation for the end of the war, Mr. MacKay introduced the Municipal Hospital Act to allow land to be taxed to support the district hospital. The first was at Lloydminster (on the Saskatchewan side) and the first entirely new hospital was at Mannville (1918). There would be 15 more by the early 1920s, to care for and treat returning soldiers requiring rehabilitation. The concept spread throughout the empire.

With only two FAs leaving behind war diaries, the contributions and tracking of Alberta physicians has been left to the few memoirs (McGill, Miller, Hepburn, Morrish, Richardson) and recent books (McGill, Norris, MacAdam).

The memoirs described tragedies and humor ¬ a dinner where everyone donned gas masks, excursions to the west end theatres in London, a secret marriage, fatalism, fear and courage. Dr. Howard H. Hepburn described his dramatic escape on the last train out of Berlin, by pretending to be an American doctor. Dr. W. Morrish was on a returning convoy at the end of the war and negotiated the end to a potential mutiny over space allocation to the officers. Dr. G. Harwood was bilingual and was the Commanding Officer (CO) of a large French hospital outside Paris at Armistice time.

Dr. E.G. Mason was the only doctor to command a battalion, losing it when he was gassed and then turning around the #1 medical supply depot at Shorncliffe. The College of Physicians & Surgeons of Alberta Registrar, Dr. George Macdonald, went over as the CO of the Southern Alberta Light Horse Battalion, until it was dispersed to fill other front-line casualties. Back in England he established the Bramshott Military Hospital before returning as a full colonel to command Calgary’s #13 Military District at Sarcee for three years. >

AMA - AlbertA Doctors’ Digest

8 The second public health department in Canada was established in 1918, the same year that a venereal disease clinic was opened by Dr. H. Orr to deal with the returning veterans’ problem. The lack of physicians to treat Albertans led to the formation of the district health nurse program in 1918 that sent nurses to areas where there were no physicians. It also resulted in government support for the creation of a full degree-granting medical school program and the building of the medical school in 1920-21. In 1921, Dr. John S. McEachern provided the leadership to turn around and save the nearly bankrupt Canadian Medical Association.

Overseas, Alberta’s physicians focused on the treatment of diseases as they arose and battlefield injuries that came in waves.

The United Farmers of Alberta (UFA)/United Farm Women of Alberta strongly supported the Liberal government’s health care initiatives. Irene Parlby created a furor when she wrote the 1919 AMA president that physicians needed to upgrade their skills. A formal Continuing Medical Education program wouldn’t begin until a decade later. She was the first to articulate the UFA’s position that health care was a right, in 1919. After the UFA was elected (1921) she would join Health Minister George Hoadley and recommend a health insurance program, with the government paying for those who couldn’t afford it, in 1935.

The UFA government was particularly interested in addressing health care issues after WW I. It benefited from a remarkable stability at the deputy and ministerial positions, which fostered the passage of Alberta’s precedent-setting health care acts over the next two decades.

The post-WW I contributions of Albertans to the improvement of health care in Canada must be one of the most significant contributions the province has made to confederation.

Editor’s note

This essay, in an expanded format, was prepared for an anthology titled Alberta and the Great War, co-edited by Adriana A. Davies, CM, PhD and Jeff Keshen, PhD, Dean of Arts, Mount Royal University, Calgary. The book will be published by the University of Calgary Press in 2015.

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AMA - AlbertA Doctors’ Digest

There are over 40,000 Albertans (725,000

Canadians) suffering from Alzheimer’s disease or other forms of cognitive impairment. Experts tell us this number may

double in the next 15 years. This massive increase in the number of Canadians living with some form of dementia will place a huge load on the health care system.

Of these individuals, many have or will experience at some point in time the phenomena of wandering. Individuals leaving assisted living facilities or hospitals without notice, and often without proper clothing, pose a significant safety risk to themselves. There are many, many documented instances of seniors ending up outside in freezing weather without adequate winter clothing and many of these cases end up with tragic results.

Enter the concept of Global Positioning Satellite (GPS) tracking.

and the time taken to locate the wearer will be reduced from hours to minutes. The project will include the involvement of researchers with AHS and the University of Alberta’s Faculty of Rehabilitation Medicine.

Aside from the obvious benefit to the patient/resident, the use of devices such as these provide much-needed comfort to relatives or friends, while freeing police resources which otherwise would be consumed with the search. In Calgary, for example, police statistics revealed over 250 missing persons investigations last year which were somehow linked to AHS facilities (either hospitals or extended care).

But what about the ethical issues? Would the placement of a GPS tracking device on a patient, or a resident of a care facility, breach that individual’s right to privacy? That is the argument advanced by critics of the program. As well, there are concerns with just how far the use of this technology might be extended. For example, could the wearing of such a device become mandatory for all patients, so that bathroom visits or attendance at suggested therapy sessions could be monitored? Or the frequency of stepping off-site for a cigarette? Undoubtedly there is a flavor of “Big Brotherliness” attached to this project.

Advocates of the project would argue, however, that patient safety should trump any suggestion of invasion of privacy, especially if use or access to the tracking program is rigidly controlled, monitored and audited.

One individual interviewed in conjunction with the pending project cares for her 84-year-old mother, who suffers from dementia and short-term memory loss. She says she wouldn’t hesitate to provide her mom with GPS if she ever felt there was a danger of her wandering off and getting lost. “We put them on our phones and I have a GPS unit in my car, so in case it gets stolen they can track it down,” she said in response to questions from a reporter. “If we have GPS for things like that, why wouldn’t we want it to protect the people most precious to us? We could prevent all sorts of tragedies.”

10 hEAlTh lAW UPDATE

Electronic tracking of dementia patients “Big Brother” or common sense?

>

Jonathan P. Rossall, QC, LLM | PARTNER, MCLENNAN ROSS LLP

Locating the patient/resident would be as easy as turning on a computer, and the time taken to locate the wearer will be reduced from hours to minutes.

Alberta Health Services (AHS) will shortly be introducing a pilot project, similar to programs in place in Europe and in other Canadian jurisdictions, whereby a GPS device worn like a bracelet is provided to dementia sufferers to facilitate prompt tracking in the instances where that individual has gone missing. Locating the patient/resident would be as easy as turning on a computer,

July - August 2014

11

Jill Petrovic, spokeswoman for the Alzheimer Society of Calgary, says keeping such patients safe is paramount ¬ and GPS, if used prudently, appears to be a useful tool. “Although it’s a widely debated issue, it really comes down to making some tough personal choices. Ideally, the family would have these discussions earlier on as part of their future planning.”

That may be the final answer to the critics ¬ consent, or advanced directives. If the patient/resident (assuming he/she is capable of giving an informed consent) is okay with wearing the device, or if the personal representative consents, surely that puts an end to the debate and provides safety and comfort to the individuals and their families.

>

Would the placement of a GPS tracking device on a patient, or a resident of a care facility, breach that individual’s right to privacy?

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AMA - AlbertA Doctors’ Digest

12 FEATURE

Going social Challenges and safeguards for the online doctor

Physicians and patients alike are drawn to the convenience of electronic communications ¬ email, mobile texting, web portals, social media. While

these channels offer benefits, they are accompanied by privacy risks and have implications for patient expectations and the clarity of communication ¬ any of which may lead to a complaint to the Office of the Information and Privacy Commissioner of Alberta (OIPC) or the College of Physicians & Surgeons of Alberta (CPSA), or result in a legal action.

In helping to manage physicians’ medico-legal risk, the Canadian Medical Protective Association (CMPA) encourages its Alberta members to be familiar with the regulatory requirements to which they are subject and to implement practices that help prevent unintended consequences of being an “online doctor.” Both the physician and patient should be aware of the risks and agree to certain conditions prior to engaging in electronic communications.

Confidentiality and security

In Alberta, the Health Information Act (HIA) establishes rules to protect the privacy of an individual’s health information and regulates how health information can be collected, used and disclosed. The CPSA Code of Conduct defines physicians’ responsibilities concerning confidentiality: physicians are expected to “regard the confidentiality and privacy of patients, research participants and educational participants as well as their associated health records as a primary obligation.”1 Further, the Information and Privacy Commissioner of Alberta states that physicians “have a duty to protect the privacy of your patients and the confidentiality of health information in your custody or control.”2

Alberta’s physicians are responsible for implementing reasonable privacy safeguards when implementing new

processes for the exchange of information with patients. Those safeguards should align with the sensitivity of the health information. The HIA requires that custodians (i.e., those with custody or control of patient health information) submit a Privacy Impact Assessment (PIA) to the privacy commissioner before implementing a new administrative practice or information system that collects, uses or discloses identifying health information.3

Both the physician and patient should be aware of the risks and agree to certain conditions prior to engaging in electronic communications.

Privacy concerns may arise if, for example: emails containing sensitive information are intercepted, misdirected, altered, or lost; unencrypted mobile devices are lost or stolen, or are used over public wireless networks; when information is stored on centralized servers as in the case of patient portals and on cloud computing services; and if physicians communicate patient information on social media platforms.

Physicians can provide patients the opportunity to exchange information using electronic channels. The physician should first explain the inherent risks of using such channels and request the patient to acknowledge those risks and consent to conditions. This can be achieved verbally or more formally by having the patient sign a consent form, such as the physician-patient email communication consent form provided by the CMPA (https://oplfrpd5.cmpa-acpm.ca/documents/10179/25117/physician-patient_email_communication_form-e.pdf). Details of any verbal agreements should be documented in the patient’s medical record and if a consent form is used it should be filed with the medical record. >

July - August 2014

13When health professionals access the provincial electronic health record (EHR) system, they are considered to be “using” health information, so they must follow the rules set out by the HIA. Notably, the HIA requires custodians to collect, use and disclose health information only in the most limited manner, with the highest degree of anonymity possible and on a need-to-know basis.

In completing a PIA, the physician or institution demonstrates due diligence in identifying and addressing potential privacy risks. The commissioner’s acceptance of a PIA ensures that reasonable efforts are in place to protect privacy and helps ensure any new systems comply with Alberta’s Freedom of Information and Protection of Privacy Act and the HIA.

Patient expectations

Online communications can help to streamline and improve efficiency of an office practice. Email, for example, is helpful because it reduces the number of telephone calls and can be an effective way to communicate about administrative matters such as appointments. However, problems can arise when a patient sends numerous emails pertaining to his or her medical condition that would be more appropriately discussed in person. Can physicians limit the number of emails and impose restrictions on acceptable topics?

Indeed, they can. Whether during the consent discussion or included in the consent form (such as in the email consent form noted above), the physician and patient should agree to conditions that set out expectations and boundaries for exchanging information using electronic channels. The patient might, for example, be required to agree not to use such channels for time-sensitive matters (e.g., emergencies) or sensitive medical information (e.g., substance abuse) and to take specific precautions to preserve confidentiality (e.g., safeguarding passwords). Physicians should always retain the right to withdraw the option of communicating electronically.

Physicians who have websites that provide patient portal services, medical information, or promotional materials may consider posting a terms-of-use agreement that outlines the

expectations of both parties as they relate to the use of such a website. The CMPA’s Terms of Use Agreement template may be used for such purposes (https://oplfrpd5.cmpa-acpm.ca/documents/10179/25091/com_terms_of_use_agreement_template-e.pdf).

Because of the inherent lack of control over information posted to social media platforms such as Twitter, LinkedIn and Facebook, physicians should maintain appropriate professional boundaries and ensure that medical advice posted by the physician is not seen as establishing a therapeutic relationship with other online users.

Clarity and tone

While clarity is important in any form of communication, online communications must be worded with particular care to avoid ambiguity and possible misunderstandings. All statements, including inappropriate or abusive ones, can live online indefinitely. The CPSA Code of Conduct stipulates that physicians are to express their opinions on health care matters “in a manner respectful of others’ views and the individuals expressing those views.”

Physicians can help prevent misunderstandings by following some best practices: avoiding use of acronyms and medical jargon unless they are explained; avoiding emotional messages (e.g., anger, regret, sarcasm, humor) which could be misinterpreted; and reading the message carefully before sending to ensure it is properly worded and accurately reflects the desired meaning.

For more information

The CMPA website at cmpa-acpm.ca offers articles and other resources about how physicians and health care institutions can meet their privacy obligations, communicate effectively with patients and implement and use electronic channels. The Electronic Records Handbook (https://oplfrpd5.cmpa-acpm.ca/documents/10179/24937/com_electronic_records_handbook-e.pdf) is an invaluable resource for health care providers concerned about medico-legal risks associated with eRecords and emerging information channels.

References available upon request.

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ShoRT AND TWEET!

Get the latest AMA news in 140 letters or lessTwitter is a great way for you to get the latest AMA: • News, events and announcements.• President’s Letter and other publications.• Important information from other medical associations.

how can you find us?• Already have a Twitter account? Follow us at

http://twitter.com/Albertadoctors.

Scan to go directly to the AMA's Twitter account, or visit us at http://twitter.com/Albertadoctors.

• Don’t have a Twitter account? Signing up for Twitter is fast, easy and free. Just go to https://twitter.com. You can open an account in under a minute.

Check in regularly at http://twitter.com/Albertadoctors or see the most recent tweets on the AMA website, e.g., the Twitter box on www.albertadoctors.org/media.

We’ll be tweeting new items almost every day. Join us!

AMA - AlbertA Doctors’ Digest

We have all heard about the “vehicle recall.”

It is a request to return to the maker a vehicle with a defect or safety issue. Parts are fixed or replaced, and the safety of the customer is restored. Have you ever wondered how they know which customers to contact? Makers keep a list of parts installed on vehicles so they may quickly identify which ones are affected. By matching the list of vehicles affected to customer sales records, the maker is able to create a list of customers to contact. During the recall the maker may also suggest routine or necessary maintenance, creating income from an expense situation. Recalling vehicles saves lives and is good business practice.

Toward optimized Practice Staff

A panel allows you to more accurately calculate how many complex patients may need a complex care plan (CCP) ¬ hence allowing you to bill for 03.04J ($214.80). As well, with an accurate panel and an electronic medical record (EMR), you can set up a notification and recall a patient when the annual CCP is due. Using the panel and EMR you can also be alerted when a new diagnosis qualifies a patient for a CCP.

An accurate panel allows you to know who “your” patients are. It has been reported that family physicians who see their own patients spend an average of two minutes less per appointment, as compared with appointments with patients they don’t know. That could mean an hour per day to see more patients, complete charting or just getting home earlier!

Clinics that have identified their panels have found they can more accurately plan staffing requirements based on patient demographics and need. For example, one clinic thought they needed a geriatric nurse to help manage their elderly patients. Although they estimated that the majority of their patients were seniors, a simple panel analysis quickly revealed that a nurse specializing in prenatal care would be more efficient and effective. Hiring the right staff for the right work saves money. With patient lists you can direct support staff to perform activities in preparation (or in place of) a visit, freeing your time to do billable physician work.

Attracting new physicians to a community or clinic is supported through panel work. Patient lists will provide realistic estimates of potential fee-for-service revenue for new physicians. Established patient lists allow new providers to grow their panel quickly as patients can be contacted for an introductory visit.

Patients value a trusting and on-going relationship with a single physician and additional allied team members. Booking patients who are your patients with you promotes this relationship and has been shown to achieve good communication and exchange of information with patients. They feel listened to and report having enough time with their physician.

Patient Panel ¬ What’s it all about?

MiND YoUR oWN BUSiNESS14

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Clinics that have identified their panels have found they can more accurately plan staffing requirements based on patient demographics and need.

Benefits of panel

Establishing and maintaining a panel (a list of patients with whom you have a relationship) is associated with improved patient outcomes. The Health Quality Council of Alberta found that patients who were highly attached (paneled) to a physician experienced fewer hospitalizations, emergency department visits and shorter length of stay than those who were lowly attached. Like auto manufacturers, physician practices focusing on quality through patient panels make good business sense.

Identifying the group of patients with whom you have a relationship can save time, money and increase satisfaction. Making a list of your patients, a panel, creates a foundation for quality and patient management opportunities.

July - August 2014

15Getting started with panel

Understanding your panel, starting to identify patients and managing patient panels can seem daunting. That’s why the Alberta Medical Association’s (AMA's) Toward Optimized Practice (TOP) program recently worked with stakeholders who share an interest in supporting strong patient-physician/team relationships to develop the new Guide to Panel Identification.1

The Guide to Panel Identification originated out of the need for a common, consistent set of tools to help provide support to physicians. The guide, which helps physicians identify and establish the characteristics of their own panel, describes why physicians need to understand who their patients are in order to improve their practice. Most physicians and patients already have an implied understanding that “I’m your doctor and you’re my patient.” The goal now is to make this explicit, so that everyone on your team understands that relationship.

Once the patient panel is established, confirming attachment should be no more complicated than checking demographic information. So when patients call or check in, the receptionist asks if they still live at the same address and if Dr. Smith is still their doctor. It may never be a perfect list, but it can be a very helpful tool.

Practical application

A clinic may recognize they have a problem with “access” ¬ not enough health care providers to meet the needs of the community ¬ and wonder how they can do screening better so the patients can be seen more efficiently (especially those who haven’t been in for a long time). The first step would be to identify which patients will need to be contacted.

> The clinic team may not have had a process for panel identification and every patient who had come through the clinic over the years for any reason was listed as “active.” As a result, a report from this clinic EMR may indicate there are more active patients than there are residents of the community! By implementing a process to identify patient/physician relationship and “cleaning up” the existing panels, the clinic will find the patient lists to be a manageable size.

One Alberta clinic reports a reduction from a clinic panel of 66,000 names to 10,000 active patients ¬ 8,000 who were attached (or “paneled”) to a physician, plus 2,000 “orphan” patients whose doctors had recently left the practice. Overall, this was a more reasonable number for the 10 part- and full-time providers and the clinic team to actively manage.

Support is available

There is support to help you. TOP is coordinating and providing various types of hands-on support to help you achieve panel management like these and other (including specialty) clinics. For more information, please contact TOP at top@topalbertadoctors.org.

Stayed tuned in the future for videos of physicians who are identifying and managing their patient panels.

Reference

1. TOP worked with Alberta AIM, Alberta College of Family Physicians, Alberta Health Services, AMA Practice Management Program, University of Alberta Faculty of Medicine and Dentistry, Health Quality Council of Alberta, Physician Learning Program and AMA Primary Care Alliance (Sections of General Practice, Rural Medicine and Primary Care Network Physician Leads Executive) to develop and refine the guide.

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AMA - AlbertA Doctors’ Digest

In our ongoing effort to provide excellent service to physicians,

TD Insurance Meloche Monnex (TDIMM) has made the following changes under our home and automobile

insurance program for Alberta Medical Association (AMA) members:

A dedicated phone line exclusive to AMA members to offer a preferred level of customer service when calling in for information on their policy (or to get a new policy or make changes to their existing one).

Advice line. In the past, when a policy holder called to inquire whether or not they should make a claim, we would count that call as an occurrence, and it would be considered a claim (whether or not you actually made a claim). From an actuarial point-of-view an inquiry is a very accurate predictor of a policy holder’s propensity to make a claim. However, from a customer service point-of-view, it makes no sense. We will be setting up a toll-free advice line where any policy holder can call for advice on whether or not they should make a claim without it counting against them as an occurrence.

So-called “three-strikes you’re out” rule. In the past, if a residential policy holder had three or more claims in a two-year period, we might have cancelled his or her coverage. It was just too expensive for us to continue to do business with this policy holder if he or she was going to make residential claims approximately every 18 months. We have changed this requirement and will no longer cancel coverage for excessive residential claims.

Exclusive for AMA members: In the event a claim is not settled (or handled) to your satisfaction, TDIMM’s vice-president of claims for Western Canada will be the single point of escalation for all AMA members. This escalation process is triggered by contacting the AMA to report your concern.

A claims advisor will review and input your claim within five minutes of calling and offer to dispatch emergency contractor services to your home. We will worry about whether or not you have coverage at a later date. Our first priority will be getting the emergency contractor services to your home (this is unique in the insurance industry).

homes will be inspected within 24 hours of reporting a claim. We are committed to having our teams mobilized and available.

Dedicated relationship manager to triage claims as a result of catastrophic events such as fire, flood, severe hail or wind storm.

Ensuring that members understand their policies. Insurance can be complicated, so we will be putting in place a number of initiatives to ensure that physicians better understand their coverage so they can appropriately manage their insurance needs:

• We will have pertinent articles in Alberta Doctors’ Digest and MD Scope on a scheduled and ongoing basis.

• When important changes occur in your coverage, we will proactively contact you to discuss these changes.

• In the past year, we have invested 6,000 hours in additional training, focused on problem resolution and needs assessment.

• We now have licensed advisors across Canada available to take your phone calls. Your calls will be re-routed seamlessly to minimize wait times.

• Myinsurance.ca can provide 24-hour availability for you to access your policies. We will be expanding on this in future issues of Alberta Doctors’ Digest and MD Scope.

iNSURANCE iNSiGhTS16

Don Warden | SENIOR MANAGER, AFFINITY MARKET GROUP, TD INSURANCE MELOCHE MONNEx

TD Insurance Meloche Monnex ramps up customer service for AMA members

July - August 2014

FEATURE 17

On a sunny June 13 afternoon at the Alberta Medical Association (AMA)

Edmonton office, the 2014 TD Insurance Meloche Monnex (TDIMM)/AMA Scholarship was awarded to Dr. Michael P. Chu. The medical oncology resident received $5,000 toward his one-year clinical research fellowship at Stanford Cancer Center, California, beginning in September.

The TDIMM/AMA Scholarship is bestowed annually to support a physician’s training in an area where clinical expertise is needed in Alberta. Scholarship recipients return the value by bringing enhanced skills to meet the needs of patients here.

Dr. Chu’s area of focus is mantle cell lymphoma (MCL). This subgroup comprises only 5-6% of Non-Hodgkins Lymphomas diagnosed, but it carries one of the poorest prognoses. Dr. Chu’s fellowship will enable his advanced study in MCL. This will include a pioneering treatment being piloted at Stanford involving the combination of therapeutic vaccination with autologous stem cell transplantation. This treatment may be able to circumvent malignancy-mediated immune tolerance. He will research the effects of adding booster vaccinations post-transplant.

The knowledge Dr. Chu gains will benefit patients at the Cross Cancer Institute upon his return to Edmonton.

Mandeep Chauhan, Relationship Manager at TDIMM and AMA President Dr. Allan S. Garbutt were on hand for the June 13 presentation of the scholarship cheque and plaque.

L to R: Dr. Allan S. Garbutt, President, AMA; Dr. Michael P. Chu, 2014 recipient; and Mandeep Chauhan, Relationship Manager, TD Insurance Meloche Monnex. ( provided by Janice H. Meredith)

A brighter future for medical oncology 2014 scholarship winner sets his sights on better care

“This clinical research fellowship at Stanford will be a milestone in Dr. Chu’s career,” said Dr. Garbutt. “Winning this scholarship not only shows how much he has achieved already in his profession, but it also gives us an idea of just how much he can accomplish in the future.”

For more information about the scholarship and other recipients who have been recognized for their tremendous work, visit the AMA website at http://bit.ly/1oei1n3.

AMA - AlbertA Doctors’ Digest

18 FEATURE

The Alberta Medical Association (AMA) Youth Run Club (YRC) has made its mark in providing kids with a healthier future.

In this age of technology, it is hard to imagine children and youth having any interest in moving anything but their hands across a touch screen. One can safely

assume less time is being spent at outdoor activities with the constant stream of new and improved electronic games and gadgets available to kids.

Coming off a successful first year, the AMA Youth Run Club, through its partnership with Ever Active Schools, has made tremendous strides in helping to halt this trend and improve the health and physical activity of school children across the province.

There are now 233 schools participating and more than 11,000 children, their teachers and volunteer coaches and leaders (including physicians!) involved.

Ever Active Schools is the delivery arm, providing assistance to schools, teachers and physicians interested in starting a run club. (To find out more about the services offered, please see the sidebar on page 20.)

Running strong! The AMA Youth Run Club crosses the finish line of a successful year

Recently, teachers from the participating schools were asked various questions about their experience with their AMA Youth Run Clubs. Here are the results and an interesting snapshot of the impact we had.

• A majority of clubs ran twice a week (57%).

• Participants ran most at lunch time (47%), but after school was a close second (41%).

• 54% said their YRC participated in bonus runs.

What other things did the survey reveal?

• Students learned more than how to put one foot in front of the other. With content provided by Ever Active Schools, topics discussed were:

- Hydration 80%

- Running technique 69%

- Injury prevention 64%

- Benefits of physical activity on mental health 57%

- Proper nutrition 57%

• 66% of participating schools said their AMA YRC program was aligned with other health and wellness initiatives.

• 96% of participating teachers said AMA YRC was easy to implement.

• 82% of teachers said that AMA YRC helped their school engage students who are not traditionally active.

Not only have the survey results demonstrated the success of this program, the teachers and community supports involved have added their kind words of support to the cause. Here are a few samples of the positive feedback:

• “The students have become better runners and have more endurance in participating in physical education classes.”

• “The children have built up to running five kilometers! We go off school property to run in the Rainbow River Valley. The kids love running in nature and have a great time.”

Ecole Dickinsfield School in Fort McMurray. ( provided by Hayley Degaust)

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July - August 2014

19• “Several children that are introverted, coded, have major behavioral issues or simply are ‘not active’ have joined and have regularly participated. This has resulted in improved behavior in the classroom and stronger teacher/student relationships.”

• “Having a student excited about coming to school who previously thought ‘there is no positive reason to come’ has improved her time, endurance and is now recruiting other students and is a positive leader in our school.”

The Comprehensive School health approach: Tying it all together

While physical activity is important, other factors influence the health, personal growth and wellbeing of students. Ever Active Schools has adopted the Comprehensive School Health (CSH) approach to health promotion that gives students numerous opportunities to observe and learn positive health attitudes and behaviors. To achieve these goals, this approach relies on four pillars:

• Teaching and learning

• Partnerships and services

• Healthy school policy

• Physical and social environments

CSH encourages and depends on active partnership among everyone who can and should contribute to the wellbeing of students, including teachers, administrators, parents, peers, health professionals and the community.

AMA Youth Run Club, through its partnership with Ever Active Schools, has made tremendous strides in helping to improve the health and physical activity of school children across the province.

Ecole St. Paul in Fort McMurray. ( provided by Hayley Degaust)

Ecole Dickinsfield School in Fort McMurray. ( provided by Hayley Degaust)

Dr. Kimberley Kelly, who initiated the Youth Run Club at her two sons’ elementary school, says that, “Ongoing collaboration with provincial partners, like Alberta Health Services and Alberta School Boards’ Association (ASBA), are essential components of my role as the AMA Comprehensive School Health representative. As a member of the ASBA Student Health and Wellness Task Force, AMA has a voice in the promotion and implementation of Comprehensive School Health across our province.”

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“Comprehensive School Health is simply about the process and creation of a healthy school community. All schools have examples of great initiatives already in place that support the wellness of its members.”

Some of the changes that a CSH approach can encourage include healthier food choices in schools and at events, using a health focus to decide on priorities for school equipment, supporting a positive social environment, encouraging neighborhood families to walk to school instead of driving and more. Ever Active Schools offer many activities to support the CSH approach. For more information, visit the CSH page on the Ever Active Schools website at www.everactive.org.

Looking forward, it seems that the AMA Youth Run Club will continue its success in helping today’s youth embrace the outdoors, sans electronics! And with such programs as CSH, this can only be a positive influence on the health and learning outcomes of our kids.

AMA - AlbertA Doctors’ Digest

20

That was the sound of 11,000 pairs of feet hitting the ground!

In October 2013, the Alberta Medical Association and our partner Ever Active Schools launched the AMA Youth Run Club – a free, school-based running

program designed to get children and youth active right across the province.

With the help of many great people – including our major sponsor the Running Room – the Alberta Medical Association Youth Run Club

jogged into its 233rd school just a few weeks ago.

More than 11,000 children and their teachers and volunteer coaches are now involved – with more to

come in September.

Thank you to our fabulous network of schools, teachers, kids, community volunteers, physician champions and sponsors who made the Alberta Medical Association

Youth Run Club a run-away success this year!

See you in September! www.everactive.org/alberta-medical-association-youth-run-club

AMA YOUTH RUN CLUB DIGEST AD.indd 1 2014-06-10 9:00 AM

Meet Hayley Degaust Hayley provides an array of resources and assistance to teachers and schools to help them get their AMA YRC started, such as the Coach’s Handbook, the Runners Handbook and the Eat Move Play challenge. This challenge encourages healthy eating habits, staying active and reducing screen time. She also sends regular email updates on the program to all AMA YRC participating schools and provides supporting incentives such as t-shirts, YRC wristbands, bookmarks and sunscreen samples as incentives for the students.

An important role for Hayley is visiting the AMA YRC schools. Hayley says, “This past year I have attended 32 school visits. The schools request the visits and each one looks different depending on what the school requests. Some schools want to learn new running games and see some of our handbook activities implemented. Other schools invite me out to watch

the kids run and talk to them about our program. After each of these school visits I learn new ideas from each run club.”

Hayley also provides assistance to physicians who wish to become involved in an AMA YRC in their child’s school or a school in their area, or help out an existing run club.

To learn more about the resources and assistance Hayley can provide, visit the Ever Active Schools website at http://www.everactive.org/alberta-medical-association-youth-run-club.

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Hayley Degaust is the AMA Youth Run Club Coordinator. She is a competitive track and field athlete and coaches young athletes. She has been running since she was eight years old.

July - August 2014

Recently, while working at the clinic, one of my residents

asked if there was a free app that could be used to explain facet joint injections to a patient with degenerative disc

disease of the lumbar spine. As I pulled out my iPad and selected an app, she said, “I wish I could just have my iPad pre-loaded with all of the apps I need.” My response was to note that if this were possible, she still wouldn’t know enough about the apps to use them regularly. Some effort in understanding and “playing with” apps is necessary in order to trust them enough to use in patient and/or learner education. However, seeking out medical apps among the tens of thousands of options available is a daunting task which most reasonable physicians would like to avoid.

as self-management of disease). This process, while welcome and laudable, is still in the very early stages. I am unaware of any similar process happening in Canada. I would direct the reader to the following FDA webpage for more information: http://www.fda.gov/medicaldevices/productsandmedicalprocedures/connectedhealth/mobilemedicalapplications/default.htm.

So, how does a typical, busy doctor, who sees the potential in his/her mobile device, safely navigate the cutting edge? iMedical apps (imedicalapps.com) is a US-based website edited and written by physicians in several stages of training which reviews apps in detail for all mobile devices. Medical apps are reviewed and rated on a regular basis and categorized, allowing for an improved search function. The Medical App Journal (http://www.medicalappjournal.com) is “an independent website created by and for medical professionals” with a “goal … to only index and review applications used by medical doctors and health care professionals in clinical care.” Both of these websites provide free subscription services to allow users regular updates to their email, Facebook or favorite RSS reader.

Another reasonable option is to ask a colleague who has some experience on which apps he/she finds most useful. This option is probably no less evidence-based than using the websites mentioned above and may offer more pertinent information. One must remember however that if there are two doctors in a room, there will be at least three opinions ¬ so what one doctor may find to be an amazing app could turn out to be incredibly annoying for another. With this in mind, I would like to list my five favorite medical apps and give one tip to those of you with iPads.

GoodReader (http://www.goodreader.com). This is not a medical application, but it is incredibly useful for organizing and annotating pdfs as well as allowing me to run almost any type of file on my iPad. I have accumulated a large database of teaching videos, spreadsheets and documents that I access regularly. It also easily links to DropBox as well as many other cloud-based servers for easy backup and access to files.

Apps, apps, apps

DR. GADGET 21

Wesley D. Jackson, MD, CCFP, FCFP

If there are two doctors in a room, there will be at least three opinions – so what one doctor may find to be an amazing app could turn out to be incredibly annoying for another.

The search for the perfect app must also include serious consideration about the quality of the data. Is it evidence based? Is the data presented in a clear and concise manner? Were medical professionals involved in the development? Is it updated regularly? The US Food and Drug Administration (FDA) has become active in the regulation of specific medical apps, especially those associated with medical devices and those apps which may pose an increased risk to the user (such

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AMA - AlbertA Doctors’ Digest

22 Evernote (https://evernote.com/evernote/). This is a great note taking app that also allows for clipping web pages, email and managing to do’s. Free for most users.

Spine Pro iii (http://applications.3d4medical.com/spine_pro). One of several detailed anatomy apps produced by 3D4Medical, it includes very useful animations for teaching. I chose this one in particular because my practice lately seems to have a lot of people with back pain.

MedCalc (https://itunes.apple.com/ca/app/medcalc/id806809930?mt=8). This is an excellent medical calculator.

AhS (http://www.albertahealthservices.ca/mobile.asp). The app provides approximate wait times for local emergency rooms as well as details on influenza and, more recently, advance care planning.

There are several other apps that I use regularly, including Dynamed (available free through the Canadian Medical Association website at http://www.cma.ca/clinicalresources/k4p), AMMI Flu (https://itunes.apple.com/ca/app/ammi-flu/id747230887?mt=8), Immunize Canada (http://www.immunize.ca/) and others. Please see this document bit.ly/1qRyiSI for more information on other apps that I have tried.

A useful tip: On your device, turn on “Guided Access” under “Settings,” “General,” “Accessibility.” This feature locks the device to a single app, allowing you to lend your device to a patient or a child while maintaining the integrity and privacy of your tablet.

The quest for the perfect set of apps may seem daunting at first, but will probably be rewarding in the end. Often the joy is in the journey.

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PhYSICIAN(S) REQUIRED FT/PT

MILLWOODS EDMONTON

Also locums required

Phone: Clinic Manager (780) 953-6733 Dr. Paul Arnold (780) 970-2070

ALL-WELLPRIMARY CARE CENTRES

Locums needed. Short-term & weekends. Family physicians & specialists.

Experience:

• Flexibility – Practice to fit your lifestyle.

• Variety – Experience different Alberta practice styles.

• Provide relief – Support rural colleagues and rural Albertans.

• Travel costs, honoraria, accommodation and income guarantee provided.

ContaCt:

Barry Brayshaw, Director, AMA Physician Locum Services®

barry.brayshaw@albertadoctors.org

T 780.732.3366 TF 1.800.272.9680, ext. 366

www.albertadoctors.org/services/physicians/practice-help/pls

AMA Physician Locum Services®

July - August 2014

There are days in clinical medicine, when in a state of being unslept, unwashed, unfed, undiuresed and unloved that the toil feels like an upstream run in

the river Styx. Sometimes we don’t fight it: we give in, we snap, we retreat and stop communicating. And yet, we also know “them”: those physicians who have shown us how to navigate these waters with a collegial spirit.

They are our mentors, teachers and colleagues. Sometimes, like Dr. Spencer R. McLean for unfairly brief periods; and others, like Dr. Ian Bennett or Dr. Hal Irvine, for a thankfully longer time. People whose presence, reassurance, feedback, assistance and advice repeatedly seem to part the roiling waters to a place more Elysian.

What is collegiality?

Collegiality, like professionalism, is an entity that is essential to our everyday practice but is challenging to define, let alone teach. The qualities that collegiality encompasses are easily taken for granted ¬ until one has one of “those” difficult encounters.

The College of Physicians & Surgeons of Alberta Code of Conduct is “intended to support … collegiality” but does not define what this entails. Similarly, in the Royal College of Physicians and Surgeons CanMEDS 2015, collegiality is mentioned and described as a desired trait that should be acquired by trainees but the attributes are not defined.1, 2

Further east, the College of Physicians & Surgeons of Ontario is more categorical and states that: “Collegiality is cooperative interaction between colleagues,” and that “[C]ollegiality of relationships can affect the comprehensiveness and continuity of care patients receive…. At times, it is as a unified voice that physicians can best advance their patients’ interests.”3

So collegiality is defined as an intrinsic duty of our profession and has clear potential benefits for patient care. What is not mentioned is the benefit it has on our colleagues and ourselves.

Dr. Douglas L. Myhre and Dr. Gavin R. Sun

The concept of a collegium has long historical roots. First used by Cicero in ancient Rome to describe a group of priests, Mangiardi and Pellegrino extend the idea of collegiality as the cultural, behavioral and structural manifestations of a collegium ¬ a group united by a collective commitment to a similar goal or idea.4

That goal should be optimum care of our patients. Particularly on hellish days, it can feel like the only option is to accept Charon’s ride and even then, one is a penny short and it’s a colleague who has tightened the purse strings!

Creating environments conducive to collegiality

There are system and local measures that can be taken to encourage collegiality. Rakes and Rakes describe qualities that can promote such behavior.5 Environments considered conducive to collegiality are supportive, people-centered, flexible, consensus-driven, open to emotional expression, consistent, respectful of differing opinion, fair in generational equity and workload equity, transparent in decision-making and collaborative in their approach. It’s easy to take such qualities for granted, and if one is unaware, collegiality can be very difficult to openly discuss or teach. That said, if collegial behavior is part of the prevailing culture, such perceptions could be mentored.

We are fortunate in medicine that, for the most part, we are not undermined by fractured compensation for the work we perform. Much of the time we take an intrinsically collaborative and collegial approach with our colleagues (contrast this with our legal colleagues whose approach may be an adversarial zero-sum game).

Issues of remuneration can be divisive. In the practice of medicine in Alberta, generally we are not competing with each other for patients and revenue. If anything, many turf wars occur over turning away work, not competing for it.

The cynic might argue that in order to appreciate the light, one has to see the darkness. Consider some of the toxic work environments and malignant colleagues you’ve had the misfortune to encounter. Do qualities like defensive, judgmental, inconsistent, autocratic, dogmatic, opaque, unequal or poorly communicative come to mind? Negative role modelling possibly does disservice to all the magnificent colleagues we have and will continue to meet. It also sets a bad example for learners.

Collegial role models make a big difference in your practice

23PFSP PERSPECTivES

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Dr. Douglas L. Myhre Dr. Gavin R. Sun

AMA - AlbertA Doctors’ Digest

24 > Are there ways, formal and informal, individual doctors can encourage collegiality? A conscious change in attitude can sometimes go a long way in creating a healthier workplace. One simple way to promote collegiality is to adopt a mindset where we all intend the best while doing the utmost with the resources at our disposal.

Our colleagues in psychology have a paradigm called actor-observer bias. When people judge their own behavior, and they are the actor, they are more likely to attribute their actions to the particular situation than to a generalization about their personality. Yet when an observer is explaining the behavior of another person (the actor), the observer is more likely to attribute this behavior to the actor’s overall disposition or character rather than to situational factors.

For someone else “they’re bad,” while for me “it was a bad day.” It’s better to contextualize someone else’s behavior, however egregious, in the frame that both they and I are doing the best we can, with the skills we have, under the conditions around us.

Time to recognize our collegial role models

Paradoxically, the selflessness and generosity of spirit that make our collegial role models so admirable are characteristics that are easy to overlook when assessing merit for formal awards. Kudo-hunting is more likely to gratify the narcissistic, not the selfless.

Nevertheless, acknowledging our colleagues both publicly and privately is important and another way to encourage collegiality. Admirable traits should be lauded: if not to encourage the winners to continue to perform (which they probably will anyway), but for others to be aware of such respectable attributes and to strive for such conduct.

The most selfless and dependable are often the most oblivious and humble regarding their own magnanimity. The surprise of unexpected peer nomination for awards, and the subsequent recognition is valuable to show the “amazing humbles” that their efforts are appreciated, admired, inspiring and hopefully will be modelled by others.

Whom do you know deserves your nomination as an outstanding preceptor in the University of Calgary Rural Medicine Recognition Award?

References available upon request.

July - August 2014

25FEATURE

Earlier this year, we asked all of our members to fill in a survey about our website. Over 1,300 members responded: a response rate of 13%. (The data is valid

19 times out of 20 within a margin of error of +/-2.49%.)

We’ve done a similar member survey every year for the past three years and it’s always fascinating to see and compare the results. More importantly, members’ responses lead to changes in the way we do things.

For example, last year, many members said that they needed our main pages to be less cluttered (fewer words!). We cleaned up these pages, so that they now show a series of easy-to-follow links.

Another major change came out of last year’s survey ¬ a central place for physicians’ financial services. The “Member services/Physicians” web page (https://www.albertadoctors.org/services/physicians) is now exclusively focused on this kind of Alberta Medical Association (AMA) service.

What do you think about our website?

And this year’s survey?

Many members asked for a way to manage their own benefits. This change has been underway for a while. Over the past year, the AMA’s Information System Group has been working on ways to allow members to manage benefits online. Eventually, all of these services will be gathered into a member self-service “dashboard” ¬ a central hub for managing your AMA benefits.

One surprising result this year was the low number of members accessing our site via mobile (still only 5.1%). A far higher number of members use mobile to access some of our publications, e.g., the percentage for MD Scope is almost 40%. We’re looking into ways to make our site as mobile friendly as possible.

We’re always interested in hearing from members, both about what works for you and what doesn’t. You can reach us at webmaster@albertadoctors.org.

You can see the full survey results below.

Comparing the 2014 and 2013 results

Survey question/result 2014 2013

Number of respondents • 1,044 physicians

• 122 resident physicians

• 149 medical students

• 39 retired physicians

1,354 total

• 982 physicians

• 87 resident physicians

• 160 medical students

1,236 total

I can find the information I need on the AMA website

Strongly agree 8.7% 9.2%

Agree 63.7% 64.1%

Neutral 22% 22.7%

Disagree 5.3% 3.3% >

AMA - AlbertA Doctors’ Digest

26 Survey question/result 2014 2013

Please tell us how you find information on the site (check all that apply)

I use the Search 42.2% 42.9%

I go to “Member services” and click on the web pages for me (physicians, resident physicians, students)

75.3% 72.2%

I use the “My favorites” feature 5.4% 5.6%

I use the top navigation tabs or just click around 37.6% 36.2%

Other 1.1% 1.5%

If you’ve logged into the website using your member number and password, did you find the login process

Very easy 16% 14.1%

Easy 50.6% 47.6%

Neutral 27.3% 31.3%

Difficult 5.5% 6.2%

Did you find the information offered on the website (in “Login help”) helpful when logging into the website?

Very helpful 0% 1.4%

Helpful 30.3% 15.3%

Neutral 43.4% 37.5%

Rarely helpful 10.5% 25%

Not helpful 9.2% 13.9%

N/A 6.6% 6.9%

Please tell us the reasons you visit the AMA website (top two)

Get information you need to carry out your role in the AMA (e.g., information for board/Representative Forum delegates)

11.2% 13.4%

Search for specific documents (e.g., CME statement, honoraria and expense claim form)

50.2% 49.7%

Access AMA benefits and services 72.3% 65%

Get information about AMA news, campaigns and events 12.1% 21.5%

Read AMA publications 20.1% 16.4%

Other 3.9% 3.1%

I most often access the AMA website (choose one)

On my mobile device 5.1% 3.1%

On my computer (laptop and desktop) 90.8% 92.9%

On my tablet device 4.2% 4%

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July - August 2014

27FEATURE

Physicians are responsible for ensuring the privacy, confidentiality and security of personal and health information. Here are some tools to help you with

the task as the “custodian” of this information.

Privacy impact Assessment

A Privacy Impact Assessment (PIA) is a legislative requirement for custodians. They must submit a PIA when they plan to implement new administrative practices or information systems that collect, use or disclose health information about identifiable individuals. This applies to changes to practices or systems (section 64 of the Health Information Act [HIA]).

information Manager Agreement

An Information Manager Agreement (IMA) is a legislative requirement under the HIA between custodians and the Information Manager(s). An Information Manager is defined in the HIA [section 66 (1)] as a person or body that (a) processes, stores, retrieves or disposes of health information, (b) in accordance with the regulations, strips, encodes or otherwise transforms individually identifying health information to create non-identifying health information, and (c) provides information management or information technology services. An example of an IMA would be one between physicians and an electronic medical record vendor.

information Sharing Agreement

An Information Sharing Agreement (ISA), as per the standards of the College of Physicians & Surgeons of

What you need to know about privacy agreements

Alberta (CPSA), is the legal contract that defines the data stewardship rules and processes that the parties have agreed to. It outlines the terms and conditions of the exchange (sharing) of custodian duties in a common manner such as within a shared electronic medical record (EMR) environment in a clinic setting. An ISA helps guide issues pertaining to the management, security requirements and professional responsibilities relating to the sharing of patient records. It is a contractual commitment that will ensure all professional obligations and legal duties related to the use and disclosure of records are fulfilled. Another important component of the ISA is that it outlines what will happen to the patient records as custodians enter and leave the clinic practice.

Disclosure Agreement

A Disclosure Agreement (DA) is a legal contract that governs the disclosure of information with third parties who will be using health information for authorized secondary purposes (e.g., population health data, planning and budget forecasting). The objective of the DA is “to record the details, purpose, scope and conditions of a disclosure of health information containing individually identifying data, where such disclosure is not mandated by legislation, court order or other such authorization.” DAs define the parameters under which the custodian agrees to disclose the specific health information and expressly limits what the recipient can do with the health information. A DA confirms that physicians have met their legal and professional obligations, as set out in the HIA and by the CPSA.

Stephanie Crichton | SENIOR IM/IT CONSULTANT, AMA & Ingrid Ruys | EMR PRIVACY AND SECURITY ADVISOR, AMA

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AMA - AlbertA Doctors’ Digest

28 Scenario You need a(n)

iMA iSA DA

Using a billing agent, external transcription service x

Using a storage firm (e.g., Iron Mountain), electronic or paper records x

Using an application service provider (ASP), remote data storage x

Sharing patient information between offices x

Sharing information within the primary care network (PCN), large clinic group setting (health care information sharing) x

Sharing information in a hospital, ambulatory, or mobile office setting x

Providing health information to your PCN to develop budgets, reports, accountability, etc. (non-health care related purpose) x

Providing health information to Health Quality Council of Alberta x

There are templates for IMAs, ISAs and DAs available through the Alberta Medical Association to assist custodians (physicians) in their responsibility to ensure due diligence in contract management. As a custodian, you must consider if the template meets the needs of the particular situation. The template may not be adequate in all circumstances and may require customization.

TooLS AT A gLANCE

Privacy Impact Assessment (PIA): legislated requirement to assess privacy impact of changing administrative practices or information systems.

Information Manager Agreement (IMA): mandatory requirement, with key factor being the vendor’s ability to alter health information or data (store, retrieve, migrate), e.g., an electronic medical record vendor, data migration service.

Information Sharing Agreement (ISA): contractual obligation to share information within limited parameters, predominantly used with common sharing of health information, e.g., clinic settings, partnerships, PCNs.

Disclosure Agreement (DA): a contractual agreement for secondary disclosure of health information, such as providing information to a third party outside of the purpose of providing health care, e.g., information on patients for budget forecasting provided to an overseeing organization such as a PCN.

For more information, or if you have questions or concerns, please contact Stephanie Crichton, Senior IM/IT Consultant, Alberta Medical Association. T 403.471.3964 stephanie.crichton@albertadoctors.org

look MA, No loGiN! Want to comment on the President’s Letter or other pages on our website, but don’t want to log into the site? You can!

We’ve produced a new way for you to tell us what you think or to participate in group discussions. We’ll be including this feature with President’s Letters and on other web pages in the coming months.

Give it a try! For example, next time we send you a President’s Letter, click on the link at the top of the email. Scroll down to the bottom of the web page and post your comment. It’s just that easy.

Take a look at our commenting policy for some common-sense advice on keeping the conversation productive. And, of course, you’ll still be able to contact the president directly by email.

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July - August 2014

>

29

Dark faces pale against that rosy flame, The mild-eyed melancholy Lotus-eaters came.

- Tennyson “The Lotus-eaters”1

Aah … pot … cannabis sativa ... in most western pharmacopoeias for hundreds of years, then outlawed as a recreational activity in 1961 by “The

United Nations Single Convention on Narcotic Drugs” ¬ signed by 180 countries led by the United States of America, is now making a comeback.2

There are more words for pot than the Inuit have for snow: marihuana, maryjane, lala, leaf, lye, kif, skunk, hash, hashish, weed, grass, dope, BC bud, ganja, hemp, hippie lettuce and hiagra. You can then carry it in a baggie and four twenty3 it in a joint, bong, spliff, toke, reefer or vaporizer. And it’s good for glaucoma, asthma, autism, epilepsy, Parkinson’s disease, Multiple Sclerosis, cancer, heart disease, anxiety, depression, nausea and appetite ¬ in fact pretty much everything. Queen Victoria used it for dysmenorrhoea.

Jay Leno, the Jaw Guy, once said in a late night show episode: “According to latest reports, medical marijuana sales are now approaching $2 billion per year. I had no idea so many people had glaucoma. Apparently this is an epidemic.”

For a full list of research on ailments, you can Google: “Granny Storm Crow’s List.” Here are all the published papers on cannabinoids ¬ everything from blood pressure to blepharospasm. Most are in-vitro studies or small clinical studies of less than 10 patients ¬ nothing that would stand scrutiny in a Health Canada review of a new pharmaceutical. I have never seen a response in a cancer patient and I’ve looked after a lot of patients taking cannabis. I have, however, seen some patients helped for mild nausea, distress, and non-specific aches and pains.

As of April 1, new Canadian regulations (Marijuana for Medical Purposes Regulations) are in effect following a transition period from June 19, 2013. Now the only legal source of marijuana for medical purposes are Health Canada licensed producers.

Alexander h.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

I’m sometimes asked about marijuana for chemo-induced nausea and I usually say (to the patient): “Hey, chill dude. We’ve been using it for, like, 20 years but find it, like, a bit sketchy.” Yes, nabilone is occasionally used for anticipatory nausea but many patients find the loss of control worrying and don’t like it. For good going chemotherapy-induced nausea-like real nausea, bro’ ¬ we’ve got much better stuff.

“Let us swear an oath, and keep it with an equal mind, In the hollow Lotus land to live and live reclined On the hills like Gods together, careless of mankind.”1

Most university students have tried it. Even one-third of high school graduates claim to have tried it. I’ve never been asked in public if I’ve tried it, but I do keep in mind the Clinton defence that, yes, one might have tried it but there was no robust evidence that any active ingredient reached one’s alveoli.

Going to pot in the cliniciN A DiFFERENT vEiN

Canada has taken an approach like many American states and has regulated marijuana by restricting its sale to those who feel they require it for medical reasons – thereby allowing businessmen to make a bit of scratch from potheads.

So there’s still societal disapproval despite numerous distinguished people admitting that, yes, they had perhaps tried it. Career concerns don’t seem to have worried federal Liberal leader Justin Trudeau, who admits smoking marijuana while a sitting Member of Parliament (MP) though not when he was actually there sitting, you know … like … in the House of Commons. He has not yet made it compulsory for all Liberal MPs to smoke marijuana.

AMA - AlbertA Doctors’ Digest

30

I’m sometimes asked about marijuana for chemo-induced nausea and I usually say (to the patient): “Hey, chill dude. We’ve been using it for, like, 20 years but find it, like, a bit sketchy.”

There have been many attempts to legalize the consumption and sale of marijuana. In the United Kingdom (UK) in the 60s, a concerted effort was made by a Parliamentary Commission to legalize pot. The late Morris Carstairs, Professor of Psychiatry and Psychological Medicine (a leader in the innovative field of sane psychiatry) at Edinburgh University (who was chair of the commission), told us gobsmacked students that despite their recommendation that the consumption of pot should be legalized, the idea was dropped. The reason: intense lobbying from the liquor and brewing industries (as well as the military chiefs of staff) together with threats of withdrawing funding to the ruling Labour Party.

Forty years on, Colorado (“free joint with a ski pass”), Washington State and Maryland have legalized the sale of small quantities of marijuana. Others will follow. Uruguay has legalized the sale of pot but that’s too far to go for most stoners. Many countries have decriminalized it. Canada has taken an approach like many American states and has regulated marijuana by restricting its sale to those who feel they require it for medical reasons ¬ thereby allowing businessmen to make a bit of scratch from potheads.

And so Health Canada has been inundated with applications to become “government approved growers” with companies smelling the acrid whiff of moola. What had previously been a cottage industry of illegal growers has become a commercial sector with an anticipated 50 larger companies shipping Health Canada regulated quality weed. Prices are set by the market. My (confidential) source tells me you can now buy enough for four joints for $10/gram in Vancouver, or $30 for an “eighth,” an eighth of an ounce for your glaucoma, of course. Most individuals use less than three grams daily of dried marijuana for medical purposes whether orally or inhaled; even that is quite a head full. There is some evidence that with the appearance of pot shops, the price is coming down.

As of April, a total of 13 suppliers had been approved. Over 1,000 applications have been received and new applications arrive at 25 per week. There are now companies taking grow ops through the regulatory hurdles and other clinic-linked companies explaining to customers how to obtain a medical license for dope.

As a “patient” you have to explain to a doctor or a licensed nurse practitioner that only cannabis can relieve your symptoms, how much dope you use in grams per day and how long you’re going to need it. If you’ve never used it before, get informed, dude.

If Dr. Downer or Nurse Ratched won’t sign your form, chill dude, and check in at the Greenleaf Medical Clinic where your cares and supplies will be taken care of, wholistically.

Illegal in Canada since 1923, recreational marijuana use continues unabated and the majority of the population

> supports either decriminalization of possession of small amounts or legalization (a recent forum research poll found 69% supporting this) although as late-night television show host Craig Ferguson (himself a reformed alcoholic) observed: “A phone survey found 70% of Americans support legalizing marijuana. I can’t believe that many marijuana supporters managed to answer the phone.”

Businessmen and politicians are rushing to the cause, generally not a good sign and former British Columbia (BC) Premier, Bro’ Mike Harcourt, is the new chairman of the board of the Vernon-based medicinal marijuana start-up, True Leaf Medicine Inc.

Heartwarming, all this toil and industry, isn’t it? Jodie Emery, wife of Mark Emery, the activist pot campaigner (currently serving time) recently announced to cheers at a meeting in Vancouver, “I believe in capitalism. I believe in making money.”

John Berfelo, a proud Canadian manufacturer, has produced the “Medtainer,” a plastic container which hermetically seals your pot, thereby avoiding the tell-tale odor floating out to those few left who may not be so enthusiastic about its medicinal properties. There is also a children’s warning sign on the container to alert the under-aged that something interesting is contained therein.

This is all very exciting but what it has to do with the medicine I practice is pretty minimal. It may be useful for chronic aches and pains but I don’t really know since there are few well-designed clinical trials. My guess is most “patients” are using it for quasi-recreational purposes. And there’s a big placebo effect on the “relief of symptoms” handle. But maybe I’m being too cynical.

When I first came to the Cross Cancer Institute in the 1970s, we occasionally prescribed medicinal brandy for appetite stimulation (Dr. Tom Baker did not approve) so I suppose there’s not a lot of difference between that and prescribing maryjane, although the smell on the ward might be a problem.

“Lo! In the middle of the wood, the folded leaf is woo’d from out the bud.”1 >

July - August 2014

31> So what is cannabis able to do? Tetrahydrocannabinol (THC) induces the release of dopamine, the happy hormone, and thereby a sense of relaxation, good humor and perception-altering phenomena. But THC is not the only constituent of cannabis; cannabidiol (CBD) constitutes 40% or so of cannabis and may be the constituent that has useful anti-inflammatory, anti-diabetic and relaxation properties but does not produce a “high.” Using CBD for aches and pains may not be so popular.

This whole thing gives us a lot to be proud of in Canada. Marijuana production could make a significant contribution to the gross domestic product and might, in time, replace our unhealthy reliance on producing filthy oil and gas. While countries such as China focus on the factory production of goods, weapons and food, our neighbors in BC can focus on the production of weed and the prevention of pipeline construction.

“Resting weary limbs at last on beds of asphodel. Surely, surely, slumber is more sweet than toil….’’1

There are some problems, however. The combination of alcohol and cannabis leads to big slowing of reaction times and sometimes a confusional state. Automobile and truck driving can be extremely dangerous. The effect of this combination on young brains is unknown. My experience of observing potheads has been depressing ¬ smiling, passive zombies who are magnificently self-involved. Lady Gaga is said to use 20 joints per day for self-medication (“numbing myself completely”) for anxiety attacks. I also have a feeling (with no evidence) that it might trigger strange reactions in some already disturbed people.

then a physical examination to check the proffered diagnosis? But that might be going too far.

You then have three choices:

1. Dismiss the patient from your presence telling them not to waste your time and gain a reputation as a Canadian Doc Martin or Gregory House.

2. Look weird and wash your hands of it saying you don’t know anything about cannabis since there are precious few really good clinical studies.

3. Capitulate (the easiest way out) and reach for the prescription pad, giving a warning about the combination of pot and alcohol, pregnancy and possibility of unknown drug interactions.

You then write on the prescription pad “Cannabis for medicinal purposes, less than three grams/day. Dosage to be titrated by patient PRN. Dispense three months’ supply.”

If you are worried about a drug interaction that you have no idea about, you can ask the patient to sign a waiver on a Canadian Medical Protective Association release form.

Decriminalization of possession of small amounts of cannabis for “medicinal purposes” is hardly a sign of moral decay. But its increased use is a bit troubling, especially the effect it may have on driving capabilities and its purported medical benefits detract from the noble aspirations of evidence-based medicine. Mind you, most clinicians who actually deal with patients know that evidence-based medicine often has a less than desired influence on managing patients in real life.

The time and effort being consumed by Health Canada paid for by our taxes, to regulate this industry, is time taken away from the review of new drugs ¬ real medicines.

And really, what has providing a euphemism (“medical marijuana”) for recreational pot use got to do with me? The feeling of being manipulated by activists and buck-passing politicians is mildly disturbing.

Welcome to the new land of the Lotus-eaters:

"O, rest ye, brother mariners, we will not wander more.”1

References

1. Alfred, Lord Tennyson, “The Lotus-eaters.” The poem retells the story from Book 9 of Homer’s The Odyssey. Odysseus and his sailors find themselves in a new strange land and eat a plant that makes them want to stay there forever.

2. The Little Black Book of Marijuana: The Essential Guide to the World of Cannabis. Peter Pauper Press Inc., White Plains, New York.

3. “Four twenty” ¬ the best time to light up ¬ unsure whether that’s a.m. or p.m.

I’ve never been asked in public if I’ve tried it, but I do keep in mind the Clinton defence that, yes, one might have tried it but there was no robust evidence that any active ingredient reached one’s alveoli.

So what should you do in the consultation?

“Doctor, do you ever prescribe marijuana?” the nice lady in her 40s asks. This is code for “Are you a broadminded person like me?”

You should look wise, relax and proceed as follows:

“Why do you ask?”

“Marijuana is natural and everybody says it will help me.”

You should then probe for precisely what ailment it is that the patient wants you to prescribe it for. Perhaps

AMA - AlbertA Doctors’ Digest

EDMoNToN AB

Family medical clinic in west Edmonton is seeking part-time and/or full-time family physicians. We offer flexible hours, low overhead (negotiable), fully computerized clinic using electronic medical records (Mediplan). The clinic is associated with Edmonton West Primary Care Network.

Contact: Dr. Patocka foodprex@telus.net

Wolf Medical Systems) electronic medical records, low overhead, no investment, no administrative burdens and a quality of lifestyle not available in most medical practices.

Contact: Marion Barrett Med+Stop Medical Clinics Ltd. 290-5255 Richmond Rd SW Calgary AB T3E 7C4 T 403.240.1752 F 403.249.3120 msmc@telusplanet.net

CAlGARY AB

Braeside on 24th Medical Clinic is recruiting three full-time family physicians and must be eligible to be licensed by the College of Physicians & Surgeons of Alberta.

Fee-for-service billing, attractive overhead split and Accuro electronic medical records. Office hours are Monday to Friday, 9 a.m. to 5 p.m.

Contact: 11466 Braeside Dr SW T 587.296.3363 braesidemed@gmail.com

CAlGARY AND EDMoNToN AB

C-era, a large multi-specialty practice is expanding. C-era requires a general internist, cardiologist (with non-invasive imaging training) and endocrinologist to join our teams in both Calgary and Edmonton.

C-era is a community based cardiometabolic and cardiopulmonary evaluation and risk assessment clinic with high patient volumes balanced with exceptional lifestyle, excellent remuneration and the opportunity for clinical stimulation and continued growth. Full electronic environment and multidisciplinary team support.

Contact: Dr. Alykhan Nanji Medical Director careers@c-era.com www.c-era.com

PhYSiCiAN WANTED

CAlGARY AB

Canada Diagnostic Centres is seeking a consulting radiologist for a rewarding career focused on women’s imaging. This would be primarily at an established outpatient clinic in Calgary with an excellent reputation for subspecialty level breast work. Fellowship training preferred.

Contact: Dr. Robert Davies Medical Director T 403.828.3849 rdavies@canadadiagnostics.ca

CAlGARY AB

MCI The Doctor’s Office™ has family practice options available in Calgary. With more than 27 years of experience managing primary care clinics and eight locations, we can offer you flexibility with regard to hours and location. We provide nursing support and electronic medical records. We’ll move your practice or help you build a practice. Walk-in shifts are also an option. All inquiries will be kept strictly confidential.

Contact: Margaret Gillies TF 1.866.624.8222, ext. 133 practice@mcimed.com

CAlGARY AB

Med+Stop Medical Clinics Ltd. has immediate openings for permanent full-time physicians to provide primary health care to patients in our four Calgary locations. Requirements: MD degree and must be able to be licensed by the College of Physicians & Surgeons of Alberta. Experience is an asset but not required. Our family practice medical centers offer pleasant working conditions in well-equipped modern facilities, high income based on fee-for-service, TELUS Health Solutions (formerly

ClASSiFiED ADvERTiSEMENTS

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32

July - August 2014

33are looking for six full-time family physicians. A neurologist, psychiatrist, internist and pediatrician are required at all four clinics.

Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton. Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray.

The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines.

The physician income will be based on fee-for-service with an average annual income of $300,000 to $450,000 with competitive overhead for long term commitments; 70/30% split. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records (paper free) and member of a primary care network.

Full-time chronic disease management nurse to care for chronic disease patients at Lessard, billing support and attached pharmacy are available at the Lessard and West Oliver locations.

Work with a nice and dedicated staff, nurse available for doctor’s assistance and referrals. Also provide on-site dietician and mental health/psychology services. Clinic hours are Monday to Friday 8:30 a.m. to 8:30 p.m., Saturday and Sunday 10:30 a.m. to 5 p.m.

Contact: Management Office T 780.757.7999 or T 780.756.3090 F 780.757.7991 lessardclinic@gmail.com

If interested in knowing more regarding this great opportunity, please contact us.

Contact: Dr. Hassen Taha T 780.905.0027 or Dr. Ataher Mohamed T 780.298.2986 thamad73@yahoo.com

EDMoNToN AB

Beverly Medical Clinic is a new state-of-the-art medical clinic that is rapidly expanding. Our team currently includes three family physicians, two internists and a pediatrician.

The clinic is growing and needs more dedicated family physicians as one of the physicians is planning on slowing down. Competitive overhead for long term commitments; 75/25% split.

We have 10 examination rooms, one treatment room and one specially designed pediatric room.

Contact: Dr. A. Elfourtia or Dr. Z. Ramadan Beverly Medical Clinic 4243 118 Ave Edmonton AB T5W 1A5 T 780.756.7700 C 780.224.7972

EDMoNToN AB

Ellerslie Medical Centre in southwest Edmonton is seeking part- and full-time physicians. The busy clinic is in a prestigious and fast-growing community which has a high public demand for family physicians. The physician income will be based on fee-for-service with an average annual income of over $300,000. The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guideline.

Contact: Walid 11140 Ellerslie Rd SW Edmonton AB T6W 1A2 T 780.884.4124 walid@ellersliemedicalcentre.com

EDMoNToN AND FoRT MCMURRAY AB

MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic each have 10 examination rooms and Alafia Clinic with four examination rooms

EDMoNToN AB

Grandview Heights Medical Clinic at 12313 63 Avenue wants you. Where do you want to be in five years? If you don’t know the answer to that question, if you aren’t sure you want the commitment of setting up your own practice, we invite you to come for a visit to the recently upgraded facilities at Grandview Heights Medical Clinic, one of Edmonton’s most respected and established family medicine clinics. Create your own schedule, work as little or as much as you like with professional, experienced, well-trained staff in a great atmosphere.

We are in a central location with plenty of parking. Our four exceptionally experienced family practitioners are available to support you in all aspects of establishing your own patient panel. Slide into your own office with everything ready for you and start charting and billing via TELUS electronic medical records (formerly Wolf Medical Systems). As a member of the Edmonton Southside Primary Care Network, we offer our patients the best in comprehensive care and health management. On the business side, we offer competitive fee splits. Stop by for a visit. If you aren’t sure where you want to be in three months, never mind five years, we welcome you to come try us out, without any commitment. We’re that sure you’ll like us.

Contact: grandviewmed@telus.net

EDMoNToN AB

North Town Medical Centre is looking for part- and full-time family physicians and specialists to join our team. North Town Medical Centre is a multidisciplinary clinic with three family physicians, two specialists and two chiropractors. The clinic is in a strip mall with plenty of free parking, close to medical imaging, pharmacy and laboratory. Modern well-equipped facility with highly trained staff allow for no administrative burdens, electronic medical records, no hospital on-call, plenty of examination rooms, offices for physicians and competitive fee split. Flexible schedule can accommodate physicians who are looking to pick up extra shifts or a new physician wanting to open their practice to new patients.

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AMA - AlbertA Doctors’ Digest

34 ShERWooD PARk AB

Well-established clinic with five family physicians recently expanded and has opportunities for one to two part- or full-time physicians. Flexible hours and competitive fee split. We are in a professional building with laboratory and x-ray on site. We have current electronic medical records, primary care network nurse support and excellent support staff.

Contact: Dr. Lorraine Hosford T 780.464.9661 lorrainehosford@gmail.com

PhYSiCiAN AND/oR loCUM WANTED

CAlGARY AND EDMoNToN AB

You require balance … you demand the best. Join the fastest growing medical group in Alberta to practice medicine the way it was meant to be.

Imagine Health Centres (IHC) is currently looking for family physicians and specialists to come and join our dynamic team in part-time, full-time and locum positions available in Calgary or Edmonton. Physicians will enjoy extremely efficient workflows allowing for very attractive remuneration, no hospital on-call, paperless electronic medical records, friendly staff and industry-leading fee splits.

Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. Come and be a part of our team which includes physicians, physiotherapists, massage therapists, psychologists, nutritionists and pharmacists.

Imagine Health Centres prides itself in providing the very best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians. There is also an optional and limited time opportunity to participate in ownership of our innovative clinics.

We currently have three Edmonton clinics with a fourth coming to Windermere (southwest Edmonton) in early 2015. The current clinics are

near South Edmonton Common, Old Strathcona and West Edmonton.

We currently have one clinic in southeast Calgary with a second clinic opening downtown in September.

If you are interested in learning more about our exceptional clinics, please contact us. All inquiries will be kept strictly confidential.

Contact: Joanne Oliver T 780.907.3777 joanne.oliver@imaginehealthcentres.ca

CANMoRE AB

The Bow Valley Medical Clinic is hiring part-time, full-time or locum physicians who enjoy steady and interesting work. Office hours are 9 a.m. to 5 p.m., Monday to Friday, no on-call, hospital privileges are available. Excellent staff, electronic medical records, full hospital with emergency and on-call coverage.

One full time and two part-time doctors currently working, but plenty of work for another full time or two part-time physicians; huge practice.

Contact: Cassie Hall Office Manager T 403.609.2136

EDMoNToN AB

Summerside Medical Clinic and Edge Centre Walk-in Clinic require part-time and full-time physicians. Locums are welcome. The clinics are in the vibrant, rapidly growing communities of Summerside and Mill Woods. Examination rooms are fully equipped with electronic medical records, printers in all examination rooms and separate procedure room.

Contact: Dr. Nirmala Brar T 780.249.2727 nimmi@theplaza.ca

RED DEER AB

Associate Medical Group was established in 1946 and is one the largest full-spectrum family medicine clinics in Red Deer. Associate Medical Group offers a diverse practice and is currently seeking part- and full-time physicians, as well as locums, interested in seeing patients in a busy walk-in environment and/or an office practice. Hospital in-patient care and an obstetrical practice are

also available. The walk-in clinic and downtown office are in high-traffic retail locations which generate large income potential with generous financial splits. A pharmacy is located at both locations and the laboratory and hospital are located within minutes.

We have an excellent and knowledgeable support team, supportive colleague base, competitive 70/30 split and fully integrated electronic medical records. All staffing and administration support is provided. The clinic is connected to the Red Deer Primary Care Network and has several health care professionals collaboratively working with family physicians.

Contact Dr. Hopfner joseph.hopfner@amgrd.ca

SPACE AvAilABlE

EDMoNToN AB

Medical office space for lease in south Edmonton, south of Southgate. Newly renovated mall in mature neighborhood. Flexible square footage at this time.

Contact: Kingsley Yeung kingsley@yandc.ca

CoURSES

CME CRUiSES WiTh SEA CoURSES CRUiSES • Accredited for family physicians

and specialists • Unbiased and pharma-free • Canada’s first choice in CMEatSEA®

since 1995• Companion cruises FREE

MEDiTERRANEAN September 8-19 Focus: Caring for the aging patient Ship: Celebrity Infinity

September 19-october 2, 2015 Focus: Challenges in medicine Ship: Celebrity Equinox

JAPAN AND ChiNA September 28-October 12 Focus: Clinical pearls in medicine Ship: Celebrity Millennium

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July - August 2014

35CANARY iSlANDS october 2-13 Focus: Musculoskeletal navigator CME: With MSK Courses of Canada Ship: Independence of the Seas

iNDiA AND SRi lANkA November 26-December 9 Focus: Adventures in medicine Ship: Azamara Quest

CARiBBEAN NEW YEAR’S December 28-January 4, 2015 Focus: Endocrinology, psychology and dermatology Ship: Allure of the Seas

AUSTRAliA AND SoUTh PACiFiC January 16-30, 2015 Focus: Rheumatology and infectious diseases Ship: Oosterdam

ANTARCTiC AND SoUTh AMERiCA February 3-24, 2015 Focus: Explorations in medicine Ship: Seabourn Quest

EASTERN CARiBBEAN March 14-22, 2015 Focus: Primary care update Ship: Independence of the Seas

TAhiTi AND TUAMoTUS March 18-25, 2015 Focus: Geriatrics, physician health Ship: Paul Gauguin

hAWAiiAN iSlANDS April 20-May 1, 2015 Focus: Improved patient care Ship: Celebrity Solstice

DAlMATiAN CoAST May 28-June 9, 2015 Focus: Clinical pearls in medicine Ship: Celebrity Constellation

BRiTiSh iSlES July 15-27, 2015 Focus: Ix annual update in medicine Ship: Celebrity Silhouette

SAGUENAY RivER (Canada) September 19-27, 2015 Focus: Third annual McGill CME cruise Ship: Crystal Symphony

RhiNE AND DANUBE RivER September 25-october 2, 2015 Focus: Endocrinology, rheumatology Ship: Avalon Impression

FiJi to TAhiTi November 10-21, 2015 Focus: Endocrinology Ship: Paul Gauguin

SoUTh AFRiCA November 24-December 9, 2015 Focus: Adventures in medicine Ship: Regent Seven Seas Mariner

For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

SERviCES

DoCUDAviT MEDiCAl SolUTioNS

Retiring, moving or closing your family or general practice, physician’s estate? DOCUdavit Medical Solutions provides free storage for your paper or electronic patient records with no hidden costs. We also provide great rates for closing specialists.

Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com

DR. RxSoNiC

I am your colleague and also a musician. I have been to many physicians’ conferences, workshops and get-togethers and felt that they could be more interesting with the live music. This is what I am trying to accomplish with my Dr. RxSonic project. I will be happy

> to play at your event whether it is a conference or workshop, seminar or friendly get-together to make it more entertaining and memorable. You will be able to listen to original music and check out unusual instruments.

Contact: andreip@shaw.ca www.DrRxSonic.com

RUTWiND BRAR PRoFESSioNAl ACCoUNTANTS

With an established medical PC clientele, we are able to efficiently and effectively meet all of your financial needs. Our services include PC incorporations, tax planning specifically designed for physicians, their families and their PCs, as well as full accounting services.

Contact: Rutwind Brar Professional Accountants T 780.483.5490 F 780.483.5492 rbadmin@rbpa.ca www.rbpa.ca

To PlACE oR RENEW, CoNTACT:

Daphne C. Andrychuk

Communications Assistant, Public Affairs

Alberta Medical Association

T 780.482.2626, ext. 275 TF 1.800.272.9680, ext. 275

F 780.482.5445

daphne.andrychuk@ albertadoctors.org

DiSPlAY oR ClASSiFiED ADS

We’re raising taxes.

And you’re going to like it. MD has been advising physicians on how to increase tax efficiency through strategies such as medical practice incorporation since 1976—all in one Expert Office. MD ExO™ is a collaboration among financial advisors and specialists who engineer total wealth management strategies exclusively for physicians. Are you wondering if incorporation is right for you? Or whether you’re making the most of your existing corporation? If so, it’s time to raise the topic of taxes with an MD Advisor. You’ll be glad you did.

The MD ExO service provides financial products and guidance to eligible clients, delivered through the MD Group of Companies (MD Physician Services Inc., MD Management Limited, MD Private Trust Company, MD Life Insurance Company and MD Insurance Agency Limited). MD Physician Services is owned by the Canadian Medical Association. Incorporation guidance limited to asset allocation and integrating corporate entities into financial plans and wealth strategies. Professional legal, tax and accounting advice regarding incorporation should be obtained in respect to an individual’s specific circumstances. Banking products are offered by National Bank of Canada’s Partnership Branch through a relationship with MD Management Limited.

Let’s talk about tax.Call 1 877 877-3707 or learn more at md.cma.ca/incorporation