April 2020: 62:3 Pages 81– 120 Digital storytelling and dialogue to support culturally safe health care for Indigenous patients

IN THIS ISSUE COVID-19 pandemic information and resources Assessing the impact of a nursing model of care on rheumatology practice patterns and patient satisfaction Changing drug policies: Ending the crisis Group medical practice is the natural evolution of medicine

bcmj.org BC Medical Journal vol. 62 no. 3 | April 2020 81 Doctors of BC Links and resources for COVID-19

Doctors of BC is taking active steps to support members with respect to coronavirus (COVID-19). Work includes advocacy on behalf of physicians with government, the provincial health officer, and health authorities, as well as ensuring members have access to appropriate benefits and insurance.

An information resource from Doctors of BC, updated regularly:

www.doctorsofbc.ca/covid-19

This page has information on: • COVID-19 changes to billing • Virtual care support • President’s Letters • Insurance updates • Support for physicians feeling stress during COVID-19

For questions or concerns about COVID-19, contact us directly at [email protected].

82 BC Medical Journal vol. 62 no. 3 | April 2020 April 2020 Volume 62 | No. 3 Pages 81–120

Group medical practice, believes Dr Mark Elliott, is the natural evolution of medicine. His article begins on page 106.

85 Editorials 89 BCCDC CLINICAL Whatever is popular is wrong and COVID-19: Responding to an 92 Guest Editorial: In search other pandemic reflections, David emerging respiratory pathogen, Esler, MD Alexis Crabtree, MD, Alexandra of collaboration between Using our position to spread kindness Choi, MD, Althea Hayden, MDCM, Indigenous traditional practices and acceptance, David Richardson, Réka Gustafson, MD, Bonnie and Western medicine, Kendall MD Henry, MD Ho, MD, Gerry Oleman 87 President’s Comment 90 College Library 94 Digital storytelling and Physician wellness, Kathleen Ross, MD Rural medicine and the College dialogue to support culturally Library, Paula Osachoff safe health care for Indigenous 88 Letters patients in British Columbia, E-cigarettes and youth health, 91 COHP Antonia Hyman, MSc, Elizabeth Aki Nilanga Bandara, Mehara Changing drug policies: What do we Stacy, MA, Kaitlin Atkinson, Seneviratne, Senara Wanniarachchi, need to end this heartbreaking crisis? BSc, Vahid Mehrnoush, MD Dereck Chang, MD MPaH, Helen Novak Lauscher, HLA-B*58:01 screening prior to the PhD, Jon Rabeneck, Gerry Oleman, prescription of allopurinol, Marisa Penny Cooper, MALT, Wendy Ponzo, MD-PhD, Jan Dutz, MD Young, PhD, Carol Kellman, BScN, Kendall Ho, MD Contents continued on page 84

Environmental impact Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. Return undeliverable copies The BCMJ seeks to minimize its negative impact on the to BC Medical Journal, 115–1665 West Broadway, Vancouver, BC V6J 5A4; tel: 604 638-2815; email: [email protected]. environment by: Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. • Supporting members who wish to read online with an e-subscription to bcmj.org © British Columbia Medical Journal, 2020. All rights reserved. No part of this journal may be reproduced, stored in a retrieval system, or trans- • Avoiding bag use, and using certified-compostable plant-based mitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without prior permission in bags when needed writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for any purpose, send an email to • Working with Mitchell Press, ranked third in North America for [email protected] or call 604 638-2815. sustainability by canopy.org Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the • Printing with vegetable-based inks institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omis- • Using FSC-certified paper sions, or from the use of information or advice contained in the BCMJ. • Printing locally in British Columbia The BCMJ reserves the right to refuse advertising.

BC Medical Journal vol. 62 no. 3 | April 2020 83 On the cover Digital storytelling and dialogue to support culturally safe health care for Indigenous patients The integration of Indigenous healing practices in the province’s health care system is being facilitated by a video that features traditional practitioners and Western medical professionals. See pages 92 to 97.

The BCMJ is published by Doctors of BC. The journal provides peer-reviewed clinical and review articles written primarily by BC physicians, for BC physicians, along with debate on medicine and medical politics in editorials, letters, and Dr David Obert took additional training in prehospital and transport medicine with BC Emergency Health Services; essays; BC medical news; career and CME listings; his article about his experiences begins on page 103. Pictured: Sergeant Ashley Barker and Sergeant Scott Hoadley, physician profiles; and regular columns. both members of 442 Transport and Rescue Squadron, participating in a medical exercise at HMCS Quadra in Print: The BCMJ is distributed monthly, Comox in the spring of 2019. other than in January and August.

Web: Each issue is available at www.bcmj.org. Contents continued from page 83 Subscribe to print: Email [email protected]. Single issue: $8.00 98 Assessing the impact of a 108 News Canada per year: $60.00 n Foreign (surface mail): $75.00 nursing model of care on Register now for Business Cost Subscribe to notifications: rheumatology practice Premium To receive the table of contents by email, visit n www.bcmj.org and click on “Free e-subscription.” patterns and patient Benefits of accelerated surgery with Prospective authors: Consult the satisfaction in British Columbia, hip fracture n “Guidelines for Authors” at www.bcmj.org Physical activity for prostate cancer for submission requirements. J. Connell, BSc, J. Kur, MD, patients and its effect on tumors J.H. Gurmin, LPhil n Doctors of BC governance and 103 Special Feature committee reporting structure n What patients lie to their doctors “That Others May Live”: Two weeks Editor Web and social media about, and why David R. Richardson, MD coordinator with the Joint Rescue Coordination Amy Haagsma Editorial Board Centre, David A. Obert, MD 111 Obituaries Jeevyn Chahal, MD Cover concept and David B. Chapman, MBChB art direction, Jerry Wong, 106 Premise Dr Hans Albert Witt Brian Day, MB Peaceful Warrior Arts Dr Barry King Cutler Caitlin Dunne, MD Group medical practice is the natural Design and production David J. Esler, MD Laura Redmond, Scout evolution of medicine, Mark Elliott, Yvonne Sin, MD 112 CME Calendar Creative Cynthia Verchere, MD MD Printing Managing editor Mitchell Press 114 Billing Tips Jay Draper Advertising Why become a medical inspector? Associate editor Kashmira Suraliwalla Joanne Jablkowski Nick Szpakowicz, MD 604 638-2815 Senior editorial and or [email protected] production coordinator 115 Guidelines for Authors ISSN: 0007-0556 Kashmira Suraliwalla Established 1959 Copy editor 116 Classifieds Barbara Tomlin

Proofreader Ruth Wilson

84 BC Medical Journal vol. 62 no. 3 | April 2020 Editorials

Defying understanding, COVID-19 has to Whatever is popular is wrong date essentially spared Africa, South America, Russia, and India; none of these population centres have reported 100 deaths. Also puzzling and other pandemic reflections and inexplicable has been the staggeringly di- vergent mortality of COVID-19 in neighboring 24 March 2020 countries. Italy’s eastern neighbor, Slovenia, has announced 4 deaths, while Austria has had 28. In short, this current pandemic, in keeping edical practice is challenging, never transmission apparently occurs before symp- with its predecessors, is proving to be fickle, more than during a pandemic. In toms peak. While the mortality of both patho- capricious, and utterly unpredictable. such times we turn to Sir William gens is likely 2.5% (this will never be known Much more predictable has been the MOsler for wisdom and perspective. with any certainty), they target different age medico-political response. In Canada and the In 1896, Osler observed that “Humanity groups. Spanish flu had a tragic predilection US, initial complacency has given way to a cry has but three great enemies: fever, famine, and for healthy young adults, while COVID-19 for total war against the virus. Measures that war; of these by far the greatest, by far the most preferentially targets frail elderly people. would have been inconceivable 2 months ago— terrible, is fever.” Before his death at the age of The most striking feature of pandemics is border closures, the shuttering of business and 70 in 1919, Osler had lived through the potato their unpredictability and inexplicability. The public institutions, and banning of all public famine, which dispatched some 1 million souls Spanish flu peaked abruptly in November 1918 gatherings, have been universally championed in Ireland; World War I, which claimed 10 at the end of World War I by the medical establish- million soldiers (including his only son, Revere then died out after a brief In short, this current ment, with politicians and Osler) and an equal number of civilians; and the peak in the spring of 1919. pandemic, in keeping the public joining enthu- Spanish flu, which is purported to have killed The SARS (novel corona- siastically in a deafen- with its predecessors, 17 to 100 million worldwide. virus) epidemic lasted only ing chorus: “We must do An expert in all facets of medicine, Osler 6 months, peaking in the is proving to be fickle, more!” regarded pneumonia as the “old man’s friend.” spring of 2013 then dis- capricious, and utterly This unprecedented “Pneumonia may well be called the friend of the appearing, claiming 774 unpredictable. response cannot help but aged. Taken off by it in an acute, short, not often lives worldwide. MERS give senior physicians painful illness, the old man escapes those ‘cold (camel flu), with a striking pause. Osler stated, “The gradations of decay’ so distressing to himself case fatality rate of 35%, emerged in 2012 and greater the ignorance the greater the dogma- and to his friends.” Osler himself succumbed to has never disappeared. Fortunately, it has to tism.” Over the course of a long career, who postpneumonic empyema 2 years after Revere date claimed only 900 lives. among us has not witnessed prominent physi- fell at Passchendaele. COVID-19 was identified in China in De- cians alternately espouse and then condemn One wonders how Osler would have viewed cember 2019, claiming 3300 lives—0.00024% medical interventions with great fervor? In the the current pandemic, and the unprecedented of China’s 1. 4 billion citizens—then quickly 1980s, surgeons insisted that physicians with- worldwide response, on the recommendation died out in the world’s most populous country. hold opiates from patients with abdominal pain of the world’s most distinguished public health Neighboring Asian countries have been com- prior to their examination—giving morphine physicians. paratively fortunate with only South Korea would preclude accurate diagnosis. In the 1990s, Osler was attuned to the diversity of disease: (120) tallying more than 100 deaths. medical thought leaders exhorted us to provide “Variability is the law of life, and as no two In the mid-east, Iran (1934) is the only opioids to those with chronic pain—addiction faces are the same, so no two bodies are alike, country to have recorded more than 100 deaths. was a myth, and denying patients relief from and no two individuals react alike and behave Western Europe has emerged as the disease epi- pain tantamount to malpractice. Liberal opioid alike under the abnormal conditions which we centre with the death toll in Italy reaching 7000 prescribing became a cri du coeur touted by vir- know as disease.” and several other countries counting over 100 tuous and compassionate physicians—few dared Not surprisingly, each epidemic behaves deaths including Spain (2808), France (1100), to question a dogma that proved fatally flawed. as a “complex system” to use today’s parlance. UK (422), Netherlands (276), Germany (157), In parallel, few physicians—a notable ex- While Spanish flu (N1H1) and COVID-19 Belgium, and Switzerland (122 each). ception being Stanford epidemiologist John (novel coronavirus) are both highly contagious In comparison, North America has been Ioannidis—have dared publicly question the respiratory viruses, they behave differently. The fortunate, with some 700 deaths in the US and wisdom of the North American public health latter has proved more insidious: significant very few in Canada (26) and Mexico (6). response to COVID-19. Does enforcing social

BC Medical Journal vol. 62 no. 3 | April 2020 85 editorials isolation and suspending access to routine medical and hospital care in the event we are overrun by patients requiring ventilation Using our position to spread in the ICU serve the greater good, given the mercifully low number of serious cases seen in Canada to date? kindness and acceptance I suspect that Oscar Wilde—never one to run with the crowd—would have re- “ t was the best of times, it was the worst an Australian boy, Quaden Bayles, who has a sponded, as he famously did when com- of times,” begins Charles Dickens in his form of dwarfism, talks about wanting to die menting on bad art: “Whatever is popular famous novel, A Tale of Two Cities, first because of the incessant bullying he faces at is wrong.” published in 1859. I would like to think that school. Heartbreaking to watch, it was shared Such a skeptical view is unpalatable in I human nature has gravi- by his mother to show the trying times, as many others have observed. tated more toward the anguish this negative be- Former Prime Minister Kim Campbell best of times in the more Every year on this havior causes her son. In it noted that “An election is no time to discuss than 160 years that have day I sport a bright she pleads for kindness in serious issues.” The philosopher Bertrand passed since this date. pink T-shirt with the thought and action toward Russell stated, “Neither a man nor a crowd Pink Shirt Day in BC Quaden and others like nor a nation can be trusted to act humanely words Be Kind Brave took place on 26 Febru- him. or to think sanely under the influence of a and Awesome. ary, marked by individu- Sadness filled my heart great fear.” Perhaps Texas-born CBS anchor als wearing pink shirts as as I thought about this Dan Rather said it best: “Once the herd a statement against bullying. This tradition boy and his struggle. It seemed like little had starts moving in one direction, it’s very hard started in 2007 after a grade 9 student in Nova changed despite public campaigns and educa- to turn it, even slightly.” Scotia was bullied for wearing a pink shirt tion. I remember being bullied as a youngster In these trying times, Osler serves as to school. In solidarity, other students started and on self-reflection, if I’m honest, at times I a voice of wisdom and comfort. From his wearing similar shirts and within a few days was the bully. What is it about human nature most famous essay, Aequanimitas: almost the whole school was adorned in pink. that leads to this less than admirable behavior? One of the first essentials in securing Every year on this day I sport a bright pink Thankfully, I was pulled from my dark rumina- a good-natured equanimity is not T-shirt with the words Be Kind Brave and Awe- tions by an outpouring of worldwide support to expect too much of the people some screened in big white letters on the front. for the young man (the best of times). amongst whom you dwell... Deal My patients are used to my colorful wardrobe, Numerous celebrities, including Hugh Jack- gently then with this deliciously but most of them realize wearing a pink T-shirt man and comedian Brad Williams, who also has credulous old human nature in in February is unusual even for me. Some pa- dwarfism, came out in support of the bullied which we work, and restrain your tients look at me suspiciously and I can tell they boy. Apparently, Quaden loves rugby and was indignation, when you find your pet want to ask about it, but they bite their tongues asked to lead an Australian all-star team out parson has triturates of the 1000th for whatever reason. Other patients are aware of onto the field before a game. A GoFundMe potentiality in his waistcoat pocket, the significance of the shirt and acknowledge page was started to send him to Disneyland, or you discover accidentally a case of this good cause. A few, like one of my elderly and it quickly built up to a few hundred thou- Warner’s Safe Cure in the bedroom patients, can’t help themselves. sand dollars. Quaden and his family, showing of your best patient. It must be that “Why are you wearing a pink shirt, Doc- absolute class, declined the trip and instead offences of this kind come, expect tor?” she blurted out. plan to donate the money to anti-abuse and them, and do not be vexed. n —David J. Esler, MD “It’s for antibullying day Mrs Smith,” antibullying charities. I replied. We can all do our part to end bullying. Phy- “Oh, I see,” she accepted. sicians are still respected members of society However, at the end of the patient encounter (well at least most of you are), and through our Information on COVID-19 she suddenly queried, “I don’t get it, what do patient interactions we can spread a message from Doctors of BC, updated you have against bowling?”* of kindness and acceptance, making stories like regularly: I love the idea of a day dedicated to the fight Quaden’s a thing of the past. I sincerely hope n www.doctorsofbc.ca/ against bullying, which I like to think we have this won’t take 160 years. been winning. But then a story highlighting —David R. Richardson, MD covid-19 the “worst of times” surfaced on social media *Who doesn’t have a problem with bowling, by the and in the news. A video appeared in which way? I mean, really, how clean are those rented shoes?

86 BC Medical Journal vol. 62 no. 3 | April 2020 president’s comment

barriers can take place and answers that respect Physician wellness the perspectives and capabilities of all parties are co-developed. Physicians cannot do this “I shall not today attempt further to define [it]. . . in isolation; neither should we leave our ad- ministrators to establish processes without our but I know it when I see it.” specific grassroots knowledge. —Justice Potter Stewart Other than the initiatives developed by Doctors of BC, medical staff associations, and divisions, a number of other systems-level so- lutions are in various stages of implementa- tion, including work with ICBC, WorkSafeBC, hile this quote applies to some- WorkSafeBC Occupational Health and Safety and health authorities, among others. As well, thing much more graphic, I feel Regulations that, by law, apply to all workers in through the Regional Physical/Psychological that it could also describe phy- BC. Tremendous variation exists across clinical Health and Safety Working Group, Doctors sicianW wellness. Wellness has a wide variety settings, which highlights the upstream system of BC will now have representatives in pro- of definitions for physicians, many of which problems requiring an overarching approach. vincial and regional structures to gather your depend on our current state of physical and In response to member identified priori- input and to help establish processes that sup- mental health, work pressures, family demands, ties, the 2019 Physician Master Agreement port physician-specific physical and psycho- and stage of career. How then do we figure generated a memorandum of agreement with logical safety projects. These representatives out the different aspects of wellness and effec- our health authorities, need your participation, tively address them to find the right solutions titled Physical and Psy- in whatever way you are and improve the working and personal lives of chological Health and A fair number of able to engage, to pro- physicians? Safety, which is intended the pressures that vide an adequate foun- I know how important this is, and fortu- to ensure physician input dation and inform new physicians face fall well nately, work on this front is moving forward at to improve physical and processes. Doctors of BC a rapid pace. At the grassroots level across BC, psychological workplace outside the individual will be reaching out and divisions of family practice and medical staff health and safety for physician’s control I encourage everyone to associations support physician wellness cham- health care workers. In and contribute to the contribute. pions (among other initiatives) who connect consultation with physi- moral injury that is BC is not alone in with their colleagues to strengthen health and cian groups across BC, our recognizing the com- wellness work. As well, the Specialist Services governance bodies have driving burnout across plexity and critical Committee has made addressing physician bur- committed to establish- our profession. timing of this issue. dens, burnout, and wellness at the local level ing occupational standards The Canadian Medi- a new strategic priority. Each local initiative across all health authori- cal Association State- is unique in its approach (many of which are ties, as defined by the Canadian Standards As- ment on Physician Health and Wellness targeted at individual processes), and while their sociation (CSA). This is a complex issue. For (www.cma.ca/sites/default/files/2018-11/ importance is valued by many, we must find those not aware of the CSA Standards, there physician-health-wellness-statement-e.pdf) system-wide solutions to tackle the problem are 13 workplace factors that it suggests ad- of 2018 established several principles for the at the source. dressing: organizational culture, psychological consideration of physicians across Canada. The Doctors of BC’s Physician Burdens sur- and social support, clear leadership with ex- aspect that resonated with me the most was that vey of members revealed that a fair number pectations, civility and respect, psychological regardless of the definition, physician wellness of the pressures that physicians face fall well demands, growth and development, recogni- should be a shared responsibility and a qual- outside the individual physician’s control and tion and reward, involvement and influence, ity indicator. For too long, we physicians have contribute to the moral injury that is driving workload management, engagement, balance, toiled in isolation, carrying our many burdens. burnout across our profession. Physicians re- psychological protection, and protection of The way forward is to share our loads and begin ported working in environments with exces- physical safety. to truly and fully address the system pressures sively high demands from clinical settings, Finding solutions that address the systemic alongside those with the organizational prowess administrators, and patients. In some cases, pressures needs to begin with face-to-face meet- to make meaningful improvements. n physicians are working in environments that ings between administrators and physicians —Kathleen Ross, MD are not physically safe and fail to meet the basic where honest and safe conversations about the Doctors of BC President

BC Medical Journal vol. 62 no. 3 | April 2020 87 SCARs. The American College of Rheuma- tology guidelines recommend screening East We welcome Letters to the editor Asian patients for the HLA-B*58:01 genotype original letters of less than 300 words; we may edit them for clarity prior to prescribing allopurinol, to eliminate and length. Letters may be emailed to [email protected], submitted 4,5 the risk of SCARs in this population. Un- online at bcmj.org/submit-letter, or sent through the post and must include fortunately, HLA-B*58:01 genotype testing is your mailing address, telephone number, and email address. Please disclose underutilized in British Columbia despite East any competing interests. Asians comprising a substantial proportion of the population.2 Other risk factors for SCARs in individuals prescribed allopurinol include heart disease and chronic kidney disease.3 E-cigarettes and youth health support can make it more likely for them to The cost-effectiveness of preventive HLA 5 Tobacco products in all forms are highly ad- make and sustain behavioral change. Develop- screening for East Asians prior to allopurinol dictive because they contain nicotine, one of ing clinical guidelines incorporating the current has been established in various populations the most addictive substances used by humans. best evidence to facilitate clinical decisions and globally and this screening needs to be more High-nicotine content in e-cigarettes poses as gain more insight into the complex reality of widely adopted in Canada. In British Columbia, a potentially disastrous innovation in the 21st e-cigarettes is of utmost importance. HLA-B*58:01 genotype screening can be or- —Aki Nilanga Bandara, Burnaby century and a well-known public health threat dered by sending blood tests to BC Transplant, to our vulnerable children’s future and their —Mehara Seneviratne, Surrey the laboratory in charge of HLA genotyping. overall health and well-being. —Senara Wanniarachchi, BSc, Coquitlam Other therapeutic options for the control of hy- Even though we clearly know that the nico- —Vahid Mehrnoush, MD, West Vancouver peruricemia include feboxustat and uricosurics. tine is addictive and poses significant challenges We believe that not performing this test prior to smoking cessation, sophisticated social media References to the prescription of allopurinol may cause campaigns tend to unduly discount the risks and 1. Bandara AN. Understanding adolescent perception on your Asian patients serious harm. e-cigarettes is vital. Am J Public Health 2016;106:e13. —Marisa Ponzo, MD-PhD, FRCPC overstate the benefits of e-cigarettes. Distorted 2. Bandara AN, Jhauj R, Mehmoush V. The major causes Vancouver risk perceptions are associated with adolescents’ of death in children. N Engl J Med 2019;380:1384-1385. —Jan Dutz, MD, FRCPC decisions to initiate e-cigarette use, decisions 3. Bandara AN. The consultation of youth in the public Vancouver they will likely regret in adulthood. health care policy-making process. Can J Public Health 2016;107:e216. We need Health Canada’s sensible pres- 4. Cohen DJ, Clark EC, Larsen PJ, et al. Identifying teach- References ence in e-cigarette prevention and control ef- able moments for health behavior counseling in pri- 1. Rai SK, Aviña-Zubieta JA, McCormick N, et al. Trends forts, including federal government regulation mary care. Patient Educ Couns 2011;85(2):e8-15. www in gout and rheumatoid arthritis hospitalizations in over e-cigarette flavored products, online sales, .ncbi.nlm.nih.gov/pmc/articles/PMC4389220. Canada from 2000 to 2011. Arthritis Care Res (Hobo- 5. Lawson PJ, Flocke SA. Teachable moments for health and social marketing. We need creative strate- ken) 2017;69:758-762. behavior change: A concept analysis. Patient Educ 2. Ponzo MG, Miliszewski M, Kirchhof MG, et al. HLA- gies to put our children on a path to a healthy, Couns 2009;76:25-30. B*58:01 genotyping to prevent cases of DRESS and tobacco-free lifestyle and ensure that young SJS/TEN in East Asians treated with allopurinol— leaders influence future tobacco control policies HLA-B*58:01 screening prior to A Canadian missed opportunity. J Cutan Med Surg in Canada and globally.1-3 2019;23:595-601. the prescription of allopurinol 3. Yokose C, Lu N, Xie H, et al. Heart disease and the risk E-cigarettes should carry health warnings of allopurinol-associated severe cutaneous adverse like combustible tobacco, which could counter- The health burden of gout continues to rise reactions: A general population-based cohort study. 1 act misinformation suggesting that they are a in Canada. Allopurinol, a common urate- CMAJ 2019;191:E1070-E1077. less harmful and safer alternative to combus- lowering medication used to treat gout, is asso- 4. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American ciated with severe adverse cutaneous drug reac- College of Rheumatology guidelines for management tible tobacco. We should train student leaders of gout. Part 1: Systematic non-pharmacologic and to become peer counselors in their schools to tions (SCARs) in specific at-risk populations, pharmacologic therapeutic approaches to hyperuri- help their peers to quit e-cigarettes. School ad- primarily people of East Asian descent. SCARs cemia. Arthritis Care Res (Hoboken) 2012;64:1431-1446. ministrators, teachers, parents, caregivers, and include Stevens-Johnson syndrome, toxic epi- 5. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 Ameri- can College of Rheumatology guidelines for manage- public health officials should build a meaning- dermal necrolysis and drug reaction with eo- ment of gout. Part 2: Therapy and anti-inflammatory ful partnership to address this issue in schools. sinophilia and systemic symptoms, and lead to prophylaxis of acute gouty arthritis. Arthritis Care Res Every adolescent consultation is a golden elevated morbidity/mortality and long-term (Hoboken) 2012;64:1447-1461. opportunity for a “teachable moment,”4 and en- sequelae. Two recent Canadian publications2,3 gaging adolescents about their desire to change have highlighted the importance of screen- health behaviors and referring them to further ing at-risk populations for the development

88 BC Medical Journal vol. 62 no. 3 | April 2020 BCCDC

COVID-19: Responding to an emerging respiratory pathogen

linicians in British Columbia have the populations at greatest risk were unknown. to estimate. In Hubei province, the epicentre been responding to COVID-19, the However, within 10 days, China identified the of the epidemic, it is estimated to be 2% to 3%, novel coronavirus that originated in virus and published the viral genetic code. This while outside this area the case fatality rate is Clate 2019 in Wuhan, China. The virus subse- enabled laboratories to quickly develop tests for well below 1%. These estimates are likely to be quently spread to countries around the globe, the virus. The BC Centre for Disease Control refined by the time this article is published, as prompting the World Health Organization (BCCDC) Public Health Laboratory was able information becomes available about the rate to declare it a Public Health Emergency of to develop a test within 3 days, and then test the of asymptomatic infections. International Concern. At the time of writing first specimen within 10 days. In the following At the early stage of a new communicable (28 February 2020), 83 324 cases have been re- month, testing protocols were developed and disease, when there is no indication of com- ported, with the vast majority still in Mainland validated, and laboratories throughout BC had munity transmission, each individual case is China. Fifty-one countries, including Canada, the ability to test for the virus. Public health managed using the core measures of public have reported imported cases, and a handful monitored emerging re- health: prompt identi- of countries, including Iran, Italy, and South search and epidemiol- The risk of serious illness fication and isolation of Korea, are responding to local outbreaks. By ogy about COVID-19 in cases, contact tracing and and death increases the time this article is published, the global order to provide advice management, and effective picture will likely look very different. This article to the public and test- sharply in the seventh infection control practices describes the health system response to a novel ing recommendations to and eighth decades of in health care settings. At pathogen as it emerges. clinicians. life and in those with the same time, the health During this period of chronic conditions. care system prepares for COVID-19 in British Columbia an emerging disease, there potential sustained local As of 28 February 2020, testing of 1425 speci- is a great deal of informa- transmission. mens has identified seven infections in BC, tion and misinformation, all in travelers or close contacts of travelers and recommendations change rapidly, often How do we prepare for the possibility to an area with community transmission. The leading to uncertainty and concern. In British of sustained community transmission very small number of cases, all of which have Columbia, the provincial health officer, your in BC? a known source of infection, indicate that at local medical health officers, and the BCCDC In February, emergency operations centres the end of February 2020 there is little com- are committed to providing you with up-to-date (EOCs) were established at provincial, regional, munity transmission of COVID-19 in British information that is relevant to your community. and hospital levels to coordinate public health Columbia. At this stage of the emergence of By the end of February, a great deal was and clinical responses across the health care a new pathogen, containment measures can learned about COVID-19. Information from system and with government and commu- be effective. the outbreak in China indicated that among nity partners. These EOCs have the goal of those with a diagnosed illness, the majority preparing for additional cases and working to How do we respond to an emerging (over 80%) of people have mild illness with minimize disruption to the health care system. respiratory pathogen? recovery in about 2 weeks. Early data from out- Clinicians across the health care system con- On 31 December 2019, China reported an out- breaks on cruise ships suggested that a sub- tinue to respond to COVID-19: by identifying break of pneumonia of unknown cause to the stantial proportion of people with infection are and managing potential cases, and by addressing World Health Organization. At that time, the asymptomatic. Children and adolescents appear patient concerns often fueled by the “infodemic” pathogen, the clinical spectrum of disease, and to be relatively spared, and the risk of serious ill- of news and social media information. ness and death increases sharply in the seventh It is still possible that the massive and un- and eighth decades of life and in those with precedented efforts of the Chinese and other This article is the opinion of the BC Centre chronic conditions including cardiovascular and governments will be successful in containing for Disease Control and has not been respiratory diseases, diabetes, and cancer. The the virus through quarantine and isolation, and peer reviewed by the BCMJ Editorial case fatality rate, which is essential to know for Continued on page 90 Board. both planning and response, remains difficult

BC Medical Journal vol. 62 no. 3 | April 2020 89 college library

Rural medicine and the College Library

nternet access and online resources have has numerous ways for doctors to access the Current online and print titles regarding rural come a long way to providing additional information they need. health are available at https://bit.ly/39LQysu. support for rural physicians. While using Most of the College Library’s resources are Most print books can be mailed to you any- online databases, point-of-care tools, textbooks, online and available throughout the province 24 where in the province at no cost. We provide I return, postage paid mailing labels; save the and journals has never been easier, rural physi- hours a day—use your CPSID and password cians still face high-stakes challenges in isolated to log in. A list of rural health journals that the envelope that your book arrived in, and when settings. Emergency medicine, geriatrics, and College Library subscribes to is available at you’re done with it, affix the new labels, reseal obstetrics/gynecology are all possible parts of https://bit.ly/2u9J1o9. Additionally, the Library the envelope, and mail it back to the Library. a rural physician’s day, and the College Library can send you any journal’s table of contents, The College Library is expanding its book and source and deliver articles from almost any collection in rural health. If you have sugges- tions, questions, or require assistance, con- This article is the opinion of the Library of journal at no cost. tact the Library at [email protected] or 604 the College of Physicians and Surgeons of First Nations patients may feature in your 733-6671. n BC and has not been peer reviewed by the practice, and we have books to help you pro- vide your patients with informed and culturally —Paula Osachoff BCMJ Editorial Board. Librarian sensitive care (visit https://bit.ly/3bOL9m7).

BCCDC Continued from page 89 the effect of this virus on our community will be during illness to prevent transmission; and iden- physicians in British Columbia, we thank you limited. However, as of late February, community tifying patients experiencing severe symptoms for your partnership. n transmission is occurring in multiple locations or at risk of severe disease who will need more —Alexis Crabtree, MD, MPH, PhD globally including South Korea, Japan, Singa- intensive management and support. Additional Resident Physician, Public Health and pore, Iran, and Italy. This raises the probability social distancing strategies, such as telecom- Preventive Medicine, University of British Columbia of sustained community transmission in BC. muting or discouraging mass gatherings, will If sustained local transmission occurs, the be recommended by public health only if the —Alexandra Choi, MD, MHSC, CCFP Medical Health Officer, Fraser Health focus of the intervention will shift. Testing for epidemiology of the disease suggests significant COVID-19 will decrease even as community transmission in these settings. Once mitigation —Althea Hayden, MDCM, MPH, FRCPC Medical Health Officer, Vancouver Coastal cases increase, as we shift from containment to is the goal, it will remain essential that measures Health mitigation. People with mild symptoms consis- to prevent health care–associated transmis- tent with COVID-19 (or with other respiratory sion, including adherence to personal protective —Réka Gustafson, MD, CCFPC Vice President Public Health and Wellness, illnesses), in whom knowledge of the infec- equipment guidelines, be maintained. Some Provincial Health Services Authority, Deputy tious agent would not change management, nonessential services may need to be paused to Provincial Health Officer will be asked to self-isolate without testing. meet demand and maintain continuity of care —Bonnie Henry, MD, MPH, FRCPC Testing capacity will focus on severe cases and for urgent medical needs. Provincial Health Officer on sentinel surveillance, which will allow us to A novel disease such as COVID-19 is a estimate the total disease burden and monitor challenge to our health care system, but also trends in disease activity in our communities. In an opportunity to strengthen our relationships Information on COVID-19 from this scenario, clinicians will be asked to support in service of patient needs. It remains essential Doctors of BC, updated regularly: patients by educating them on basic self-care to have a rational and measured response to measures at home when symptomatic; reinforc- COVID-19 while ensuring that uncertain- www.doctorsofbc.ca/ ing messaging about hand hygiene, respiratory ty and fear do not lead to undue disruption covid-19 etiquette and the importance of self-isolation and delay of care. On behalf of public health

90 BC Medical Journal vol. 62 no. 3 | April 2020 coHp

Changing drug policies: What do we need to end this heartbreaking crisis?

ince the overdose crisis was declared a In terms of safe supply, Switzerland offers our patients struggling with addiction can stay public health emergency in 2016, nearly a good example. Like much of Europe, the alive and have an opportunity to access the 14 000 Canadians have died as a result. country experienced a rapid rise in IV heroin treatment and support they need. By doing so, SDue to the number of fatal overdoses, BC’s use during the 1970s and 80s, which led to high we are sending a clear message to society that life expectancy has fallen for the first time in rates of HIV transmission and drug-related drug addiction is a health issue, not a crimi- modern history. deaths. Since the mid- nal issue, which in turn Facing this crisis, many organizations, such 1990s, Switzerland has helps reduce stigma and as Nurses and Nurse Practitioners of BC,1 offered heroin-assisted We are sending a clear encourages more individ- Moms Stop the Harm,2 the Canadian Asso- treatment (HAT). With message to society uals to access care or call 3 ciation of People Who Use Drugs, and the over 20 years of data, it’s that drug addiction 911 in case of an overdose City of Vancouver,4 have called for a change in clear that HAT has sub- without the fear of being is a health issue, not drug policies, including drug decriminalization stantially improved the incarcerated. and increased access to a safer supply of drugs. well-being of the partici- a criminal issue. As doctors in the Nonetheless, both the federal and provincial pants, reduced continual province with the highest government have been hesitant to fully com- use of illicit heroin, and number of overdoses and mit to these ideas. decreased criminal activities. Locally, the deaths in Canada, we should engage in a broad- The concept of drug decriminalization is BC Centre on Substance Use published an er discussion about these important issues. n not new. Portugal decriminalized personal evidence-based document last year that high- —Derek Chang, MD possession of all drugs in 2001. While having lights the benefits and rationale for safe supply, drugs for personal use is no longer a criminal and a proposed model for implementation.5 References 1. Nurses and Nurse Practitioners of BC and Harm Reduc- offence, it remains an administrative violation. I can think of a particular patient whose tion Nurses Association. Nurses and Nurse Practitioners The money saved in the criminal justice sys- story reinforced my support for changing drug of British Columbia (NNPBC) and the Harm Reduction tem has freed up resources to be invested in policies. Over the years, my team and I provided Nurses Association (HRNA) call for the decriminalization addiction treatment, mental health, and social her with medical and psychosocial treatment for of people who use drugs in BC. August 2019. Accessed services. Within a decade of decriminalizing her opioid-use disorder while she worked dili- 27 February 2020. www.nnpbc.com/pdfs/media/press -releases/PR-HRNA-NNPBC-Statement.pdf. drugs in Portugal, continuation rates of drug gently on her recovery. By the time she moved 2. Moms Stop the Harm. Key beliefs. Accessed 27 Febru- use dropped by 15%. In addition, the rate of on to another clinic closer to her new home, she ary 2020. www.momsstoptheharm.com/key-beliefs. HIV, hepatitis, and drug-related deaths and had obtained her diploma and was ready to start 3. Canadian Association of People Who Use Drugs. Safe crimes decreased. This shift from a criminal to a new job to help youth struggling with addic- supply concept document. February 2019. Accessed 27 February 2020. https://vancouver.ca/files/cov/capud public health approach to drug use has received tion. I still remember the light in her eyes and -safe-supply-concept-document.pdf. praise from many international organizations, the confidence in her smile when she told me 4. City of Vancouver. Safe supply statement. July 2019. Ac- including the United Nations. about her graduation and the new job. Mean- cessed 27 February 2020. https://vancouver.ca/people while, as I recalled the multiple overdoses she -programs/safe-supply-statement.aspx. 5. BC Centre on Substance Use. Heroin compassion clubs: had in the past, a shivering thought came to A cooperative model to reduce opioid overdose deaths mind: she could have died so many times. Sadly, This article is the opinion of the and disrupt organized crime’s role in fentanyl, money not every patient of mine was as lucky as she laundering and housing unaffordability. February 2019. Emergency and Public Safety Committee, was; many had died from overdoses and were Accessed 27 February 2020. www.bccsu.ca/wp-con a subcommittee of Doctors of BC’s tent/uploads/2019/02/Report-Heroin-Compassion never able to continue the journey of recovery. Council on Health Promotion, and is not -Clubs.pdf. I truly believe that decriminalization of peo- necessarily the opinion of Doctors of BC. ple who use drugs and safe supply save lives. This article has not been peer reviewed by We need to change outdated drug policies so the BCMJ Editorial Board.

BC Medical Journal vol. 62 no. 3 | April 2020 91 guest editorial

In search of collaboration between Indigenous traditional practice and Western medicine

An emergency physician’s experience and a traditional practitioner’s experience.

Kendall Ho, MD, Gerry Oleman

Dr Kendall Ho: What if one day a patient Elder Gerry Oleman: In 1995 families with practices. I see my involvement as providing asks you for therapy based on Indigenous tra- a loved one in hospital started to call me. When what is missing for the patient: attention for ditional medicine? This happened to me 6 years I reflect on these first calls, I think about how the soul/spirit of the patient. With my words, ago when I was working in the emergency de- I had not been formally identified as someone songs, prayers, and spiritual tools I am helping partment. I saw an Indigenous patient after to call in the Indigenous world when there is a to strengthen the spirit of the individual. If I he had a car accident and I recommended a medical crisis. I was called because I was known accomplish this, the patient can become an ac- standard treatment plan. He politely declined for practising Indigenous ceremony, meaning I tive participant in the healing process. I believe and asked for Indigenous traditional medicine was taught and mentored by Elders in Indig- that what Indigenous practitioners provide in instead. I was unsure how to proceed as I knew enous ways of helping those in need. Today this moment of damage to physical health can very little about this approach. He thanked me when I am called to the hospital, I connect improve the mental and spiritual health of the and we parted company amicably. This began with the family first so I can learn what is going patient. I also believe practitioners have a re- my journey to explore Indigenous traditional on with the patient. Once I have the informa- sponsibility to assist family and friends who are medicine and how it might be used in combi- tion, I share with the family and patient what I present so that they can support the patient and nation with Western medicine. Soon afterward will be doing and carry on only after obtaining medical staff in the healing process. I met Elder Gerry Oleman, who became my their approval. Since I am working in a hospital When I look at my involvement and jour- teacher and guide, opening my eyes to how setting, I understand that the patient is in the ney working with patients, families, and health traditional practitioners contribute to the BC hands of competent medical professionals and care professionals in the medical system, I see medical system. that we should not interfere with each other’s the need for all involved to understand each

We have just begun the journey and look forward to expanding this work of integrating traditional and Western medical systems to best support Indigenous patients.

Kendall Ho, MD, Professor, Department of Emergency Medicine, University of British Columbia.

92 BC Medical Journal vol. 62 no. 3 | April 2020 guest editorial

other’s roles and responsibilities. Working with patients and families early on, I came to ap- preciate the rhythm of the hospital and would It has been my plan my work around that rhythm. As a result, I have never had conflict with the system. I do experience that not have formal recognition when I am called those in the medical to the hospital, yet the Indigenous practices I system will respect offer patients are not disallowed. I have heard of Indigenous practitioners having difficulties an Indigenous carrying out their work of assisting patients. practitioner when This may very well be because of ignorance or racism on the part of the health care staff. It has they understand that been my experience that those in the medical the two systems can system will respect an Indigenous practitioner support one another when they understand that the two systems can support one another and benefit the patient. I and benefit the believe that although there are differences, when patient. we work together and do not interfere with each other these differences can be worked out. After all, Indigenous practitioners are involved in the Gerry Oleman, Elder and Traditional Practitioner, the St’at’imc Nation. medical system at the request of families and patients. I am grateful to the Canadian medical system for all the services it has provided to me particularly the First Nations Health Authority, and my family. I am also extremely grateful to Acknowledgments Vancouver Coastal Health, and Island Health. the traditional practitioners who have provided We would like to acknowledge that the ac- I would also like to thank the BC Ministry of comfort, hope, and success for members of my tivities discussed in this issue of the BCMJ took Health for providing support through the Pa- family and for myself personally. place on the traditional unceded homelands of tients as Partners Initiative. We have just begun the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh the journey and look forward to expanding this Dr Kendall Ho: As an emergency physician, (Squamish), Səlílwətaʔ/Selilwitulh̓ (Tsleil-Waututh) work of integrating traditional and Western my journey with Elder Gerry Oleman and other Nations, and the land of the W̱ SÁNEĆ (Pauquachin, medical systems to best support Indigenous traditional practitioners has helped me better Tsartlip, Tsawout, Tseycum) peoples. patients. If you feel inspired by our stories, I understand the context of Indigenous patients, invite you to join us on our journey to learn their caregivers, and their communities regard- more and to collaborate with us. n ing a holistic approach to health and wellness, and the potential anxiety some patients may experience when seeking Western medical care. This journey raises my awareness of the need for cultural safety and positively changes my practice when I interact with Indigenous pa- tients. My journey also challenges me to be more aware of and seek understanding from all patients I encounter and treat. As executive director of the interCultural Online Health Network (iCON), I would like to thank the many collaborators and support- ers who have been part of this journey so far to incorporate traditional healing into the BC health care system. I would like to thank the numerous Indigenous Elders and their com- munities and all of the BC health authorities,

BC Medical Journal vol. 62 no. 3 | April 2020 93 Clinical

Antonia Hyman, MSc, Elizabeth Stacy, MA, Kaitlin Atkinson, MPaH, Helen Novak Lauscher, PhD, Jon Rabeneck, Gerry Oleman, Penny Cooper, MALT, BScN, RN, Wendy Young, PhD, Carol Kellman, BScN, RN, Kendall Ho, MD, FRCPC

Digital storytelling and dialogue to support culturally safe health care for Indigenous patients in British Columbia

The integration of Indigenous healing practices in the province’s health care system is being facilitated by a video that features traditional practitioners and Western medical professionals.

ABSTRACT: The interCultural Online Health Net- decision-makers, and policymakers in transform- Ms Hyman was a project coordinator in work (iCON) at the University of British Columbia ing the health system to better serve all British Digital Emergency Medicine at the University has been collaborating since 2010 with health Columbians. The team welcomes feedback about of British Columbia when this article was authorities and Indigenous communities across experiences with traditional healing practices and written. Ms Stacy was a research coordinator the province to support the integration of tradi- efforts made to improve access to culturally safe in Digital Emergency Medicine in the eHealth tional medicine practices into Western primary health care for Indigenous patients in BC. Strategy Office at UBC when this article was care and acute care settings. This is being done to written. Ms Atkinson was a researcher in fulfill recommendations contained in health policy Digital Emergency Medicine at UBC when n 2010 the interCultural Online Health frameworks and strategic documents, including this article was written. Dr Novak Lauscher Network (iCON) at the University of Brit- the Truth and Reconciliation Commission report, is associate lead, research, in Digital ish Columbia set out to explore problems the United Nations Declaration of the Rights of Emergency Medicine at UBC. Mr Rabeneck faced by Indigenous peoples in British Colum- Indigenous Peoples, and the BC Declaration on I is the Coast Salish community engagement bia seeking health and wellness. Since then, Commitment to Cultural Safety and Humility coordinator with the First Nations Health iCON has been collaborating with health au- in Health Services. With the help of an advisory Authority. Elder Oleman is a member of the thorities and Indigenous communities across committee, a video and a discussion guide were St’at’imc Nation and has been involved as a the province to support the integration of tradi- produced in 2016. The video features the stories, change agent for First Nations communities tional medicine practices into Western primary experiences, and insights of individuals who have and agencies. Ms Cooper is interim director of care and acute care settings. used traditional medicine in different health care Aboriginal Health at Island Health. Dr Young Providing culturally safe care for all Indig- settings. A workshop was organized to share the is a research facilitator and knowledge enous patients has been found to include: video and guide with patients and communities. translator with Island Health. Ms Kellman • Ensuring all health care employees under- This event focused on identifying gaps and barri- is an Aboriginal nurse practice leader at take cultural safety training. ers within regions and the wider system and on Providence Health Care. Dr Ho is a practising • Fostering an understanding of Indigenous proposing actions to enable change. Participant emergency medicine physician at Vancouver perspectives on health and wellness. recommendations were grouped according to General Hospital. He is also a professor in the • Allocating time to build connections, re- whether the actions proposed could be taken at Department of Emergency Medicine at UBC lationships, and trust in the community. the individual, advocacy, community, or health and lead, Digital Emergency Medicine. • Supporting the integration of traditional care system level. The iCON team continues practices through policy. to cohost discussions designed to share learn- This article has been peer reviewed. ings and engage communities, administrators,

94 BC Medical Journal vol. 62 no. 3 | April 2020 Hyman A, Stacy E, Atkinson K, Novak Lauscher H, Rabeneck J, Oleman G, Cooper P, Young W, Kellman C, Ho K CliniClinicalcal

Context and background The colonization of Indigenous peoples in Canada has adversely affected how the current Canadian health care system responds to the needs of Indigenous patients. Structural bar- riers, power imbalances, and the perseverance of stereotypes and racist attitudes all play a part.1,2 One outcome of colonization is a lack of emphasis on traditional medicine and prac- tices as important components of wellness for Indigenous peoples. Research and an environ- mental scan conducted by the First Nations Health Authority (FNHA) affirms the contin- ued value of traditional medicine and practices within Indigenous communities.1 Health policy frameworks and strategic documents, includ- ing the Truth and Reconciliation Commission report and the United Nations Declaration of the Rights of Indigenous Peoples (UNDRIP), Figure. The video and discussion guide, A Coming Together of Health Systems, features traditional practitioners, highlight the need for improved services and Elders, and Western health care professionals. Elder Gerry Oleman is pictured. support for Indigenous patients.2-5 Specifically, UNDRIP article 24.1 states: Indigenous peoples have the right to exposure to Indigenous traditional practices. had been formed in 2012. This committee was their traditional medicines and to main- This means that many newly trained health originally a tripartite collaboration between tain their health practices, including the care providers are unable to provide culturally iCON, the VCH Aboriginal Health Strategic 16,17 conservation of their vital medicinal safe care. Initiative, and the former UBC Institute for plants, animals and minerals. Indigenous Aboriginal Health. Members included tra- individuals also have the right to access, Supporting cultural safety ditional practitioners, Elders, and the project 18 without any discrimination, to all social iCON began developing educational tools team. 19,20 and health services.5 to support cultural safety in 2015. As part With the committee’s help, stories and in- In November 2019 British Columbia was of a community-based initiative operated by sights into traditional medicine were featured in 21 the first province to legally implement UND- Digital Emergency Medicine at UBC, iCON the video. Traditional practices were described RIP. Bringing BC laws in line with UNDRIP explored how to partner with Indigenous com- along with the experiences of individuals who is part of a major shift in provincial and local munity members to address specific health pri- have used traditional medicine in hospital set- commitments to improve health access and orities and develop culturally relevant health tings. Key messages and learning objectives were outcomes for Indigenous patients. The Dec- resources. iCON then worked with Vancouver summarized in the guide and included with laration of Commitment on Cultural Safety Coastal Health (VCH) to create A Coming reflection questions and additional resources. 22 and Humility in Health Services was signed by Together of Health Systems, a video featuring The video and guide were piloted with the BC Ministry of Health and all BC’s health Indigenous traditional healers [Figure] and a health care professionals at Vancouver General 23 authorities in 20156 and by Doctors of BC in discussion guide. The aims of the video and Hospital and St. Paul’s Hospital to validate 2019.7,8 The declaration commits health care guide were to: them, ensuring that the content was accessible professionals and organizations to culturally safe • Increase understanding of the role of tradi- and deepened understanding of traditional heal- and appropriate practices and a process of mu- tional healing and the work of traditional ing practices that patients might request in tual trust and respect when delivering services practitioners. hospital settings. to Indigenous peoples. Specific health authority • Encourage the integration of traditional The video and guide have now been dissemi- policies9-14 and programs such as the San’yas healing into the care of Indigenous patients. nated through education sessions with health Indigenous Cultural Safety Training Program15 • Support positive health care experiences authorities, integrated into VCH cultural safety have been developed to support health care through a culturally safe care framework. training, and presented at various conferences, professionals. Nevertheless, medical trainees in Throughout the development of the video including the 2016 Fourth Global Symposium Canada still receive limited education on the and accompanying discussion guide, feedback on Health Systems Research and the BC Min- 22-24 impacts of colonization and racism and little was sought from an advisory committee that istry of Health summit in 2017. The video

BC Medical Journal vol. 62 no. 3 | April 2020 95 CliniClinicalcal Digital storytelling and dialogue to support culturally safe health care for Indigenous patients in BC and guide are also now integrated into the UBC • In what ways can access to traditional prac- • Integrate learning into their work. medical school undergraduate curriculum. titioners be improved in your work setting • Increase knowledge of resources already A Coming Together of Health Systems is not at the clinical/practice level? in place at hospitals (e.g., how to access intended to be a definitive resource concern- • How should we start thinking about traditional practitioners). ing traditional practitioners and healing ser- shifting and changing health care system • Continue the dialogue and share with col- vices but a starting point for dialogue. Before settings to better incorporate traditional leagues (e.g., start conversations at staff medical professionals can be comfortable and medicine? meetings). confident providing culturally safe care, they • What type of policy needs to be in place to • Respond to the patient’s need in the mo- must first recognize the value of offering dual facilitate and enable the changes discussed? ment (e.g., ask “What do you need/want?” services (traditional Indigenous and Western) or “Are there any resources outside the ones in serving their patients, and must gain a more Before medical we are providing that might help you?”). nuanced view of the nature of traditional heal- ing practices. Watching the video and sharing professionals can Advocacy actions experiences with a diverse group of stakeholders be comfortable and Advocacy for traditional healers and practi- can produce attitude shifts and practice changes confident providing tioners should include actions that encourage and have rich cultural impacts for both Indig- culturally safe care, they individuals, community-based organizations, enous and non-Indigenous British Columbians. and policymakers to: must first recognize the • Respect the use of Indigenous language Community dialogue value of offering dual and worldviews as integral to the healing To understand how the health care system can services … and gain a process. best integrate traditional healing into every- more nuanced view of • Promote a better understanding of the value day practice, a community dialogue workshop of culturally safe care and the different per- the nature of traditional was cohosted by iCON, VCH, Island Health, spectives Indigenous patients may have on and FNHA on 15 March 2017. Elders, tra- healing practices. health and wellness. ditional practitioners, nurses, physicians, stu- • Shift the definition and understanding of dents, and Ministry of Health representatives “health” to incorporate mental and spiritual were invited to Tsawout, located on the home- Perspectives and proposed actions health. lands of the W’SÁNEĆ peoples on the Saan- The post-workshop evaluation surveys that were • Address misconceptions and mistrust ich Peninsula, and asked to identify gaps and completed by 59 participants showed how per- through education about traditional healing barriers in the system and to produce a list of spectives were changed: 93% felt the workshop and its value. recommendations. helped them better understand traditional heal- • Recognize and embrace the power of story­ The workshop began with more than 100 ing and the role of traditional practitioners; telling to create a space for shared under- participants viewing the video. A storytelling 89% agreed they would use the information standing and self-reflection and to build session followed, with Elders and tradition- from the workshop to better facilitate access community resiliency. al practitioners sharing their experiences of to traditional practitioners; and 81% agreed • Avoid tokenism. seeking and/or delivering traditional wellness they would make a change to improve the BC and healing. The candid and personal accounts health care system to better incorporate tradi- Community actions created a sense of community that carried on tional medicine. Community-based organizations should engage throughout the workshop. Participant recommendations gathered with others to: Participants were divided into small groups from the breakout sessions were analyzed and • Include more policymakers in future work- for breakout sessions. Each group included a grouped according to whether the actions pro- shops and dialogue. mix of health care professionals and commu- posed could be taken at the individual, advocacy, • Build experiential learning and training nity members to ensure a range of perspectives, community, or health care system level. opportunities for health care professionals, expertise, and experiences were represented. In trainees, and medical students. these sessions, participants were invited to share Individual actions • Increase involvement of community their views on ways to provide better access to All health care employees, including admin- advocates, patient voices, and Aboriginal traditional medicine within the BC health care istrative staff, should engage in cultural safety liaison nurses. system and how to harmonize Indigenous and training as part of an ongoing learning journey • Codevelop protocols led by traditional Western approaches. Guiding questions were that helps individuals to: practitioners in partnership with health provided: • Practise humility and self-reflection in authorities. words, actions, and work activities.

96 BC Medical Journal vol. 62 no. 3 | April 2020 Hyman A, Stacy E, Atkinson K, Novak Lauscher H, Rabeneck J, Oleman G, Cooper P, Young W, Kellman C, Ho K CliniClinicalcal

AboutUs/MediaCentre/PublicationsNewsletters/Doc • Develop a directory for contacting tradi- Competing interests uments/Healthier You - Summer 2016.pdf. tional practitioners. UBC Digital Emergency Medicine has received 10. Island Health Authority. Learn about health: Indigenous • Use a Plan-Do-Study-Act model for quality funding from the BC Ministry of Health to orga- health. Accessed 11 February 2020. www.islandhealth .ca/learn-about-health/aboriginal-health. improvement to increase access to tradi- nize these events. tional practitioners in work settings. 11. Fraser Health Authority. Aboriginal health. Accessed 11 February 2020. www.fraserhealth.ca/health-topics • Allocate time to build connections, develop Acknowledgments -a-to-z/aboriginal-health#.XaddHuhKi70. relationships, and increase trust with tradi- We would like to acknowledge that the activi- 12. Northern Health Authority. Cultural safety: Supporting tional practitioners and community leaders. ties discussed in this issue of the BCMJ took place increased cultural competency and safety throughout • Create space for authentic discussions and Northern Health. Accessed 11 February 2020. www on the traditional unceded homelands of the .indigenoushealthnh.ca/initiatives/cultural-safety. meaningful relationships. xʷməθkwəyəm̓ (Musqueam), Skwxwú7mesh (Squa- 13. Provincial Health Services Authority. Indigenous health. mish), and Səlílwətaʔ/Selilwitulh̓ (Tsleil-Waututh) Accessed 11 February 2020. www.phsa.ca/our-services/ Health care system actions First Nations, and on the land of the W̱ SÁNEĆ (Pau- programs-services/indigenous-health. Policymakers should engage with others to: 14. First Nations Health Authority. FNHA overview. Ac- quachin, Tsartlip, Tsawout, Tseycum) peoples. We cessed 11 February 2020. www.fnha.ca/about/fnha • Acknowledge the spiritual side of well- would like to say a special thank you to all of the -overview. being in policy. participants, event organizers, and panel speakers 15. Provincial Health Services Authority. San’yas Indig- • Incorporate healing rooms into the health at the inaugural 2017 workshop for their invaluable enous cultural safety training. 2018. Accessed 11 Feb- system. ruary 2020. www.sanyas.ca/about-us. contributions. Thank you also to Allison Boothe and 16. DeCoteau MA, Lavallee B. Lessons learned and path- • Make cultural safety training mandatory Susan Powell for their invaluable support. Finally, ways forward Indigenous medical workforce develop- (e.g., San’yas Indigenous Cultural Safety thank you to the BC Ministry of Health Patients as ment in Canada since 2004. Focus Health Prof Educ Training). Partners Initiative for making this work possible. 2011;13. • Navigate and translate policy at the local 17. Baker AC, Giles AR. Cultural safety: A framework for interactions between Aboriginal patients and Cana- level. dian family medicine practitioners. Int J Indig Health • Incorporate appropriate language in new References 2013;9:15. policy mandates (e.g., avoid inappropriate 1. First Nations Health Authority. Traditional wellness 18. interCultural Online Health Network (iCON). Welcome strategic framework. 2014. Accessed 11 February 2020. terms such as “our Indigenous people,” to the interCultural Online Health Network. Accessed www.fnha.ca/WellnessSite/WellnessDocuments/ 11 February 2020. https://about.iconproject.org. which implies ownership). FNHA_TraditionalWellnessStrategicFramework 19. Zibrik L, Khan S, Bangar N, et al. Patient and commu- • Develop protocols and policy for accessing .pdf#search=Traditional Wellness Strategic Framework. nity centered eHealth: Exploring eHealth barriers and traditional practitioners. 2. Truth and Reconciliation Commission of Canada. Calls facilitators for chronic disease self-management within • Adapt funding models to incorporate tra- to action. 2015. Accessed 11 February 2020. http://trc British Columbia’s immigrant Chinese and Punjabi se- .ca/assets/pdf/Calls_to_Action_English2.pdf. niors. Health Policy Technol 2015;4:348-356. ditional practitioners, Aboriginal liaison 3. Ministry of Health. The transformative change accord: 20. Zibrik L, Khan S, Novak Lauscher H, et al. iCON: Sup- nurses, and Elders-in-residence. First Nations health plan. 2006. Accessed 11 Febru- porting Chinese and South Asian BC citizens for opti- ary 2020. www.health.gov.bc.ca/library/publications/ mal self-management. BCMJ 2015;57:244-245. Feedback welcomed year/2006/first_nations_health_implementation_plan 21. University of British Columbia. Digital Emergency Medi- .pdf. iCON, FNHA, and the province’s health au- cine. Department of Emergency Medicine. Accessed 4. First Nations Health Council. British Columbia First 11 February 2020. https://digem.med.ubc.ca. thority partners remain committed to collabora- Nations perspectives on a new health governance 22. interCultural Online Health Network (iCON). A coming tive, inclusive dialogue that helps participants arrangement: Consensus paper. 2011. Accessed 11 Feb­ together of health systems: Traditional practitioners reach a greater understanding of barriers, chal- ruary 2020. www.fnha.ca/Documents/FNHC_Consen in acute care settings. Video. Vancouver: iCON; 2016. sus_Paper.pdf. lenges, and experiences in accessing culturally Accessed 12 February 2020. https://indigenous.icon 5. United Nations. United Nations declaration on the project.org. safe care. rights of Indigenous peoples. 2007. Accessed 11 Feb- 23. interCultural Online Health Network (iCON). A coming The iCON team continues to cohost dis- ruary 2020. www.un.org/development/desa/indi together of health systems: First Nations traditional cussions that provide an opportunity for Indig- genouspeoples/wp-content/uploads/sites/19/2018/11/ practitioners in acute care settings discussion guide. UNDRIP_E_web.pdf. enous peoples to share insights and guidance on Vancouver: iCON; 2016. Accessed 12 February 2020. 6. First Nations Health Authority. Declaration of commit- https://indigenous.iconproject.org. forging a pathway to culturally safe care and that ment on cultural safety and humility in health services. 24. Stacy E, Ho K. Integrating cultural humility into health engages administrators, decision-makers, and 2015. Accessed 11 February 2020. www.fnha.ca/Doc care using a video on Indigenous health. Presented at policymakers in transforming the health care uments/Declaration-of-Commitment-on-Cultural BC Patient Safety and Quality Council Quality Forum -Safety-and-Humility-in-Health-Services.pdf. system to better serve all British Columbians. 2018, Vancouver, 22 Feburary 2018. 7. Doctors of BC. Supporting cultural safety for First Na- We welcome feedback from readers about tions. 2018. Accessed 11 February 2020. www.doctors their own experiences with traditional healing ofbc.ca/news/supporting-cultural-safety-first-nations. practices and any efforts made to improve ac- 8. BC Medical Journal. A commitment to cultural safety cess to culturally safe health care for Indigenous and humility. BCMJ 2019;61:249. n 9. Interior Health Authority. Healthier you. Summer 2016. patients in BC. Accessed 11 February 2020. www.interiorhealth.ca/

BC Medical Journal vol. 62 no. 3 | April 2020 97 Clinical

J. Connell, BSc, MPH, J. Kur, MD, FRCPC, J.H. Gurmin, LPhil, PhD Assessing the impact of a nursing model of care on rheumatology practice patterns and patient satisfaction in British Columbia

Study results from three clinics indicate a significant increase in outpatient encounters and high levels of patient satisfaction after implementation of a rheumatology multidisciplinary care assessment billing code.

ABSTRACT of BC rheumatologists. A study was proposed to 30.4 patients per week in 2016, an increase of 74.7% Background: Timely access to care and control of explore how patient access to rheumatology care (13 patients per rheumatologist per week). When disease activity in inflammatory arthritis is crucial has changed since the implementation of the Mul- encounters were considered by diagnosis, there to maintain patient quality of life and prevent joint tidisciplinary Conference billing code G31060 (as was a mean increase of 84.0% for diffuse diseases damage and loss of function. In 2010 BC faced a of 1 April 2020 called the Multidisciplinary Care of connective tissue (3.8 patients per rheumatol- shortage of rheumatologists caused in part by Assessment billing code) and how acceptable this ogist per week), 56.9% for rheumatoid arthritis disparities between rheumatology and other model of care is to patients. (4.6 patients), 118.3% for ankylosing spondylitis subspecialties. To address the resulting service (2.4 patients), and 75.3% for psoriatic arthritis shortages, rheumatologists in BC explored mul- Methods: In 2018 a review of electronic medical (2.2 patients). Survey results for patient satisfaction tidisciplinary patient care approaches, including records was conducted in three rheumatology show the care was highly acceptable, with a mean a new fee-for-service code that allows nurses to clinics in British Columbia to measure changes in overall patient score of 4.35 out of 5.00. Survey provide education and counseling to patients the number of outpatient encounters before and results for rheumatologist practice patterns show concerning medication, diet, and exercise. The after the implementation of a nursing model of an increase in the use of nursing support, with nursing model of outpatient rheumatology care care. Data from the records were used to generate only 23% having access to nursing support in 2010 that resulted has changed the practice patterns descriptive statistics. RCPSC-certified rheumatolo- and 71% having access after implementation of gists in BC were asked to respond to a survey about the billing code. practice patterns. Patients were asked to respond to a survey about six aspects of care: general sat- Conclusions: More outpatient encounters for all Mr Connell is an independent health isfaction, giving of information, empathy with the disease types were seen at all three participating economics and outcomes research patient, technical quality and competence, attitude rheumatology clinics after implementation of the consultant. Dr Kur is president of the toward the patient, and access and continuity. A billing code. Rheumatologists received increased BC Society of Rheumatologists and a literature review was completed to identify studies remuneration and had time to see more patients clinical associate professor in the Division of physician-led care in similar patient populations. while nurses assisted with patient assessments and of Rheumatology at the University of educated patients about medications, diet, and British Columbia. Dr Gurmin is a research Results: The mean number of weekly outpatient exercise. Patient satisfaction scores for six aspects consultant affiliated with Artus Health encounters per rheumatologist for all inflammatory of care were all higher than 4.00 out of 5.00. Centre. diseases was 17.4 patients per week in 2009 and

This article has been peer reviewed.

98 BC Medical Journal vol. 62 no. 3 | April 2020 Connell J, Kur J, Gurmin J CliniClinicalcal

Background FTEs. In addition, 33% of rheumatologists the billing code and how acceptable this model Rheumatologists are internal medicine sub- reported that wait times for nonurgent consults of care is to patients. specialists who care for patients with systemic were longer than 4 months, suggesting that autoimmune diseases such as rheumatoid ar- the shortage of rheumatologists was having an Methods 4 thritis, lupus, vasculitis, and inflammatory impact on patient outcomes. An electronic medical record (EMR) review diseases of the back. In addition, rheuma- To address these service shortages, rheuma- was conducted in the summer of 2018 to mea- tologists care for patients with complicated tologists in BC explored patient care approach- sure changes in the number of patient visits in musculoskeletal problems such as advanced es through the Specialist Services Committee three urban rheumatology clinics in Vancouver osteoarthritis, injuries, and tendinopathies. (SSC). This eventually led to the introduction and Victoria. Public Health Agency of Canada data indi- of a Multidisciplinary Conference billing code Each rheumatology clinic was run by cate that the burden of rheumatic diseases is G31060 (as of 1 April 2020 called the Multi- a single specialist, was using the same EMR increasing.1 disciplinary Care Assessment billing code) that system, and was operating both before and af- In BC rheumatologic care is primarily de- allowed for nursing sup- ter implementation of the livered in an outpatient private practice clinic port in outpatient rheu- billing code in 2010. The setting. The patients seen in a rheumatologist’s matology care. total number of distinct clinic suffer from some of the most complicated The new billing code The new billing code patients seen per year was allows patients with measured for 2009 and for diseases in medicine. Disorders in rheumatol- allows patients with ogy strike multiple organ systems, including the complex inflammatory 2016 to allow for a 6-year joints, heart, skin, muscle, lungs, and kidneys. disease to receive per- complex inflammatory period of adjustment af- The rheumatologist is often a coordinator of sonalized counseling and disease to receive ter the billing code was care for patients with complicated disease who education from rheuma- personalized counseling implemented. Each pa- require a holistic, multidisciplinary approach to tology nurses, including and education from tient was counted only their multiorgan pathology. education about medica- once in a year, regardless Timely access to care and control of disease tions, diet, immunization, rheumatology nurses. of the number of visits to activity in inflammatory arthritis is crucial to and exercise, training in the clinic, to determine if prevent joint damage and loss of function and self-injection of rheuma- more individual patients to maintain quality of life. Joint damage can tologic agents, and coun- were being seen with the 5 occur within 3 months of disease and lead to seling for DMARD therapy. This support from change in the model of care as opposed to the disability. Research has shown that intervention nurses in the management of patients frees same patient being seen more often. The num- with disease-modifying antirheumatic drug up more physician time and allows for more ber of days the clinic’s rheumatologist worked (DMARD) therapy will help patients with care to be delivered in fewer encounters, thus that year were taken into account, and the en- inflammatory arthritis achieve disease remis- reducing the number of visits to other health counters were stratified by inflammatory disease sion, improve physical function, and prevent care professionals. type (connective tissue diseases, rheumatoid long-term disability. Previous studies in BC Since the billing code was introduced, there arthritis, ankylosing spondylitis, and psoriatic have shown that only 39% of the early incident has been a dramatic shift in the delivery of arthritis). rheumatoid arthritis population and 45% of the rheumatology care for outpatients in BC. A Additional data were obtained from 2010 prevalent late rheumatoid arthritis population specialty nursing group has been established, and 2018 surveys by the BC Society of Rheu- were receiving DMARD therapy, suggesting BC Rheumatology Nurses, and rheumatologists matologists. Each online, self-administered the existence of large service gaps.2,3 throughout the province have engaged nurses survey consisted of questions on demographics In 2010 BC was faced with a shortage of in their clinics part-time and full-time. and practice patterns. The surveys were sent rheumatologists. Recruitment and retention The introduction of multidisciplinary teams out to all RCPSC-certified rheumatologists pressures, caused in part by disparities between that include rheumatology nurses has changed in BC. The response rate for 2010 was 98% rheumatology and other subspecialties, had re- the practice patterns of BC rheumatologists and (n = 45) and for 2018 was 91% (n = 77). These sulted in poor access to care for BC residents has potentially changed patient access to care. data were supplemented with billing infor- with rheumatic diseases. At that time, there Because access to care is a quality indicator, the mation provided by the BC Medical Services were only 32 full-time equivalent (FTE) rheu- changes made have the potential to alter the Plan (MSP), the sole insurer for rheumatology 6 matologists in the province, or one rheumatolo- quality or acceptability of care for patients. A services in the region. gist for every 140 000 residents.4 Guidelines study was proposed to explore how patient ac- Data on patient satisfaction were collected recommend a rheumatologist-to-patient ratio cess (the number of rheumatology patients seen using the Leeds Satisfaction Questionnaire of 1:70 000, which meant that the BC popu- in a period of time by an individual rheumatolo- (LSQ), a validated and reliable tool for assess- 7 lation was underserviced by approximately 32 gist) has changed since the implementation of ing care in rheumatology outpatient clinics.

BC Medical Journal vol. 62 no. 3 | April 2020 99 CliniClinicalcal Assessing the impact of a nursing model of care on rheumatology practice patterns and patient satisfaction in BC

Patients were asked to consider 45 statements between physicians. The study was done as part The Leeds Satisfaction Questionnaire was and use a Likert scale to rate six aspects of their of an evaluation of labor market adjustment completed by 92 patients at two of the three rheumatology care: general satisfaction, giving (LMA) fees. Funding for the evaluation was rheumatology clinics studied. The mean overall of information, empathy with the patient, tech- provided by the Specialist Services Commit- satisfaction score was 4.35 out of 5.00 and all nical quality and competence, attitude toward tee, a joint collaborative committee of Doctors aspects of care received ratings higher than 4.00. the patient, and access and continuity. The LSQ of BC and the BC Ministry of Health. Ethics When these results were compared with results was administered in English to outpatients with approval for the study was obtained from the from studies in Alberta and Norway, the scores inflammatory disease 19 years and older who University of British Columbia Behavioural in British Columbia were found to be equal or were attending a follow-up appointment and Research Ethics Board. significantly higher [Table]. were able to complete the survey on their own. Only 23% of rheumatologists in 2010 The questionnaire was completed in the wait- Results had access to nursing support as part of their ing room before the appointment to ensure the In 2009, before implementation of the bill- practice, but that number increased to 71% in responses were not biased by the most recent ing code for rheumatology, 1493 patient en- 2018, after implementation of the billing code interaction or by acquiescence bias resulting counters occurred over 439 working days. In [Figure 3]. From 2011 to 2018, the use of the from the presence of the rheumatologist. 2016, after implementation, 2761 patient en- code across BC increased by 234%. Billings per The completed questionnaires were sealed counters occurred over 463 working days. The rheumatologist went from 140 in the 2011/12 in envelopes and patients were assured they mean number of weekly outpatient encoun- fiscal year (the first year after code G31060 was would remain anonymous and their responses ters per rheumatologist for all inflammatory implemented) to 467 billings in the 2017/18 would not be viewed by diseases was 17.4 patients fiscal year (written communication with Raaj the treating rheumatolo- per week in 2009 and Tiagi, senior health economist, Doctors of BC, The mean overall gist. Questionnaires were 30.4 patients per week 16 January 2019) [Figure 4]. As of 2018, 22 collected in two of the satisfaction score was in 2016, an increase of FTE nurses were employed in rheumatology three rheumatology clinics 4.35 out of 5.00. 74.7% (13 patients per community outpatient clinics in BC, compared studied. Means from the rheumatologist per week) with only one nurse in 2010. responses were pooled and [Figure 1]. Clinic 1 Clinic 2 Clinic 3 compared with values from studies identified When encounters were considered50 by di- Conclusions in a literature review as having similar patient agnosis, there was a mean increase45 of 84.0% The number of outpatient encounters is a vi- populations but more traditional physician-led for diffuse diseases of connective40 tissue (3.8 tal metric when determining accessibility of 8,9 35 service delivery methods. patients per rheumatologist per week),30 56.9% care for rheumatology patients. Increases in Descriptive statistics were calculated during for rheumatoid arthritis (4.6 patients),25 118.3% patient visits were seen for all three rheuma- data analysis. As this was an exploratory health for ankylosing spondylitis (2.4 patients),20 and tology clinics studied and for all disease types services study, the patient access measure was 75.3% for psoriatic arthritis (2.215 patients) after implementation of the billing code. This 10 not powered to allow for statistical comparisons [Figure 2]. 5 suggests that rheumatologists can care for more

Outpatient encounters per week 0 2009 2016

Clinic 1 Clinic 2 Clinic 3 2009 2016 50 14 45 12 40 35 10 30 8 25 6 20 15 4 10 2 5 Outpatient encounters per week Outpatient encounters per week 0 0 2009 2016 Di use diseases Rheumatoid Ankylosing Psoriatic of connective arthritis spondylitis arthritis tissue 2009 2016 Figure14 1. Number of weekly outpatient encounters by rheumatologist at three Figure 2. Number of weekly outpatient encounters by diagnosis at three BC

BC clinics12 in 2009 (before implementation of billing code G31060) and in 2016 clinics in 2009 (before implementation of billing code G31060) and in 2016 (after (after implementation). implementation). 10 2010 2018

100 BC Medi8 cal Journal vol. 62 no. 3 | April 2020 6 11 21 4

2 36 51 Outpatient encounters per week 0 Di use diseases Rheumatoid Ankylosing Psoriatic of connective arthritis spondylitis arthritis tissue Yes No

2010 2018

500 11 450 21 400 350 300 51 36 250 200 Yes 150 Services/physician 100 No 50 0 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Fiscal year

500 450 400 350 300 250 200 150 Services/physician 100 50 0 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Fiscal year Clinic 1 Clinic 2 Clinic 3 Connell J, Kur J, Gurmin J 50 CliniClinicalcal 45 40 Table. Results from Leeds Satisfaction Questionnaire35 (LSQ) completed in British Columbia, Alberta, and patients with nursing support than they can Norway by patients at rheumatology clinics 30using a multidisciplinary care model. without this support. 25 Rheumatology is a time-intensive specialty 20British Columbia, Alberta, 20179 Norway, 201310 LSQ aspects of care 15 2018 with patients having complex histories, requiring (95% CI) (95% CI) 10 (95% CI) detailed physical examinations, and needing in- 5

formation about the expanding field of biologic General satisfaction Outpatient encounters per week 04.26 (4.10, 4.41) 4.25 (4.10, 4.40) 4.06 (3.82, 4.30) 2009 2016 treatments. The observed increase in patient ac- Giving of information 4.34 (4.23, 4.45) 4.2 (4.06, 4.34) 3.81 (3.29, 4.03) cess is substantial given the complexity of the Empathy with the patient 4.28 (4.17, 4.39) 4.02 (3.85, 4.19) 3.83 (3.62, 4.03) patients involved. Also, it is important to note 2009 2016 that the increase in access at the three rheuma- Technical quality and competence 144.59 (4.49, 4.69) 4.53 (4.40, 4.66) 4.49 (4.31, 4.68) tology clinics studied meansClinic that 1 jointClinic damage 2 Clinic 3Attitude toward the patient 124.42 (4.32, 4.53) 4.46 (4.30, 4.62) 4.05 (3.83, 4.27) and function50 loss in those patients with inflam- Access and continuity 104.21 (4.09, 4.33) N/A* 3.40 (3.18, 3.62) matory conditions45 was probably prevented. 40 Overall satisfaction 84.35 (4.25, 4.45) 4.30 (4.17, 4.43) 3.95 (3.80, 4.11) 35 Ophthalmology 6 3 (1–7) 55 310 Advantages30 of the nursing model 4 Studies25 have shown that nurse-led care in Plastic surgery 5 (3–8) 75 189 20 2 rheumatology is acceptable, safe, and equally Radiology 3 (1–9) 56 84 15 10 effective as physician-led care. A systematic Outpatient encounters per week 0 10 Immunology Di use1 (0–4) diseases Rheumatoid50 Ankylosing 70 Psoriatic review by5 Garner and colleagues demonstrates of connective arthritis spondylitis arthritis *Results could not be compared because researchers altered the questions for access and continuity.

Outpatient encounters per week 0 tissue conflicting evidence about2009 the cost-effectiveness 2016 of implementing nurse-led care, but most stud- ies suggest that it either costs the same or less implementing a nursing model of rheumatology Recommendations from the European 2009 2016 than other models of care. care has not been significant, with all aspects of League against Rheumatism (EULAR) state 14 2010 2018 When assessing patient satisfaction with care scoring more than 4.00 out of 5.00. that patients should have access to nursing sup- 12 this model, we compared our results with those Results from the 2018 BC Society of Rheu- port for education purposes. The league also from two10 recent studies with similar patient matologists survey suggest multiple advantages concluded11 that statistically significant higher populations,8 namely traditional physician-led 21 8 to having additional nursing support in outpa- levels of knowledge were found in patients with health service6 delivery methods in Alberta and 9 tient rheumatology practices. Rheumatologists access to nursing support compared with those Norway. The equal and significantly higher 11,12 4 benefit from increased remuneration and 36from seen only by rheumatologists. In addition,51 scores found in our study suggest greater sat- 2 having time to see more patients while nurses the recommendations state that the participa- isfaction with multidisciplinary care in BC as assist with patient assessments and educate tion of nurses canYes help control disease activity Outpatient encounters per week 0 compared with physician-led care in Alberta 6 Di use diseases Rheumatoid Ankylosingpatients Psoriatic about medications, diet, and other as- and improve patient-preferredNo outcomes. and Norway.of Anyconnective negative impactarthritis causedspondylitis by arthritis tissue pects of care.

2010 2018 500 450 400 350 11 21 300 250 200 36 51 150 Services/physician 100 50 Yes 0 No 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Fiscal year

Figure 3. BC rheumatologists with access to nursing support for care of Figure 4. Use of code G31060 billings per rheumatologist by fiscal year, outpatients in 2010 (before implementation of billing code G31060) and in 2018 2011–2018. (after500 implementation). 450 400 BC Medical Journal vol. 62 no. 3 | April 2020 101 350 300 250 200 150 Services/physician 100 50 0 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Fiscal year CliniClinicalcal Assessing the impact of a nursing model of care on rheumatology practice patterns and patient satisfaction in BC

5. Sun M, Jamal S, Kur J. Analysis of rheumatology nurs- Study limitations Summary ing interventions in out-patient practice settings. CRAJ The results of our study have limited generaliz- Implementation of the rheumatology billing 2014;24:18-22. Accessed 6 February 2020. http://craj. ability to rural and remote communities as the code G31060 in BC has been associated with ca/archives/2014/English/Fall/PDFs/CRAJ%20Fall% three participating clinics were all in urban cen- a significant increase in outpatient encounters 202014%20-%20Sun_Jamal_Kur.pdf. tres. In addition, demographic shifts and other for individual physicians managing patients 6. Saag KG, Yazdany J, Alexander C, et al. Defining qual- ity of care in rheumatology: The American College of changes in the BC health system that were not with inflammatory disease. Implementation Rheumatology white paper on quality measurement, measured may have had an has also been associated arthritis care and research. Arthritis Care Res (Hoboken) impact on the change in As of 2018, 22 FTE with high levels of patient 2011;63:2-9. patient visits over time. satisfaction. Our findings 7. Hill J, Bird H, Hopkins R, et al. Survey of satisfaction with nurses were employed care in a rheumatology outpatient clinic. Ann Rheum Regarding results from indicate nursing support Dis 1992;51:195-197. the Leeds Satisfaction in rheumatology has become an accept- 8. Hall JJ, Katz SJ, Car MK. Patient satisfaction with Questionnaire, informa- community outpatient able and integral part of pharmacist-led collaborative follow-up care in an am- tion was not collected on outpatient rheumatology bulatory rheumatology clinic. Musculoskeletal Care clinics in BC, 2016;15:186-195. demographics or disease care provincially, and has compared with only 9. Koksvik HS, Hagen KB, Rodevand E, et al. Patient satis- progression, so confound- the potential to improve faction with nursing consultations in a rheumatology ing variables could not be one nurse in 2010. service delivery and qual- outpatient clinic: A 21-month randomised controlled accurately analyzed to de- ity of care. n trial in patients with inflammatory arthritis. Ann Rheum Dis 2013;72:836-843. termine their effect on ac- Competing interests 10. Garner S, Lopatina E, Rankin J, Marshall D. Nurse-led ceptability of care. Regarding the studies used care for patients with rheumatoid arthritis: A system- for comparing patient satisfaction, there were None declared. atic review of the effect on quality of care. J Rheuma- two issues. First, the Norway study had a dif- tol 2017;44:757-765. 11. van Eijk-Hustings Y, van Tubergen A, Bostrom C, et al. ferent time frame as compared to the Alberta References 1. Public Health Agency of Canada. Canadian Chronic EULAR recommendations for the role of the nurse in and British Columbia studies. Second, a control Disease Surveillance System. Accessed 28 March 2019. the management of chronic inflammatory arthritis. clinic with rheumatologist-only care could not https://infobase.phac-aspc.gc.ca/ccdss/data-tool. Ann Rhuem Dis 2012;71:13-19. be found in BC because all clinics approached 2. CATCH: Canadian Early Arthritis Cohort. Information 12. Hill J, Bird HA, Harmer R, et al. An evaluation of the effec- to participate were already using nurses in some about arthritis. Accessed 28 March 2019. www.early tiveness, safety and acceptability of a nurse practitio- arthritis.ca/participants_education.php. ner in a rheumatology outpatient clinic. Br J Rheumatol capacity, and a control clinic serving patients 3. Widdifield J, Bernatsky S, Paterson JM, et al. Quality 1994;33:283-288. with noninflammatory disease would be inap- care in seniors with new-onset rheumatoid arthritis: propriate since patient satisfaction is known A Canadian perspective. Arthritis Care Res (Hoboken) to vary by disease type. In future, comparisons 2011;63:53-57. 4. Kur J, Koehler B. Rheumatologist demographics in Brit- might be made in other provinces where nursing ish Columbia: A looming crisis. BCMJ 2011;53:128-131. care is not common in rheumatology clinics.

102 BC Medical Journal vol. 62 no. 3 | April 2020 special feature

search and rescue mission coordinators at the “That Others May Live”: JRCC spring into action. Depending on the circumstances, a variety of resources may be Two weeks with the Joint tasked to respond, ranging from civilian vessels and other nearby assets to Royal Canadian Air Force planes and helicopters as well as Canadian Rescue Coordination Centre Coast Guard vessels. During 2 weeks in May 2019, I was very An inside look into how the centre coordinates air and maritime fortunate to get an inside look at the operations search and rescue for BC and Yukon. of the JRCC Victoria in fulfilling its mission to coordinate air and maritime search and rescue David A. Obert, MD, MPP for BC and Yukon. As an emergency medi- cine resident pursuing training in prehospital and transport medicine, the experience was Dr David A. Obert is a resident physician in his fifth bush plane crashes in Yukon’s wilder- invaluable in offering a contrast between feder- year in the UBC Royal College Emergency Medicine ness. A fishing boat strikes a log off ally mandated search and rescue services and program at Vancouver General Hospital. During British Columbia’s coast and is rapidly those of the provincially administered civilian his fourth year, he took additional training in taking on water. A caller reports seeing several emergency medical services system in British A Columbia (BC Emergency Health Services), prehospital and transport medicine and participated red flares in a remote area on the rugged western in several rotations and experiences with BC shores of Vancouver Island. In these and other with which I am more familiar. While there are Emergency Health Services. When he completes air and sea rescue situations, the Joint Res- obvious inherent differences between search and his residency, he will pursue an emergency medical cue Coordination Centre ( JRCC) in Victoria, rescue and emergency medical services, there services fellowship at Stanford University. BC, sits atop the nexus of the fast-paced, often are also areas of significant overlap and the multi-agency response that follows. Often with echoes of several similar challenges. It is here, This article has been peer reviewed. limited initial information and lives on the line, in the overlap, where we can benefit from the insights gleaned in seeing each other’s worlds. The JRCC Victoria (one of three JRCCs in Dr Obert on the open ramp of the CH-149 Cormorant as it navigates a valley on Vancouver Island. Canada) is truly a joint operation. Located at Canadian Forces Base Esquimalt, Royal Ca- nadian Air Force and Canadian Coast Guard personnel at the JRCC work together on op- posite sides of a large room. The air force side of the room is staffed by a Royal Canadian Air Force air controller (an experienced pilot or air combat systems officer) who, during day- time hours, is joined by an assistant air control- ler. The marine side consists of two seasoned Canadian Coast Guard mariners. Despite a computer-monitor-to-person ratio of well over five to one, the room is open and designed to facilitate communication and collaboration. The marine and air search and rescue mission coordinators work 24/7 answering a variety of calls from the public, the Canadian military, the Canadian Coast Guard (and sometimes their US counterparts), RCMP, and other agencies. I even witnessed a call from the North American Aerospace Defense Command. Many are small matters—an empty boat adrift or an acciden- tally activated emergency locator transmitter.

BC Medical Journal vol. 62 no. 3 | April 2020 103 special feature

Others can be multiday search operations in- tides, currents, and wind patterns—are input retention difficulties further burden the exist- volving multiple search and rescue mission co- into complex models to generate a search area ing complement of search and rescue mission ordinators and a variety of air and sea assets. based on predicted drift patterns. Search maps coordinators who are often forced to pick up Generally, calls are categorized as either are then updated in real time to factor in con- extra shifts to keep the JRCC staffed 24/7/365. air, marine, or humanitarian. Air calls include tinued drift, while also accounting for areas Additionally, as the older, experienced search monitoring notifications of distress communi- already searched. To say that the job requires a and rescue mission coordinators begin to retire, cations picked up from pilots such as “mayday” high degree of skill is an understatement. there is risk of significant institutional knowl- and “pan-pan” calls. As well, all emergency lo- Outside the walls of the JRCC, I also had edge loss. cator transmitter signals (which could indicate the privilege to witness the exceptional prow- Securing adequate funding in an era of re- a plane crash) that are picked up by satellites ess of a team of search and rescue technicians straint is but one factor in addressing these is- monitored at the Canadian Mission Control from the 442 Transport and Rescue Squad- sues. Among other things, the JRCC must also Centre and that fall with- ron in Comox, BC—the continue to be innovative and agile in respond- in JRCC Victoria’s search The medical care “pointy end of the spear” ing to challenges. Collaboration and resource and rescue area are inves- that was delivered for air-based search and pooling with related organizations is one strat- tigated by search and res- rescue. As part of a medi- egy for achieving these ends and has the poten- cue mission coordinators. was impressive in cal simulation exercise, tial to produce mutually beneficial outcomes. If a crash is determined to its scope and in the I watched as the team, The relationship between the BC Emergency have occurred, JRCC then ability of personnel to which had been inserted Health Services’ Emergency Physician Online coordinates the search and adapt on the fly to the by helicopter, rushed to Support program and the JRCC is a shining rescue effort. Marine calls the scene of an incred- example of such a collaboration. The Emergency operate similar to air calls, fluid and technically ibly realistic plane crash Physician Online Support program gives pre- but owing to the higher challenging conditions. mock-up (complete with hospital providers around-the-clock telephone number of vessels on the twisted fuselage and air- access to a BC Emergency Health Services water than aircraft in the craft parts strewn about physician advisor for clinical decision support. sky, they are far more frequent. All incidents the landscape). Multiple mock casualties, played BC Emergency Health Services has made the involving a threat to life or limb that occur in by Canadian Forces personnel, were quickly Emergency Physician Online Support service the waters contained within JRCC Victoria’s assessed and triaged as the search and rescue available to JRCC, as well as to Canadian Forces search and rescue zone are managed by marine technicians got to work. The sound of a circling search and rescue technicians and Canadian search and rescue mission coordinators. Such Buffalo aircraft thundered overhead, and soon Coast Guard rescue specialists. This has proven incidents may include sinking vessels, persons after several blaze-orange parachutes appeared to be an invaluable resource. For example, as is in the water, medical emergencies occurring across the sky bringing additional personnel to the case with BC Emergency Health Services at sea, and any emergency position indicating the scene. The medical care that was delivered paramedics, the search and rescue technicians radio beacon activation (the marine equivalent was impressive in its scope and in the ability of and rescue specialists report greatly increased of an aircraft emergency locator transmitter). personnel to adapt on the fly to the fluid and confidence in their ability to provide the high- Finally, humanitarian calls make up an increas- technically challenging conditions. At the con- est quality of patient care knowing that Emer- ing number of calls and include JRCC assis- clusion of the simulation exercise, several mock gency Physician Online Support advice is only tance offered in situations that otherwise fall patients had been stabilized and remained in the a phone (or satellite phone) call away. outside its federal air and maritime search and capable hands of the search and rescue techni- From the JRCC’s perspective, a frequent rescue mandate. Examples include assisting cians. In a real-life scenario, the JRCC would issue in recent years has been calls from cruise land-based search and rescue agencies (such have already been hard at work facilitating the ships for medevacs. Given the finite air and as the RCMP) as well as the BC Ambulance transfer of care to the provincial trauma system. sea assets at JRCC’s disposal, it is necessary to Service to evacuate patients from more remote However, technical skills are only one part of appropriately steward these resources for use and difficult-to-access areas. the equation. Equally important are the softer where and when they are most needed. Thus, Whether a call technically falls to the air skills, the interpersonal aptitude necessary to calls must be medically triaged, a task that at or marine side does not betray the teamwork coordinate effectively between multiple players a command level is generally best handled by necessary for the more involved calls. The level in an emotionally charged, fast-moving situa- a physician. By bringing an Emergency Phy- of complexity that search and rescue mission tion. The parallels to the worlds of both emer- sician Online Support doctor on the line, coordinators are sometimes called on to grapple gency medicine and prehospital medicine are physician-to-physician communication can oc- with can be mind boggling. For example, in easy to spot. Unfortunately, so too are some of cur with the cruise ship’s medical officer and, the case of a missing person in the water, a the challenges. Posttraumatic stress and burn- working with the search and rescue mission multitude of variables—including last location, out are ever-present issues. Recruitment and coordinators, a plan using resources appropriate

104 BC Medical Journal vol. 62 no. 3 | April 2020 special feature to the urgency of the medevac can be put in motion. Judging from the taped calls I listened to while observing at the JRCC, the system works exactly as designed. It is important to note that the collaboration goes both ways. While it is beyond its federal air and maritime search and rescue mandate, assist- ing BC Emergency Health Services to evacuate While it is beyond patients from particularly difficult-to-access parts of BC has often been part of JRCC’s work. its federal air and maritime Canadian Coast Guard vessels with rescue spe- search and rescue mandate, cialists aboard can reach many of the remote water-access-only communities found in BC. assisting BC Emergency One would be hard pressed to find a place in Health Services to evacuate BC that is beyond the combined reach of these patients from particularly organizations. Furthermore, patients in these remote areas can be confident that, once they difficult-to-access parts of are reached, they will be under the care of highly BC has often been part of competent professionals. Above one of the desks at the JRCC is a JRCC’s work. large Canadian flag with the motto “That Oth- ers May Live” below the words “RCAF Para- rescue.” Despite the many differences between federal search and rescue and the prehospital medicine world of BC Emergency Health Ser- vices, the driving motivation behind their re- spective efforts is the same. “That Others May Live” is part of the search and rescue techni- cians’ pledge, and it aptly sums up this motiva- tion. During my 2 weeks with the JRCC (and on-field excursions to 442 Squadron in Comox and two Canadian Coast Guard lifeboat sta- tions), I saw this mentality on full display. I am extremely grateful to have been welcomed into their world. It is my hope that, through this reflection, I am able to share with the wider prehospital medicine world an understanding of the mandates, capabilities, and operations of the JRCC, Royal Canadian Air Force, and Ca- nadian Coast Guard in delivering world-class search and rescue coverage. With this common understanding and shared ethos, collaboration between the federal air and maritime search and rescue and BC Emergency Health Services can be at its most fruitful. n

Acknowledgments Dr Obert would like to acknowledge and give par- ticular thanks to Captain Sébastien Lemire, CD, and Lieutenant Philip Yoon, MD, for organizing and facilitating this unique experience with the JRCC. Dr Obert in front of the CH-149 Cormorant after a challenging confined space landing at the foot of a waterfall on Vancouver Island.

BC Medical Journal vol. 62 no. 3 | April 2020 105 premise

And evolution is not perfect. If an adap- Group medical practice is the tation is selected at one level, this inevitably creates problems the next level up. So what is natural evolution of medicine good for me may not be good for my family, what is good for my family may not be good for the community, what is good for the com- Eight core design principles that favor cooperation and the welfare of munity may not be good for the province, what groups, applicable to the evolution of medical practice. is good for the province may not be good for the country, and so forth. Mark Elliott, MD, FRCPC There is a well-known example involving hens to illustrate how group selection trumps individual selection.4 Let’s say you have groups he most famous quote about evolution For at least 50 years, biological dictum has of hens in cages (10 to a cage) on a modern has got to be Theodosius Dobzhan- said that it is the individual who is subject to agricultural egg farm. You might think that sky’s, “Nothing in biology makes sense evolution. It is now believed that the small co- breeding the most productive individual hens exceptT in the light of evolution.” This applies to operative group is the fundamental unit of an would give you more eggs. But what happens medical practice as well. organization that evolves. In fact, the evolution after about five generations of this breeding is We have all been taught that Darwinian probably happens at many different levels. This the hens peck each other’s feathers out and egg evolution is based on the principles of random has been termed “multilevel selection.” production plummets. If, on the other hand, mutation and natural selection. However, there are many people now questioning the com- pleteness of these principles. There is a third principle, which is sometimes called group se- lection1 and sometimes called cooperation.2 Even Darwin had doubts about the complete- ness of his theory.3

Dr Elliott is a staff anesthesiologist at Providence Healthcare in Vancouver.

This article has been peer reviewed.

106 BC Medical Journal vol. 62 no. 3 | April 2020 premise

you select and breed the hens in the cages that to group medical practice. Basically it means and/or jointly. Think about the difference be- have the most eggs, production goes way up you can’t steal your money; you must earn it. tween one surgeon struggling for hours versus after five generations. The rational usually given two surgeons together struggling for hours with for the disastrous outcome in the first scenario Three: Ensure those affected by the rules can a bad outcome. is that you are breeding bullies who then do participate in modifying the rules nothing but fight each other. Maybe one bully The group must agree to things collectively so Eight: Build responsibility for governing the in a cage of 10 hens was okay, but 10 bullies no one individual can be bossed around. common resource in nested tiers from the low- in a cage is problematic, at least as far as egg est level up to the entire interconnected system production goes. Four: Ensure the rule-making rights of com- Interconnectedness is what defines a complex Elinor Ostrom won a Nobel prize in eco- munity members are respected by outside adaptive system. Health care is just one of many nomics in 2009 for outlining eight core design authorities such systems. Johnny von Neumann said that principles that favor cooperation and the welfare In the case of doctors, the rules they enact must the defining characteristic of a complex system of groups.5 This work greatly influenced biolo- be respected by the larger collective system, is that it constitutes its own simplest behavioral gists developing the theory of evolution at the whether that be a hospital administration, a description. If we try to reduce the system’s group level.6 These principles are very applicable regional health authority, or a provincial gov- behavior to any formal description it makes to medical practice. They are outlined here. ernment. This is where it is good to have a things more complicated, not less. This seems group leader who is able to communicate well rather demoralizing in our health care system, One: Define clear group boundaries with the authorities and not simply be their but the responsibility that Ostrom’s eighth prin- The group must have clear boundaries so its hired hand. ciple suggests needs to be developed is better members know they are members and know than anarchy. what the group does. Five: Develop a system, carried out by com- Evolution is not top-down like the hierarchy munity members, for monitoring members’ of the military or hospital administration. Nor Two: Match rules governing the use of com- behavior is it completely bottom-up, with evolution only mon goods to local needs and conditions There must be a system to monitor the actions working its wonders on genes that mutate and The group must ensure the use of common of a group’s members. This is where a good then get randomly selected (like laissez-faire goods by individuals matches the welfare of leader shows their other side by being able to capitalism with its inevitable booms and crush- the group. This may seem more relevant to fish- communicate well with group members, con- ing busts). Evolution tinkers with things. It ers regulating some area of the sea or farmers vincing them to change a practice if it is in the experiments, lets most things fail, and keeps the regulating crops in fields, but it is also pertinent interest of the group. things that work until they, too, fail. Medical practice is no different.n Six: Use graduated sanctions for rule violators If an individual doctor in a group breaks a rule, References 1. Wilson DS. This view of life. Completing the Darwin- there must be a graduated, agreed-upon sys- ian revolution. New York, NY: Penguin Random House; tem of escalating sanctions against that mem- 2019. ber. The sanctions must start out benignly and 2. Nowak MA, Highfield R. Supercooperators. Altruism, should build up to a real sting after repeated evolution, and why we need each other to succeed. New York, NY: Free Press; 2012. transgressions. 3. Darwin C. On the origin of species by means of natu- ral selection, or preservation of favoured races in the Seven: Provide accessible, low-cost means for struggle for life. London, John Murray; 1859. dispute resolution 4. Muir W. Group selection for adaptation to multiple hen cages. Poultry Sci 1996;75:447-458. Disputes must be settled with very little cost 5. Ostrom E. Governing the commons: The evolution of to the group. If they aren’t, then medicolegal institutions for collective action. Cambridge, UK: Cam- problems arise. Most lawsuits stem from long- bridge University Press; 1990. standing grudges between doctors that result in 6. Wilson DS, Ostrom E, Cox M. Generalizing the core de- a patient either overhearing one doctor com- sign principles for the efficacy of groups. J Econ Behav Organ 2013;90:S21-S32. plaining about how bad another doctor is or a doctor telling that directly to the patient. If a disastrous complication results from some situ- ation, it is much easier for the individual doctor if everyone in the group does things similarly

BC Medical Journal vol. 62 no. 3 | April 2020 107 News We welcome news items of less than 300 words; we may edit them for clarity and length. News items should be emailed to [email protected] and must include your mailing address, telephone number, and email address. All writers should disclose any competing interests.

Register now for the Business number. The claims system will apply the per- Benefits of accelerated Cost Premium centage for the premium and calculate the daily surgery in patients with hip maximum. In order to identify the physical loca- fracture The new Business Cost Premium (BCP) was tion in which services are provided and for the negotiated in the 2019 Physician Master Agree- correct percentage premium to be applied, phy- Accelerated time to surgery—within an average ment to help physicians offset some of the costs sicians need to register their community-based of 6 hours after a hip fracture diagnosis—re- associated with running their office. Physicians office for a facility number, which is a unique sulted in a lower risk of delirium and urinary will be able to claim the BCP on fees for con- physician/office location-identifier. tract infections, moderate to severe pain, faster sultation, visit, counseling, and complete ex- If an eligible physician is responsible for mobilization, and a shorter length of hospital amination services to help cover the rising rent, some or all of the lease, rental, or ownership stay compared to standard care (when surgery lease, or ownership costs of a community-based costs at more than one community-based loca- occurred an average of 24 hours after a hip office. Physicians need to register their facility tion, they need to register each location where fracture diagnosis). and attach themselves as a practitioner of the eligible services are provided. The HIP Fracture Accelerated Surgical facility. The BCP came into effect 1 April 2020. Community-based offices with multiple Treatment and Care Track (HIP ATTACK) Eligible physicians are those who provide eligible physicians should assign one physi- Trial, published in The Lancet, was led by re- eligible services in an eligible community-based cian to act as the administrator and register the searchers of the Population Health Research office and who are responsible for some or all office for a facility number. It is not required Institute (PHRI) of McMaster University and of the lease, rental, or ownership costs of that that all physicians in the same clinic apply for Hamilton Health Sciences (HHS) in Hamil- office, either directly or indirectly. Physicians a facility number. However, each eligible phy- ton. HIP ATTACK involved 2970 people at must also be entitled to receive and retain pay- sician is required to complete an Attach Prac- 69 sites in 17 countries. ment for the eligible fees directly from MSP titioner to MSP Facility Number application Ten years ago, Dr P.J. Devereaux, principal (that is, payments assigned to health authorities form using the facility number obtained by investigator of the HIP ATTACK trial, as well are not eligible for the premium). your administrator. as senior scientific lead of PHRI’s perioperative The BCP will be applied to eligible fees sub- See the “Business Cost Premium links” box and surgery program, professor of medicine at mitted on a physician’s billing claims, and will for links to forms and more information. McMaster, and cardiologist with HHS, was be paid to the physician’s (or assigned) payee consulted to manage a 73-year-old female with a hip fracture who also had elevated troponin, Business Cost Premium links demonstrating heart injury. The referring doc- List of eligible fees tor told Dr Devereaux the patient’s heart issue • www.doctorsofbc.ca/sites/default/files/bcp_eligible_fees_current.xlsx had to be treated before surgery for her hip fracture could occur. Despite the best of inten- Online application tions, with the medical treatment Dr Devereaux • Apply for facility number: https://my.gov.bc.ca/bcp/register-facility provided based on current practice at that time, • Attach practitioner to MSP facility number: https://my.gov.bc.ca/bcp/ the patient died before she was able to undergo practitioner-registration surgery for her hip fracture. Fill and print forms Dr Devereaux wondered if the prevail- • Apply for facility number: www2.gov.bc.ca/assets/gov/health/forms/2948fil.pdf ing dogma regarding the need to medically • Attach practitioner to MSP facility number: www2.gov.bc.ca/assets/gov/health/ optimize patients before hip fracture surgery forms/2950fil.pdf was the wrong approach. He contacted Dr For more information Mohit Bhandari, co-principal investigator of • www.doctorsofbc.ca/news/what-you-need-know-about-business-cost-premium HIP ATTACK and an orthopaedic surgeon in Hamilton, to get his perspective on the case. Dr

108 BC Medical Journal vol. 62 no. 3 | April 2020 news

Bhandari told Dr Devereaux that observational had elevated troponin when they presented to increased likelihood of accepting and acting studies suggested that shorter time to surgery the hospital with their hip fracture, accelerated on their health care provider’s lifestyle change may prevent death and major complications surgery lowered the risk of death compared to recommendations because of their diagnosis. in patients with a hip fracture. Based on this standard care. Vancouver Coastal Health Research Institute evidence, they initiated a large randomized con- scientist Dr Ryan Flannigan is currently study- trolled trial to understand the effects of accel- Physical activity for prostate ing whether the teachable moment offers an erated surgery in patients with a hip fracture. cancer patients and its effect opportunity to get prostate cancer patients into Accelerated surgery did not result in a re- on tumors a regular exercise routine that may change the duction in death or a collection of major com- genetic expression and molecular makeup of plications; however, patients randomized to Prostate cancer affects 15% to 20% of North their tumor and improve their diagnosis. accelerated surgery had a lower risk of delir- American men. Living with a cancer diagnosis Dr Flannigan is a urologist focused on ium, urinary tract infection, moderate to se- can be frightening and anxiety-inducing, but men’s health at Vancouver General Hospital vere pain, and were faster to stand, mobilize, at the same time there exists a hopeful phe- and senior research scientist at the Vancou- and go home compared to patients random- nomenon called the “teachable moment.” The ver Prostate Centre. He is also clinical lead of ized to standard care. Among patients who teachable moment describes cancer patients’ the Prostate Cancer Supportive Care Sexual

Doctors of BC governance and committee reporting structure This graphic was created by Doctors of BC senior staff as a tool to help the Board of Directors, the Representative Assembly, members, and staff visualize and better understand the complex relationships and reporting structures of the committees and other bodies represented.

DOCTORS OF BC GOVERNANCE

Medical Services Ministry of Health Doctors of BC Representative Commission (Government) Board of Directors Assembly

MSC Advisory Ministry Joint Committees Statutory Standing Ad Hoc External Committees Committees with Ministry Committees Committees Committees Committees

 Advisory Committee  Data Stewardship  Audit & Finance  Allocation Support  None at this time  We appoint members to on Diagnostics Committee Physician Committee Committee 7 external committees: Services Committee  Audit & Inspection  Hospital Appeal  Governance Committee  Alternative Payment • Drivers Fitness Board  General Practice Physicians Issues Advisory Group Guidelines & Protocol Nominating Committee  Services Committee  Committee Committee (GPAC)  Provincial Surgical • Emergency Services  Tariff Committee Executive  Specialist Services  Awards Committee Advisory Patterns of Practice  Committee Committee  Digital Health Board  Statutory Negotiating  BC Medical Journal • Hamber Foundation Committee  Shared Care Committee  Reference Committee  Continuing Professional • Information Privacy  Review Committee  Joint Standing Committee Development Nucleus and Security on Rural Issues  Council on Health • Medical Quality  Joint Benefits Committee Economics & Policy Oversight

Other Joint Committees  Physicians Health Program  Council on Health Sub Committees • Provincial Dictionary Steering Committee Promotion Advisory Committee WorkSafeBC  WorkSafeBC Liaison  Council on Public Affairs  Athletics & Recreation • BC Road Safety Committee & Communication Committee Strategy Steering Special Ad Hoc Committees Committee WorkSafeBC  WorkSafeBC Projects Developed from the 2019 PMA  Health Benefit Trust  Nutrition Committee & Innovations Fund Board of Trustees  Environmental Health  After Hours Adjudication Panel UBC  Clinical Faculty Insurance Committee Committee Working Group  Allocation Committee (2019) Negotiations  Emergency & Public ICBC  ICBC Liaison  Compensation Model Coordinating Group Safety Committee Working Group Consultation Committee Negotiations Forum  Geriatrics & Palliative Ministry  Provincial MOCAP  Ministry of Children & Family Committee Review Development Rural Issues Committee

 Provincial Laboratory Physician  WorkSafeBC Model Committee Negotiation Committee

 Provincial Workload Measures  WorkSafeBC Working Group Negotiating Coordinating Group  Workload Advisory Committee

 Regional Physician/Psychological Health and Safety Working Group January 2020

BC Medical Journal vol. 62 no. 3 | April 2020 109 news

Medicine Program, British Columbia, direc- tor of the Male Infertility & Sexual Medicine What patients lie to their doctors about, and why Research Program, and assistant professor in the Department of Urologic Sciences at UBC. Doctors know that patients Of patients who admitted to lying to their doctors... There have been a number of research stud- are not always fully truth- ies on a population level that have identified ful with them, but just how 50% the association between exercise and reduced much do patients lie, and risk for acquiring prostate cancer, prostate 46% about what? A recent Poll- 43% cancer-specific mortality, and delayed disease 37% fish survey found that 43% of 25% 29% progression. Studies have also shown a con- those who admitted to lying nection between regular exercise and improved say they lie about their ex- 0% quality of life for patients in terms of allevi- ercise habits; the only thing Smoking Exercise Drinking Sexual Partners ating treatment-associated side effects such that more people admitted as fatigue and decreased muscle strength and to lying about was smoking physical function. (46%). Patients 35 and older Dr Flannigan’s study participants were 20 were more likely to lie about men diagnosed with immediate-risk prostate their exercise habits than cancer, meaning eventual surgery to remove younger patients, while those the prostate gland. Ten participants were ran- under 35 were more likely to domly assigned to an 8- to 12-week exercise lie about smoking. intervention completed prior to surgery. The More men lied to doctors about alcohol consumption than women (50% men vs. intervention comprised two 1-hour sessions of 32% women), while women were more likely to lie about sexual partners (33% women supervised resistance and aerobic training per vs. 21% men). week, as well as home aerobic training at least twice weekly. The other 10 participants received Why are patients lying? standard prostate cancer care that included edu- • 75% of respondents cited embarrassment. cation about healthy exercise and diet. • 31% lie to avoid discrimination. The study found that introducing exercise • 22% lie because they don’t think their doctor will take them seriously if they tell the during the teachable moment (after diagnosis truth. and before surgery) led to increased physical Of those who admitted to lying to their physician, the group that lied to avoid dis- activity among participants 6 months post- crimination was overwhelmingly female (80% female, 20% male). surgery and well after the exercise interven- On the bright side, in general most people (77% of those surveyed) are honest with tion period. The study also found that prostate their doctor, and 34% said they were comfortable talking with their doctor about anything. cancer–specific quality of life and depressive The survey was conducted for insurance aggregator TermLife2Go, and had 500 re- symptoms were similar 6 months after surgery spondents from throughout the US. More results are available at https://termlife2go as before surgery. .com/lying-to-your-doctor. Studies using animal models have demon- strated decreased tumor activity following exer- cise treatments. For example, research suggests that exercise may interfere with oxygen delivery in prostate cancer tumor microcirculation and tumor proliferation, decreasing chances of the cancer spreading to other parts of the body and delaying tumor growth. As part of their study, Dr Flannigan and his team are testing participants’ tumor specimens to see if there are any changes resulting from the exercise intervention. They hope to have preliminary molecular and genetic study results by summer 2020.

110 BC Medical Journal vol. 62 no. 3 | April 2020 Obituaries We welcome original tributes of less than 300 A loving husband and father, Barry was a words; we may edit them for clarity and length. Obituaries may be emailed compassionate physician and surgeon in the to [email protected]. Include birth and death dates, full name and name Powell River area for 32 years. After Barry com- deceased was best known by, key hospital and professional affiliations, relevant pleted his high school education at University of Toronto Schools and medical training at biographical data, and a high-resolution head-and-shoulders photo. the University of Toronto, he and Judy left ex- tended family and moved to BC in 1968 to raise a family and begin a lifelong mission of car- will save your life.” His passion for lifelong ing for the members of Powell River’s thriving learning was evidenced when he became a stu- coastal community. Barry was president of the dent once more and, at age 82 at UBC Okana- BC Surgical Society (1986–87) and president gan, achieved his dream of attaining a Bachelor of the Powell River Medical Society (1991–95). of Arts degree. Indeed, he is a role model for Barry was an avid athlete, farmer, outdoors- anyone whose life circumstances are challeng- man, mariner, and fan of all things related to ing. His love of learning is indeed a legacy he sports. A pioneer in every sense of the word, and leaves the next generation of family. a gentle spirit, Barry would count his contribu- In 2018, Hans was diagnosed with cancer. tions to the Powell River community among He underwent surgery and radiation, but in his proudest accomplishments. He was recently Dr Hans Adalbert Witt December his health challenges increased. He named to the Powell River Sports Hall of Fame died peacefully at Kelowna Hospice House on 1934–2020 as team physician for the Power River Regals 21 January 2020. Hockey Club and its run to the Allan Cup —Heidi Grogan championship in 1969. He was a member of Dr Hans Adalbert Witt was born in Brasdorf, Calgary East Prussia, on 29 August 1934. At the out- the medical team at the Montreal Olympic break of World War II, Hans’s life changed in Games, and as president of the Powell River ways that would shape his character and influ- Golf Club (1984–88), he was instrumental in ence his legacy of tenacity. initiating the planning and construction of the In 1945, Hans, his seven siblings, and their Myrtle Point Golf Club. mother fled to Schleswig-Holstein. There, Hans In 2000 Barry and Judy began spending completed his schooling and apprenticed as a winters in Ajijic, Mexico, and in 2013 they tool and die maker. In 1955 the family, spon- moved to North Vancouver to be closer to sored by the Mennonite Church, immigrated family. In 2006, Barry began a 13-year battle to Canada and settled on a farm in Virgil, On- with Parkinson disease and Lewy body demen- tario. To support his family, Hans worked as tia. His family thanks Drs Doug Toole, Steve a newspaper truck driver and then as a tool Burns, Silke Cresswell, Arvind Kang, and Garry Dr Barry King Cutler and die maker with GM. During this time, he Jenkins, and the nurses, care aids, and staff of took courses at night to learn English, and his 1937–2019 Berkley Care Centre for their exceptional and hard work saw him enter medical school. He dedicated care for Barry over the years and dur- became a family doctor and then specialized in Dr Barry King Cutler, 82 years of age, passed ing his 3½ years living at the care centre. anesthesia. He married Nancy McAdam and away peacefully at the Berkley Care Centre A Mass of Christian Burial was held on 15 they lived in various towns in BC with their on 16 December 2019, surrounded by family. January 2020 at Christ the Redeemer Parish, two children, Heidi and Jonathan. Sadly, his A man of faith, Barry is lovingly remem- 599 Keith Road, West Vancouver. Please visit marriage did not continue. bered by his wife of 58 years, Judith; his chil- Barry’s online memorial page at www.mckenzie In 1994, Hans returned to Toronto and dren, Duffy (Shari) and Rob ( Joanne); his sister, funeralservices.com for more information and began practising psychotherapy. He retired in Diane (Doug Porter); his grandchildren, Cam- to post to the online book of condolences. In 2005. On a visit to Kelowna, he met Ela Jackel eron, Emily, and McKenzie, and Gemma and lieu of flowers, memorial donations may be and their beautiful relationship began. In addi- Declan. He will also be remembered by many made to the Pacific Parkinson’s Research In- tion to dancing and gardening with Ela, Hans friends and colleagues from Canada, the United stitute: www.pacificparkinsons.org. was an avid bridge player. States, and Mexico. Barry was predeceased by —Judith Cutler, MD North Vancouver As a young immigrant, his career was his mother, Wilma (nee King); his father, Don; shaped by his mother’s words that “education and his eldest son, Scott.

BC Medical Journal vol. 62 no. 3 | April 2020 111 CME calendar Rates: $75 for up to 1000 characters (maximum), plus GST per month; there is no partial rate. If the course or event is over before an issue of the BCMJ comes out, there is no discount. Deadlines: Online: Every Thursday (listings are posted every Friday). Print: The first of the month 1 month prior to the issue in which you want your notice to appear, e.g., 1 February for the March issue. The BCMJ is distributed by second-class mail in the second week of each month except January and August. Planning your CME listing: Advertising your CME event several months in advance can help improve attendance; we suggest that your ad be posted 2 to 4 months prior to the event. Ordering: Place your ad at www.bcmj.org/cme-advertising. You will be invoiced upon publication. Payment is accepted by Visa or MasterCard on our secure online payment site.

MINDFULNESS IN MEDICINE WORKSHOPS passionate specialists from the fields of vestibu- TROPICAL & GEOGRAPHIC MEDICINE & RETREATS lar medicine and rehabilitation who aim to pro- INTENSIVE Various locations and dates, 17 Apr–24 May vide the most up-to-date, evidence-informed Vancouver, 4–8 May (Mon–Fri) intelligence about vestibular care. We hope the Physician heal thyself. Join Dr Mark Sherman This is the 7th annual CME accredited course audience will leave with a better understanding and your community of colleagues for a trans- for physicians, medical trainees, public health of the relationship between vestibular diagnosis formative retreat! Foundations of Theory and practitioners, nurses, and other health care and appropriate management and interven- Practice Workshop for Physicians and Their workers who intend to practise in the tropics, tion. Speakers (5 p.m. to 9 p.m.): Dr Margaret Partners, 17–20 Apr and 25–28 Sep, will be in resource-limited settings, or who require an Aron, MD, FRCSC, ENT specialist neurotol- held at Long Beach Lodge Resort, Tofino. A update on infectious, parasitic, and other major ogy; Fred Matta, MClinAud, R AUD, RHIP, Physician Meditation Retreat, 24–29 May, tropical diseases. The course will be held at the audiology specialist; Abeed Hirji, OT, certified will be held at Hollyhock, Cortes Island. The UBC Vancouver campus. Through interactive vestibular therapist, 2007. The evening’s format workshops focus on the theory and practice of lectures, small-group case-based discussions, will include dinner, presentations, and panel mindfulness and meditation—reviewing defini- and practical laboratory teaching, attendees Q&A. For full event details, a detailed agenda, tions, clinical evidence, and neuroscience, and will learn a clinical approach to the evaluation and to register (by 12 April) visit: http://bit.ly/ introducing key practices of self-compassion, and management of tropical diseases, practical EverythingVestibular. breath work, and sitting meditation to nurture laboratory skills with a focus on the identifica- resilience and healing. This annual meditation CME ON THE RUN tion of parasites important for the diagnosis of retreat is an opportunity to delve deeply into VGH and various videoconference tropical diseases, and public health principles meditation practice in order to recharge, heal, locations, 1 May–5 Jun (Fri) and applications including outbreak manage- and build a practice for life. Each workshop ment. Early registration rate effective until 6 is accredited for 16 Mainpro+ group learning CME on the Run sessions are held at the Paet- April 2020. Register early on the course website credits and has a 30-person limit, so please reg- zold Lecture Theatre, Vancouver General Hos- as space is limited. More information at www ister today! Contact us at hello@livingthismo pital, and there are opportunities to participate .spph.ubc.ca/continuing-education/tgm2020/. ment.ca, or check out www.livingthismoment via videoconference from various hospital sites. Contact [email protected]. .ca/event for more information. Each program runs on Friday afternoons from 1 p.m. to 5 p.m. and includes great speakers and HEALTHCARE PROVIDERS CONFERENCE EVERYTHING VESTIBULAR learning materials. Dates and topics: 1 May Victoria, 14 May (Thu) (prenatal, pediatric, and adolescents). Topics Vancouver, 23 Apr (Thu) Join us for an evening of educational sessions include Management of anxiety in children; To be held at St. Paul’s Hospital, Cullen Fam- at LifeLabs 4th Annual Healthcare Providers Pediatric asthma management update; Abnor- ily Lecture Theatre (Rm. 1477), 1400–1081 Conference to be held at the beautiful Oak mal gait in children: Diagnosis and manage- Burrard St., this will be a panel presentation of Bay Beach Hotel, 1175 Beach Dr. If you think ment; ADHD: Clinical tips for diagnosis and specialists in the fields of vestibular medicine of laboratory medicine as a “black box,” or if treatment; Depression in teens; Management and rehabilitation. Though dizziness is one of you would like to know more about ordering of childhood obesity; Doc, I’m pregnant. Now the most common reasons for consulting a phy- and interpreting lab testing, or if you’d like to what? An update on antenatal screening; Pe- sician, establishing an accurate diagnosis and connect with lab medicine specialists, this is diatric rashes. The last session is 5 Jun (internal treatment plan can be tricky. In recent years, the conference for you. Topics will be of inter- medicine). To register and for more information great strides have been made to understand, est to GPs and specialists, nurse practitioners, visit ubccpd.ca, call 604 675-3777 or email cpd evaluate, and manage vestibular disorders bet- naturopathic doctors, and allied health care [email protected]. ter. This panel presentation brings together providers—particularly those providing primary

112 BC Medical Journal vol. 62 no. 3 | April 2020 calendar care and ordering and interpreting lab tests. Physician Leaders will be held at the Hyatt session, participants complete a further 30 days Our PhD and MD laboratory medicine staff Regency Hotel. This 2-day educational event of clinic experience at the Cancer Centre where includes specialists in biochemistry/toxicology, brings together physician leaders from across their patients are referred. These are scheduled hematology, microbiology/infectious diseases, Canada and internationally and is designed to flexibly over 6 months. Participants who com- and genetics. They will share their expertise engage and educate physician leaders at all lev- plete the program are eligible for credits from through formal presentations and also be avail- els. Take advantage of our four 2-day intensive the College of Family Physicians of Canada. able for informal discussion before and after the and interactive preconference courses (27–28 Those who are REAP-eligible receive a stipend sessions. Presentations will use a case-based for- May). For more information email carol@phy and expense coverage through UBC’s Enhanced mat to address clinical topics in laboratory test sicianleaders.ca, or visit www.physicianleader Skills Program. For more information or to selection and interpretation. A complete list of shipconference.com. apply, visit www.fpon.ca, or contact Jennifer presentation topics will be posted to our website Wolfe at 604 219-9579. closer to the meeting date. Conference regis- GP IN ONCOLOGY TRAINING tration includes a free gourmet buffet dinner Vancouver, 14–25 Sep and 8–19 Feb 2021 and nonalcoholic beverages. This educational (Mon–Fri) event may qualify up to 2 hours of unaccredited BC Cancer’s Family Practice Oncology Net- group learning activity. Registration is free. Sign work offers an 8-week General Practitioner in up now as space is limited: www.lifelabs.com/ Oncology education program beginning with annual-conference. a 2-week introductory session every spring and fall at BC Cancer–Vancouver. This program CANADIAN CONFERENCE ON PHYSICIAN provides an opportunity for rural family physi- LEADERSHIP cians, with the support of their community, to Vancouver, 29–30 May (Fri–Sat) strengthen their oncology skills so that they can The Canadian Conference on Physician Lead- provide enhanced care for local cancer patients ership—Accepting Our Responsibility as and their families. Following the introductory

2,300 BC pedestrians are injured in car crashes every year.

Doctors of BC has launched a safety campaign to help make the province’s roadways a safer place for pedestrians.

BE SEEN KEEP YOUR USE EYE HEAD UP CROSSWALKS CONTACT IS KEY Let British Columbians know that the province’s physicians care about their safety by hanging a

armbands for your patients.

To get posters and armbands for your practice, email: [email protected]

BC Medical Journal vol. 62 no. 3 | April 2020 113 Billing Tips

Why become a medical inspector?

rom time to time you will see requests When the Audit and Inspection Committee • Not be subject to circumstances that could for medical inspectors or audit hearing (AIC) requests an on-site audit of a medical give rise to a conflict of interest. panel members, and you may wonder practice, an attempt is made to match the medi- Inspectors are required to: Fwhy anyone would want to be a medical inspec- cal inspector with the type of practice being • Sign a 3-year contract, with possible ex- tor and audit their peers. audited. Having a peer physician conduct the tension, to be placed on a call list with the The Medical Services Commission (MSC) review is preferred by both the AIC and the Ministry of Health. Once under contract, is responsible for administering the Medical physician undergoing the audit and inspection. medical inspectors will be contacted to Services Plan (MSP), which includes remu- The AIC is accepting applications for conduct audits on an as-needed basis. If a nerating physicians. As part of administering medical inspectors from any section, but it is medical inspector is contacted, the audit MSP, audits are conducted to ensure physicians currently looking to fill medical inspector roles will be scheduled based on the medical in- have appropriate billing patterns. for the following specialties: spector’s availability. • General practice • Attend an orientation and training session. • Pediatrics • Attend on-site audits, which may include Having a peer physician • Infectious diseases travel and stay at accommodations outside conduct the review is • Neurosurgery the medical inspector’s city (length varies • Endocrinology from 3 to 5 days). preferred by both the • Neurology • Work as part of a team with members of AIC and the physician • Psychiatry the Billing Integrity Program while on site. undergoing the audit • Otolaryngology • Inspect medical records, make determinations and inspection. • Anesthesiology about compliance with the payment schedule, • Sleep medicine and flag any quality-of-care concerns. • Internal medicine and other medical • Have an exit interview with the auditee to subspecialties clear up any unanswered questions or obtain As a medical inspector, you will participate • General surgery and other surgical explanations of billing issues. in one or more audits by reviewing medical sub­specialties • Review and sign the final audit report. records to assess whether a physician’s MSP Inspectors are appointed by the AIC under • Act as a witness before a panel established billings comply with billing rules. In this inter- the Medicare Protection Act. Inspectors are under the Act, if necessary. esting and rewarding role, you will be making responsible for reviewing medical records in • Maintain confidentiality and independence decisions about appropriate billing practices in order to assess compliance with the MSC Pay- at all times as required by Section 49 of the accordance with the MSC payment schedule, ment Schedule, the Act, and the Regulations. Act. and you will also help provide explanations to the physician who is being audited. If appointed Conditions of appointment Compensation as a medical inspector, you will be placed on a Candidates must: Medical inspectors are paid an hourly rate de- call list and asked to participate in audits related • Have a minimum 5 years’ experience in the rived from the hourly equivalent of Doctors of to your specialty and/or scope of practice. If you applicable specialty. BC’s sessional rate for GPs or specialists. In- are called, the audit will be scheduled based on • Be an active registrant with the College of spectors also receive compensation for eligible your availability, and you will have the option Physicians and Surgeons of BC. travel expenses. to decline to participate if you are unavailable • Have billing practices that fall within the at that time. accepted standards of the profession or gen- If you are interested in becoming a medical erally designated by the Patterns of Practice inspector, please contact Tara Hamilton, project This article is the opinion of the Patterns Committee. coordinator, audit and billing, at 604 638-6058 of Practice Committee and has not been • Have the ability to exercise sound judgment. or [email protected]. n peer reviewed by the BCMJ Editorial • Have an understanding and knowledge of —Nick Szpakowicz, MD Board. the MSC payment schedule. Vice-Chair, Patterns of Practice Committee

114 BC Medical Journal vol. 62 no. 3 | April 2020 BCMJ Guidelines BCMJ Guidelines

Guidelines for authors (short form)

The British Columbia Medical Journal welcomes letters, vidual patient is described, written consent from the Permissions articles, and essays. Manuscripts should not have been patient (or his or her legal guardian or substitute deci- It is the author’s responsibility to obtain written per- submitted to any other publication. Articles are sub- sion maker) is required. mission from both author and publisher for material, ject to copyediting and editorial revisions, but authors Papers will not be reviewed without this document, including figures and tables, taken or adapted from remain responsible for statements in the work, includ- which is available at www.bcmj.org. other sources. Permissions should accompany the article ing editorial changes; for accuracy of references; and when submitted. for obtaining permissions. Send submissions to: The References to published material Editor, BC Medical Journal, [email protected]. Try to keep references to fewer than 30. Authors are Tables and figures responsible for reference accuracy. References must be Tables and figures should supplement the text, not For all submissions numbered consecutively in the order in which they duplicate it. Keep length and number of tables and fig- • Avoid unnecessary formatting. appear in the text. Avoid using auto-numbering as this ures to a minimum. Include a descriptive title and units • Double-space all parts of all submissions. can cause problems during production. of measure for each table and figure. Obtain permission • Include your name, relevant degrees, e-mail address, Include all relevant details regarding publication, and acknowledge the source fully if you use data or and phone number. including correct abbreviation of journal titles, as in figures from another published or unpublished source. • Number all pages consecutively. Index Medicus; year, volume number, and inclusive page Tables. Please adhere to the following guidelines: Clinical articles/case reports numbers; full names and locations of book publishers; • Submit tables electronically so that they may be for- Manuscripts of scientific/clinical articles and case inclusive page numbers of relevant source material; full matted for style. reports should be 2000 to 4000 words in length, includ- web address of the document, not just to host page, and • Number tables consecutively in the order of their first ing tables and references. Email to journal@doctorsofbc date the page was accessed. Examples: citation in the text and supply a brief title for each. .ca. The first page of the manuscript should carry the 1. Gilsanz V, Gibbons DT, Roe TF, et al. Vertebral bone • Place explanatory matter in footnotes, not in the heading. following: density in children: Effect of puberty. Radiology • Explain all nonstandard abbreviations in footnotes. • Title, and subtitle, if any. 2007;166:847-850. • Ensure each table is cited in the text. • Preferred given name or initials and last name for (NB: For more than three authors, list first three, fol- Figures (illustrations). Please adhere to the following each author, with relevant academic degrees. lowed by “et al.”) guidelines: • All authors’ professional/institutional affiliations, 2. Mollison PL. Blood Transfusion in Clinical Medicine. Ox- • Send scans of 300 dpi or higher. sufficient to provide the basis for an author note ford, UK: Blackwell Scientific Publications; 2004:178-180. • Number figures consecutively in the order of their first such as: “Dr Smith is an associate professor in the 3. O’Reilly RA. Vitamin K antagonists. In: Colman RW, Hirsh citation in the text and supply a brief title for each. Department of Obstetrics and Gynecology at the • Place titles and explanations in legends, not on the University of British Col umbia and a staff gynecolo- J, Marder VJ, et al. (eds). Hemostasis and Thrombosis. illustrations themselves. gist at Vancouver Hospital.” Phil adelphia, PA: JB Lippincott Co; 2005:1367-1372. • Provide internal scale markers for photo micrographs. • A structured or unstructured abstract of no more 4. Health Canada. Canadian STD Guidelines, 2007. www than 150 words. If structured, the preferred head- .hc-sc.gc.ca/hpb/lcdc/publicat/std98/index.html • Ensure each figure is cited in the text. ings are “Background,” “Methods,” “Results,” and (accessed 15 July 2018). • Color is not normally available, but if it is necessary, an exception may be considered. “Conclusions.” (NB: The access date is the date the author consulted • Three key words or short phrases to assist in indexing. the source.) Units • Name, address, telephone number, and e-mail address Report measurements of length, height, weight, and of corresponding author. References to unpublished material volume in metric units. Give temperatures in degrees These may include articles that have been read at a Authorship, copyright, disclosure, and consent Celsius and blood pressures in millimetres of mercury. meeting or symposium but have not been published, or Report hematologic and clinical chemistry measure- form material accepted for publication but not yet published ments in the metric system according to the Interna- When submitting a clinical/scientific/review paper, all (in press). Examples: tional System of Units (SI). authors must complete the BCMJ’s four-part “Author- 1. Maurice WL, Sheps SB, Schechter MT. Sexual activity ship, copyright, disclosure, and consent form.” with patients: A survey of BC physicians. Presented at Abbreviations 1. Authorship. All authors must certify in writing that the 52nd Annual Meeting of the Canadian Psychiatric Except for units of measure, we discourage abbrevia- they qualify as an author of the paper. Association, Winnipeg, MB, 5 October 2008. tions. However, if a small number are necessary, use Order of authorship is decided by the co-authors. 2. Kim-Sing C, Kutynec C, Harris S, et al. Breast cancer and standard abbreviations only, preceded by the full name 2. Copyright. All authors must sign and return an risk reduction: Diet, physical activity, and chemopre- at first mention, e.g., in vitro fertilization (IVF). Avoid “Assignment of copyright” prior to publication. Pub- vention. CMAJ. In press. abbreviations in the title and abstract. lished manuscripts become the property of the BC Medical Association and may not be published else- Personal communications are not included in the ref- Drug names where without permission. erence list, but may be cited in the text, with type of Use generic drug names. Use lowercase for generic 3. Disclosure. All authors must sign a “Disclosure communication (oral or written) communicant’s full names, uppercase for brand names, e.g., venlafaxine of financial interests” statement and provide it to the name, affiliation, and date (e.g., oral communication hydrochloride (Effexor). BCMJ. This helps reviewers determine whether the with H.E. Marmon, director, BC Centre for Disease paper will be accepted for publication, and may be used Control, 12 November 2017). Full guidelines for a note to accompany the text. Material submitted for publication but not accepted Please see www.bcmj.org/submit-article for the full 4. Consent. If the article is a case report or if an indi- should not be included. Guidelines for Authors.

270 BC MediCal Journal vol. 61 no. 7 | september 2019 BC Medical Journal vol. 62 no. 3 | April 2020 115 Classifieds Advertisements are limited to 700 characters. Rates: Doctors of BC members: $50 + GST per month for each insertion of up to 350 characters. $75 + GST for insertions of 351 to 700 characters. Nonmembers: $60 + GST per month for each insertion of up to 350 characters. $90 + GST for insertions of 351 to 700 characters. Deadlines: Ads must be submitted or canceled by the first of the month preceding the month of publication, e.g., by 1 November for December publication. Visit www.bcmj.org/classified-advertising for more information. Ordering: Place your classified ad online at www.bcmj.org/classified -advertising. Payment is required at the time that you place the ad.

KELOWNA—CHIEF MEDICAL Employment counselors, and counseling are known to be the best, helping HEALTH OFFICER interns. Compensation is your day run smoothly. Lucrative ARE YOU A PHYSICIAN provided via a combination of Interior Health is seeking a chief 6-hour shifts and no headaches! LOOKING FOR A NEW ROLE? fee-for-service (MSP), sessional medical health officer (CMHO) For more information, or to Physicians for You—leaders in payments, and a service contract to fulfill the role of chief of book shifts online, please contact physician recruitment in Canada. agreement. Applicants must have medical and population health Kim Graffi at kimgraffi@ Our strong reputation is built on FRCPC and be eligible for full services for the beautiful hotmail.com or by phone at exceptional service and results. licensure with CPSBC. Please Southern Interior region of BC. 604 987-0918. contact Dr Patrice Ranger at Located in Kelowna, the Locum, contract, long-term, city, POWELL RIVER—LOCUM rural, we have it all. Whether [email protected] or HCS director CMHO is responsible for you’re a physician looking for Martin Mroz at [email protected]. leading public health, health The Medical Clinic Associates is work across Canada, or a See our website at www.students promotion and prevention, and looking for short- and long-term medical facility requiring .sfu.ca/health. health protection in addition to locums. The medical community overseeing the work of Interior offers excellent specialist backup physicians, we can help. Your EDMONTON, AB—FAMILY Health’s medical health officers. and has a well-equipped 33-bed needs are our focus. Save time PRACTICE PHYSICIAN For details or to apply online, hospital. This beautiful commu- and effort; let us do all the REQUIRED legwork. Let our 10 years of visit https://jobs.interiorhealth nity offers outstanding outdoor Callingwood Crossing Medical experience in Canada, extensive .ca/job/kelowna/chief-medical recreation. For more information Clinic is vibrant and growing! knowledge of the processes for -health-officer/602/15219666. contact Laurie Fuller: West Edmonton location. Newly licensure, and our personalized, 604 485-3927, renovated dynamic office NANAIMO—GP friendly service work for you. email: [email protected], operating for over 28 years with General practitioner required for Check out our current job website: powellrivermedical an extremely loyal patient base. locum or permanent positions. postings online and contact us clinic.ca. We use Med Access EMR, have The Caledonian Clinic is located today. Website: www.physicians SOUTH SURREY/WHITE an attached pharmacy, and are in Nanaimo on beautiful foryou.com. Email: info@ ROCK—FP one of the largest clinic members Vancouver Island. Well- physiciansforyou.com. of Edmonton West Primary established, very busy clinic with Busy family/walk-in practice in Office: 1 778 475-7995. Care Network. We have imme- 26 general practitioners and two South Surrey requires GP to BURNABY—PSYCHIATRIST, diate openings for a physician specialists. Two locations in build family practice. The SFU, HEALTH AND with enough patient volume Nanaimo; after-hours walk-in community is growing rapidly COUNSELLING SERVICES where your panel could be filled clinic in the evening and on and there is great need for family Simon Fraser University’s in 3 to 6 months. You would weekends. Computerized physicians. Close to beaches and Health and Counselling Services work as an independent contrac- medical records, lab, and recreational areas of Metro is seeking a part-time psychia- tor with a fee-for-service split. pharmacy on site. Contact Lisa Vancouver. OSCAR EMR, trist to join its multidisciplinary We also offer an attractive Wall at 250 390-5228 or email nurses/MOAs on all shifts. team providing services to signing bonus and look forward [email protected]. CDM support available. domestic and international to hearing from you soon! Please Visit our website at Competitive split. Please contact university students at the SFU email Amy Markovitz, Amy. www.caledonianclinic.ca. Carol at Peninsulamedical@live [email protected], or Nanci .com or 604 916-2050. Burnaby campus. Our mental NORTH VAN—FP LOCUM health team includes physicians, Harper, nanci_anne@hotmail mental health nurses, a transi- .com. Physician required for the tion case manager, case manager, busiest clinic/family practice on psychologists, registered clinical the North Shore! Our MOAs

116 BC Medical Journal vol. 62 no. 3 | April 2020 Classifieds

SURREY (GATEWAY PRIMARY Remuneration is two sessions per to see only booked patients or occasional walk-in shifts CARE CLINIC)—GPs, LOCUM & day. Contact loretta.kane@ add walk-ins for variety. Oscar available. FT/PT GP post also PART-TIME fraserhealth.ca. EMR. Positions in Richmond available. Contact drianbridger@ The Gateway Primary Care also available. Contact Dr Balint gmail.com. SURREY/DELTA/ Clinic is looking for a part-time Budai at [email protected]. ABBOTSFORD—GPs/ locum (1 day/week in February; Medical office space SPECIALISTS VICTORIA—FULL/PART-TIME 2 days/week from March to FAMILY PHYSICIAN MAPLE RIDGE—MEDICAL September 2020) as well as Considering a change of practice OFFICE SPACE FOR LEASE part-time GPs (1 day/week) to style or location? Or selling your Option to bring your own join our team. The clinic, practice? Group of seven practice or for long-term locum. Turnkey opportunity to establish conveniently located at the locations has opportunities for Our office is bright, friendly, and or relocate your practice. Brand Gateway Skytrain station, family, walk-in, or specialists. well run with low shared new medical offices in a three- provides medical care to indi- Full-time, part-time, or locum expenses. We value work-life story, state-of-the-art, new viduals experiencing mental doctors guaranteed to be busy. balance. Work in the most professional medical building in health and substance use issues, We provide administrative beautiful place on earth. Contact Maple Ridge. Custom-made and their families. The clinic staff support. Paul Foster, Narissa Arter, office manager, reception area, free parking on includes GPs with special 604 572-4558 or phone: 250 478-2133, email: site, staff room, six to eight interest in mental health and [email protected]. [email protected]. exam/office rooms in each clinic, bright and spacious, private substance use, family NP, RNs, VANCOUVER/RICHMOND—FP/ VICTORIA—GP/WALK-IN and MOAs. We use a team SPECIALIST washrooms, security surveillance approach to service delivery Shifts available at three beautiful, with enterphone for private through coordination of care The South Vancouver Medical busy clinics: Burnside (www access. Steps away from down- with mental health and addic- Clinic seeks family physicians .burnsideclinic.ca), Tillicum town Maple Ridge. Near the tions, hospital, and other and specialists. Split is up to (www.tillicummedicalclinic.ca), local hospital. Life Lab and community agents. 80/20. Closing your practice? and Uptown (www.uptownmedi pharmacy nearby. Very attractive Want to work part-time? Join us calclinic.ca). Regular and and competitive rate. Contact

T 604 638 2904 E [email protected] W doctorsofbc.ca/insurance

BC Medical Journal vol. 62 no. 3 | April 2020 117 Classifieds

Ross: 778 688-7453 or email 604 560-8811, juan@westcoast Vacation properties storage for your active paper or medkineticmedicalsupplies@ health.ca. Website: www electronic patient records with gmail.com. .westcoasthealth.ca. PROVENCE, FRANCE—YOUR no hidden costs, including a VILLA patient mailing and doctor’s web NORTH VAN—MED OFFICE VANCOUVER (BROADWAY page. Contact Sid Soil at SPACE ACROSS FROM LIONS CORRIDOR)—OFFICE FOR SALE Les Geraniums, a luxury GATE HOSP 3-bedroom, 2½ bath villa, is your DOCUdavit Solutions today at Broadway Medical (943 W home in the heart of Provence. 1 888 781-9083, ext. 105, or Bright, south-facing, fully Broadway). Spectacular North Expansive terrace with pool and email [email protected]. finished 600 sq. ft. office space. Shore view, turnkey, 650 sq. ft. panoramic views. Walk to lovely We also provide great rates for Ideal for one or two physicians. seventh-floor office with three market town. One hour to Aix closing specialists. Underground parking available. exam rooms and one office (one and Nice, 45 minutes to Very short walk to Lions Gate exam room and office with VANCOUVER—OFFICE Mediterranean coast. Come and Hospital, Whole Foods, phar- mountain view), waiting area, EQUIPMENT FOR SALE enjoy the sun of southern macy, and diagnostic imaging. and reception area with two France! 604 522-5196. Suction pump, cautery units, Available February/March 2020. built-in desks. Lots of storage [email protected]. centrifuge, headlights, and many If interested call 604 375-0692 space. Office designed by more items including lasers and or email Lotusland855@gmail Richard Salter. Ideal for two miscellaneous operating microscopes for sale. .com. physicians: pediatrician, family Call 604 657-1599 or email physician, or specialist. Contact CANADA-WIDE—MED SALT SPRING ISLAND— [email protected] for TRANSCRIPTION EXECUTIVE HOME AND [email protected]. complete list. PROFESSIONAL OFFICE VANCOUVER—IDEAL Medical transcription specialists VANCOUVER—TAX & since 2002, Canada wide. Executive home and professional PSYCHIATRIST/ ACCOUNTING SERVICES Excellent quality and turn- office: 3190 sq. ft., four bed- PSYCHOTHERAPIST OFFICE around. All specialties, family Rod McNeil, CPA, CGA: Tax, rooms, three baths, extensive SPACE practice, and IME reports. accounting, and business gardens, separate garage/ West Point Grey office space Telephone or digital recorder. solutions for medical and health workshop, sauna, two decks, available 1 January (date flexible) Fully confidential, PIPEDA professionals (corporate and good access, off-street parking, for rent full-time or part-time. compliant. Dictation tips at personal). Specializing in health centrally located, detailed Ideal for psychiatrist/psycho- www.2ascribe.com/tips. Contact professionals for the past 11 brochure available, contact owner therapist. Bright, spacious, us at www.2ascribe.com, years, and the tax and financial at 250 931-7785, $820 000. mountain view, very reasonable [email protected], or toll free at issues facing them at various Video: https://youtu.be/ rent. Shared common waiting 1 866 503-4003. career and professional stages. S3lhpx6aSrM. room, no secretary, designated The tax area is complex, and doctor parking, easy transit FREE MEDICAL RECORD SOUTH SURREY—MED OFFICE practitioners are often not aware access. Email [email protected] STORAGE SPACE of solutions available to them .ca or [email protected] for Retiring, moving, or closing your and which avenues to take. My Flexible workspace available in a further details. family practice? RSRS is goal is to help you navigate and new clinic in South Surrey Canada’s #1 and only physician- keep more of what you earn by designed specifically for health VANCOUVER—NEW MED managed paper and EMR minimizing overall tax burdens care practitioners. West Coast OFFICE SPACE IN KITS medical records storage company. where possible, while at the same Neuro Health Clinic offers fully New medical office space Since 1997. No hidden costs. time providing you with person- furnished, IT-enabled workspace available at 2667 West Broadway Call for your free practice closure alized service. from half-day sessional rates to as of 1 May 2020. Space shared package: everything you need to Website: www.rwmcga.com, full-time long-term leases. Rates with a three-physician family plan your practice closure. email: [email protected], vary from office-only to fully practice (not walk-in) with Phone 1 866 348-8308 (ext. 2), phone: 778 552-0229. serviced, including receptionist, experienced MOA support. email [email protected], or visit cloud based EMR (Accuro), Please contact kitsfamily www.RSRS.com. scheduling appointments, [email protected] if interested. appointment reminders, refresh- PATIENT RECORD ments, and online forms for STORAGE—FREE patients prior to appointment. Retiring, moving, or closing your Free parking for staff and family or general practice, patients. For enquiries, please physician’s estate? DOCUdavit contact Juan Patuel, Medical Solutions provides free

118 BC Medical Journal vol. 62 no. 3 | April 2020 Exclusive deals from brands you trust You work hard. Your downtime is important and we want to help you make the most of it to do the things you love. Club MD provides exclusive deals from trusted brands so you can spend your time on what’s important.

CAR PURCHASE & LEASE • ENTERTAINMENT • FITNESS & WELLNESS • FOOD & BEVERAGE • HOTELS & TRAVEL

COAST HOTELS

PREFERRED RATES Exceptional value and friendly FOR DOCTORS OF BC service, there’s no place like MEMBERS Coast! Call 1 800 716 6199 or book online with company ID: doctorsofbc.ca/coast CLUBMD, Doctors of BC.

DUECK GM

VEHICLES PRICED AT Excellent selection of new and DEALER’S COST PLUS pre-owned vehicles.

3.5% Call 604 324 7222 or email [email protected] and quote promo code doctorsofbc.ca/dueck DOCTORSOFBC.

THE MORTGAGE GROUP

EXCLUSIVE RATES AND Experts at finding the right TERMS solution to fit your financial needs.

Call 604 351 1569 or email [email protected] and doctorsofbc.ca/tmg mention Club MD.

P 604 638 7921 TF 1 800 665 2262 ext 7921 E [email protected] doctorsofbc.ca/club-mdBC Medical Journal vol. 62 no. 3 | April 2020 119 Confident Parents: Thriving Kids - Anxiety Help families is a free program helping BC families overcome anxiety challenges team up in children ages 3–12. This web- and phone-based against coaching service helps parents and caregivers learn effective skills and strategies for managing anxiety. ANXIETY It’s available by referral from physicians, clinicians and pediatricians.

Download referral forms at confidentparents.ca 120 BC Medical Journal vol. 62 no. 3 | April 2020