April 2018; 60:3 Pages 137–180

Bariatric surgery A nonsurgeon’s guide to bariatric surgery Bariatric surgical options and future directions Clinical assessment to determine suitability for surgery Prevention & management of complications after surgery

Also in this issue Regional variations in access to orthopaedic care in BC www.bcmj.org 138 bc medical journal vol. 60 no. 3, april 2018 bcmj.org April 2018 Volume 60 • Number 3 Pages 137–180 contents

141 Editorials Rain-birding, David R. Richardson, MD (141) My back pages, Timothy C. Rowe, MB (142)

143 President’s Comment The art and heart of medicine Trina Larsen Soles, MD

145 BC Centre for Disease Control Cyclospora infection: A tropical disease in our midst Eleni Galanis, MD, Linda Hoang, MD

On the cover Management of obesity requires Clinical Articles lifestyle modification counseling, diagnosis and treatment of psy- chological and eating disorders, THEME ISSUE: BARIATRIC SURGER teaching of coping mechanisms, medication use, and an assess- ment for bariatric surgery. When 146 Guest editorial: A nonsurgeon’s surgery is included in this ap- proach, patients can lose more guide to bariatric surgery than 70% of their excess weight. Sharadh Sampath, MD Theme issue articles begin on page 146. 148 Bariatric surgical options and future directions Ekua Yorke, MD

151 The BCMJ is published by Clinical assessment to determine a Doctors of BC. The journal patient’s suitability for bariatric surgery provides peer-reviewed clinical Ali Zentner, MD and review articles written primarily by BC physicians, for BC physicians, along with 156 debate on medicine and medical Prevention and management of politics in editorials, letters, and complications after bariatric surgery essays; BC medical news; career Jacqueline Chang, MD, Nam Nguyen, MD, Sharadh Sampath, MD, Nooshin and CME listings; physician profiles; and regular columns. Alizadeh-Pasdar, PhD Print: The BCMJ is distributed monthly, other than in January and August. 160 Regional variations in access to Web: Each issue is available at www.bcmj.org. orthopaedic care in BC Subscribe to print: Email Kevin Wing, MD, Alastair Younger, MD [email protected]. Single issue: $8.00 Canada per year: $60.00 Foreign (surface mail): $75.00 164 WorkSafeBC Subscribe to the TOC: Managing type-III acromioclavicular joint injuries To receive the table of contents Ben Jong, MD, Danny P. Goel, MD by email, visit www.bcmj.org and click on “Free e-subscription.” Prospective authors: Consult 166 Obituaries the “Guidelines for Authors” at Michael Moscovich, MD www.bcmj.org for submission Dr Charles Rally, requirements.

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 139 contents

BC Medical Journal 167 General Practice Services Committee Vancouver, Canada 604 638-2815 A mental health resource for all communities: The Salt Spring Island [email protected] Youth Suicide Intervention Toolkit www.bcmj.org Afsaneh Moradi

168 News Editor Facility Engagement: Relationships drive change, Sam Bugis, MD (168) David R. Richardson, MD PVD: It’s not in your head (168) Editorial Board Respect in the maternity ward, J. Stewart (169) Jeevyn Chahal, MD (169) David B. Chapman, MBChB Stories for Caregivers: Finding solace in a social platform Brian Day, MB Timothy C. Rowe, MB 170 Yvonne Sin, MD Council on Health Promotion Cynthia Verchere, MD Is current medical training preparing physicians to prescribe exercise Willem R. Vroom, MD to their patients? Managing Editor Kara Solmundson, MD Jay Draper

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Postage paid at Vancouver, BC. Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. Canadian Publications Mail, Product Sales Agreement #40841036. © British Columbia Medical Journal, 2018. All rights reserved. No part of this journal may be reproduced, stored in a retrieval Return undeliverable copies to BC Medical Journal, system, or transmitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without 115–1665 West Broadway, Vancouver, BC V6J 5A4; prior permission in writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for tel: 604 638-2815; email: [email protected]. any purpose, send an email to [email protected] or call 604 638-2815. Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omissions, or from the use of information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising.

140 bc medical journal vol. 60 no. 3, april 2018 bcmj.org editorials

Rain-birding

y the time this editorial is to patients describe seasonal affec- matter the time of day or night. I re- published I will have surviv­ tive disorder, I would think to myself, turn solar satiated but filled with dis- Bed another winter. Now, don’t nope, not me. I certainly don’t remem- gust and self-loathing of my gluttony. get me wrong, I love living in British ber lying around as a teenager (well, Looking for an alternative, I attended Columbia and particularly the Lower yes, I do, but that is just a side effect a cycling camp in sunny California Mainland. I have called it home since of being a teenager) thinking about the this past February. Daily guided rides preschool, and love the people and rain and hoping it would stop. offset the evening gorging and calorie beauty of our province. I can’t imag- fest so I at least returned home weight ine residing anywhere else. I have I intend to fine tune neutral but not without a few tender taken care of numerous retirees who my winter escape plan as areas. disappear around November only to I don’t think my late onset Moving forward I intend to fine reappear in my office the next April. tune my winter escape plan as I don’t seasonal affective problem These snowbirds escape winter by think my late onset seasonal affective fleeing to warmer destinations. Ire- is likely to resolve. problem is likely to resolve. In fact, member thinking that if I were retired I anticipate some worsening as the I wouldn’t have a need to go south and So, what to do? I don’t feel my years go by. would spend my time enjoying all the symptoms merit medication, and Lastly, if you think about it, fabulous local activities. However, sitting in front of a light box would shouldn’t retirees who leave Vancou- over the years I find myself dreading detract from couch surfing and Net- ver from November to April really be the onset of another Vancouver winter. flix bingeing. Therefore, I decided called rain-birds? It’s not that I’m afraid of being wet or to build sun breaks into my winter —DRR cold (I realize we are waterproof and schedule. Thankfully, I have the fi- I can always put on more clothes) but nancial means to get on an airplane find the seemingly endless dreary, wet, and head to sunnier destinations. I am and grey days harder to tolerate with still working out the details, as all- each subsequent year. I become less inclusive vacations to places such as motivated and slightly irritable. My Mexico nurture my inner 300-pound energy plummets and I drag myself alcoholic who can’t seem to refuse around. Previously, when I listened any offered beverage or food item no

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bc medical journal vol. 60 no. 3, april 2018 bcmj.org 141 editorials

My back pages

was a heckuva year, natal mortality rates in the province by EEG findings. Thinking back to 1971 as George W. Bush and pediatric bed utilization. The only those glory days, radio-immunoassays might have said. Justin Trudeau was article in 1971 that described a study had limited availability; steroid hor- born in 1971; so too were Elon Musk, with a prospective design was one re- mone assays were performed using Amy Poehler, and Pavel Bure. So, porting the effects of different forms colorimetry in large-volume urine too, was Greenpeace. As if that wasn’t of exercise on cardiac rehabilitation collections. Antibiotics had barely enough, 1971 was the year in which I in 14 men after myocardial infarction. reached a second generation. The graduated from medical school. That The authors noted that the average at- management of cancer was aggressive was 47 years ago, and medical prac- tendance of participants for the exer- and grim. How did we manage? tice was … different. cise programs was more than 95%, in Well, medical practice relied on In 1971, the BCMJ was already 12 contrast with the dropout rate of 50% a basis of theoretical knowledge fol- years old and had become an essen- in such programs elsewhere, and pro- lowed by an accumulation of clini- tial part of provincial medical life. The grammed exercise resulted in signifi- cal experience. The older you were, pages of the BCMJ at that time includ- cant improvements in physical work the more you had seen. In 1971 there ed some clinical articles, but the ma- capacity, blood pressure, and serum were far fewer medical journals than jority of space was taken up with that cholesterol. In the context, it was a today, and those that were most read era’s pressing practice issues: a physi- brave and important study, and the re- contained many more clinical studies cian’s take-home income, difficulties lated article was starkly different from and case reports than is the case today. with peer review of practices, and (be- the others published in that year. Did it The BCMJ did provide some, but it lieve it or not) the increasing problem change things? There was no immedi- primarily provided a community for of “narcotic addicts.” The April 1971 ate related correspondence. BC physicians—a place to share ex- issue gave an overview of a proposed Many of the tools of practice that periences in a collegial way. treatment program, noting that the we now cannot do without were either As such, the BCMJ was invaluable treatment facilities at the Narcotic Ad- unavailable in 1971 or were in the ear- and, now in its 60th year, it has re- diction Foundation of BC should be liest stages of development. In medi- mained invaluable for those of us who expanded to include subclinics in the cal imaging, there was no ultrasound, live and work here in a vibrant medi- four major “problem areas” outside no CT scanning, and certainly no cal community. In another 60 years, the Greater Vancouver area: Victoria, MRI. According to the BCMJ, in 1971 though, will there be a BCMJ ? Will Prince George, Kamloops-Vernon, surgical management of intracranial advancing technology and social me- and Trail-Nelson. The July 1971 issue vascular anomalies relied entirely on dia have made everyone a physician— included the results of a survey of gen- arteriography; hemispherectomy was and thereby marginalized the need for eral practitioners’ contact with heroin performed in children with neurologi- a medical profession? Discuss. users. Other articles reported on peri- cal challenges characterized primarily —TCR

142 bc medical journal vol. 60 no. 3, april 2018 bcmj.org president’s comment

The art and heart of medicine

hen I went to university, by a machine. We deal with human would appear the first major decision I beings with physical and emotional this is what W had to make was whether complexity. The daily challenge of di- happened to choose the Faculty of Arts or the agnosis and treatment requires a solid to him as a Faculty of Science. I was drawn to background in physiology, pathology, patient. science because I wanted to be a doc- and perhaps microbiology or genet- Too often tor (and thus needed the prerequisites) ics, as well as the skills to deal with we focus on and because I saw it as more intellec- humans. The ability to really look, treatment op- tually challenging. But my university listen, and empathize, and to deter- tions for a offered something unique: the option mine when the presenting complaint disease with- of a Bachelor of Arts degree with a is merely a clue to an underlying emo- out taking time to inquire about our science major. The philosophy was tional trauma. This is one part of the patient’s wants or goals. With some that the broader-based education of my cancer patients it is particularly would ensure both a depth of knowl- challenging to discuss the fact that edge in your major and a breadth of Quality, safety, evidence, palliative chemotherapy does not of- knowledge across disciplines, and it and standards are fer a cure for their disease. One must explains why I have a BA in zoology. important, but they are weigh the potential increase in quan- I think this broad-based philoso- meaningless without tity of life against the quality, and if phy is integral to the study of medi- compassion, caring, and we make the patient sicker than the cine and is too often buried in the disease has already done, then we communication. quest to only study and eventually have done them no favors. One of practise in a concrete, evidence-based my patients had a very specific goal: world. This attitude fuels the trend to- art that is medicine. Sir William Osler to experience another enjoyable ski ward more and more specialization described medicine as “an art, based season. The medical team was able to and subspecialization, where it is pos- on science” and stated, “The art of the tailor the treatment to make this pos- sible to tackle the immense amount of practice of medicine is to be learned sible—by focusing on how the pa­tient scientific knowledge available. This only by experience; ’tis not an inheri- wanted to live the remainder of their in turn fuels the development of silos tance; it cannot be revealed. Learn to life. of care, and the disrespect often ex- see, learn to hear, learn to feel, learn I believe the art of medicine is hibited to more broadly based gener- to smell, and know that by practice equally as important as the science of alist disciplines. alone can you become expert.” medicine. To focus medicine exclu- I recently attended a meeting Recently there was a discussion on sively on the pursuit of scientific ac- where physicians expressed some social media about the experience of curacy and achievement is doomed to burning issues and concerns. One that Dr Bernard Lown, a retired Harvard failure, given our constantly evolving interested me in particular was a fear cardiologist, who authored The Lost landscape. Many of yesterday’s stan- of the impact of artificial intelligence Art of Healing. Dr Lown was recently dards of care and guidelines are obso- on certain areas of practice. If com- hospitalized with pneumonia at the lete today. Quality, safety, evidence, puters can do a better job of inter- age of 96, and he described his experi- and standards are important, but they preting diagnostic tests, what are the ence of being the last one to know any- are meaningless without compassion, implications for physicians? If certain thing about his treatment plan, finding caring, and communication. Science procedures can be performed by ro- that his opinion hardly mattered to his is essential, but the art lies in how we bots, what does this imply for the doc- medical team. In his book he warned use it in the practice of medicine. Our tors performing the same procedures? that when one only considers the profession needs balance in all things, This made me consider my job in biomedical sciences, then “healing and we must restore a healthy medical general practice, where the undiffer- is replaced with treating, caring is culture that supports us all to be heal- entiated patient with a list of 10 com- supplanted by managing, and the art ers in the truest sense of the word. plaints presents to my office. I don’t of listening is taken over by techno- —Trina Larsen Soles, MD have much fear that I’ll be replaced logical procedures.” Unfortunately, it Doctors of BC President

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 143 KEY CONTACTS: Directory of senior staff

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144 bc medical journal vol. 60 no. 3, april 2018 bcmj.org bc centre for disease control

Cyclospora infection: A tropical disease in our midst

45-year-old healthy female following infection. Symptoms may try and leads to an outbreak investiga- presents to you with a 3-week resolve spontaneously, but patients tion ( Table ). A history of nonbloody diar- with a severe or prolonged course and Physicians play an important role rhea. Initially she experienced 5 to 10 those who are immunocompromised in identifying outbreaks in the com- watery bowel movements per day should be treated with TMP/SMX or munity. If patients present with acute with abdominal pain, low-grade fe- ciprofloxacin.2 but prolonged relapsing diarrhea, con- ver, fatigue, and nausea. Although Cyclospora infection is diagnosed sider stool O&P testing even when no she has improved, she continues to by stool ova and parasite (O&P) by travel is reported. Cyclospora infec- have relapsing semiliquid stools ev- microscopic examination. All BC lab- tion is reportable to public health. If a ery 2 days with abdominal pain and oratories use acid-fast staining to de- patient may be part of an outbreak or bloating. She is otherwise well and on tect Cyclospora on all O&P samples. there is more than the usual number no medications. She has not traveled The Infectious Diarrhea – Guideline of patients with similar symptoms in recently, nor has she had contact with for Ordering Stool Specimens3 rec- a short period, report this to your local other symptomatic people. A stool ommends O&P testing for patients health unit or medical health officer C&S performed at a walk-in clinic with mild to moderate diarrhea with for public health investigation. was negative. You order a stool O&P. a likely infectious cause lasting more —Eleni Galanis MD, MPH, The laboratory reports the presence than 2 weeks. If initial results are neg- FRCPC of Cyclospora cayetanensis oocysts. ative and symptoms persist, a second —Linda Hoang, MD, MHSc, You decide not to treat but to see her O&P may be necessary. FRCPC again in a week, at which point her People are infected by ingesting symptoms have improved consider- contaminated food or water. The in- References ably. A few weeks later, the media fection is not spread from person to 1. Ortega YR, Sanchez R. Update on Cy- reports that BC is affected by a Cy- person. Infected individuals excrete clospora cayetanensis, a food-borne and clospora outbreak associated with oocysts in their feces. Oocysts require waterborne parasite. Clin Microbio Rev imported fresh herbs. 7 to 15 days to sporulate in the envi- 2010;23:218-234. Spring marks the start of the ronment before becoming infectious 2. Bugs & Drugs. Accessed 9 February Cyclospora risk period in Canada and may contaminate food where it is 2018. www.bugsanddrugs.org/Home/ (www.bccdc.ca/health-info/diseas grown. Index/bdpage62B55D83D9294CF6AA es-conditions/cyclospora-infection). Cyclospora is not endemic in BC 576C8B045C139F. Nearly every year for the last decade, or Canada. Most infections are ac- 3. BC Guidelines. Infectious diarrhea–guide- BC has been affected by outbreaks of quired from consuming contaminated line for ordering stool specimens. Ac- locally acquired Cyclospora infection food or water during travel to Cen- cessed 26 February 2018. www2.gov ( Table ). tral and South America or Asia in the .bc.ca/gov/content/health/practitioner Cyclospora cayetanensis is a pro- spring and early summer. When infec- -professional-resources/bc-guidelines/ tozoan parasite that causes a protract- tion occurs in a BC resident who did infectious-diarrhea?keyword=infectious ed, relapsing gastrointestinal illness. not travel, it is likely associated with &keyword=diarrhea&keyword=guidelines. Symptoms include frequent watery imported food from an endemic coun- diarrhea, anorexia, abdominal cramps and bloating, nausea, flatulence, fever, Table. Cyclospora outbreaks affecting BC residents, 2013–2017. and weight loss.1 Symptoms typically last 2 weeks to 2 months, and often Year Duration of outbreak Number infected Suspected imported food sources wax and wane in intensity. Biliary dis- 2013 June–September 25 Blackberries, raspberries, lettuce ease, Guillain-Barré syndrome, and 2014 April–August 85 Blackberries, cilantro reactive arthritis have been reported 2015 May–August 97 Blackberries, lettuce, basil 2016 May–August 87 Blackberries, lettuce This article is the opinion of the BC Centre for Disease Control and has not been peer 2017 May–August 158 Blackberries, cilantro reviewed by the BCMJ Editorial Board. Source: PHAC 2018 Table.

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 145 Guest editorial

A nonsurgeon’s guide to bariatric surgery

Dr Sharadh Sampath

he subject of bariatric surgery struggle to discuss it with patients. make no mistake, this is a disease often receives very little at- Obesity is a complex disease and was and a very complex one. Telling pa- T tention despite the profound only officially recognized as such by tients to “eat less and exercise more” impact it can have on the care of pa- the Canadian Medical Association in is often futile and unsustainable. Re- tients suffering from the disease of 2015. It is ubiquitous and epidemic strictive diets and exercise typically obesity and its related comorbidities. and, in my opinion, the mother of produce limited results in the long Some of the myths about bariatric sur- many other diseases. term.4 Telling patients that this dis- gery need to be countered with the re- ease is “their fault” can only harm our alities, and the surgical outcomes and What is bariatric surgery? relationships with them. current treatment options available It is important to start by stating what Management of this disease re- in British Columbia need to be better bariatric surgery is not: it is not a cos- quires a multimodal approach: understood. metic procedure, nor is it a quick fix lifestyle modification counseling, di- When I was a medical student, the or an easy way out. Bariatric surgery agnosis and treatment of psychologi- subject of bariatric surgery was not is a treatment for obesity and obesity- cal and eating disorders, teaching of covered, nor was the larger subject related diseases. It is safe and excep- coping mechanisms, medication use, of obesity management. I received a tionally effective when done for the and assessment for bariatric surgery. single 30-minute lecture on the sub- right patient using a multidisciplinary When surgery is included in a ject during my entire 6-year general approach. The two gold standard pro- multimodal approach, patients can surgery residency. During residency, cedures, the proximal gastric bypass lose more than 70% of their excess when we encountered bariatric sur- and the sleeve gastrectomy, are both weight.5,6 Without surgery, treatment gery patients in the ER, they were performed laparoscopically and are for obesity is often far less effective.7,8 often suffering from dreadful compli- fully covered by MSP in British Col- More importantly, surgery combined cations after aggressive open proce- umbia. When the surgery is done in a with multimodal therapy can have dures. The sordid history of bariatric high-volume centre with today’s sur- an almost unbelievable impact on surgery from the 1970s to the 1990s gical techniques, patients rarely suffer obesity-related comorbidities such as was one of high complication rates from chronic diarrhea, malabsorption, diabetes. After bariatric surgery, more and poor outcomes that left the subject or other surgical complications.1-3 than 70% of diabetic patients can shrouded in mystery and controversy. cease taking medications for diabe- It is no wonder that so few medi- Why should you care? tes.6,9 Mortality rates are dramatically cal professionals are familiar with Whether you practise in primary or improved10-11 and health care costs are bariatric surgery for obesity and subspecialty medicine, you almost reduced.12-14 definitely care for patients who suf- This article has been peer reviewed. fer from the disease of obesity. And

146 bc medical journal vol. 60 no. 3, april 2018 bcmj.org Guest editorial

What is metabolic surgery? agement of surgical complications. I therapy for diabetes — 5-year outcomes. The dramatic impact of weight-loss hope you enjoy these articles and find N Engl J Med 2017;376:641-651. surgery on a whole spectrum of obes- them useful in future discussions with 8. Sjöström L. Review of the key results ity-related diseases has become in- your patients. from the Swedish Obese Subjects (SOS) creasingly apparent. Conditions such —Sharadh Sampath, MD, FRCSC trial – a prospective controlled intervention as gastroesophageal reflux disease, Head, Division of General Surgery, study of bariatric surgery. J Intern Med polycystic ovary syndrome, dyslipi- Richmond Hospital 2013;273:219-234. demia, degenerative joint disease, Director, Richmond Metabolic and 9. Buchwald H, Estok R, Fahrbach K, et al. and obstructive sleep apnea have been Bariatric Surgery Program Weight and type 2 diabetes after bariatric found to improve within days and Clinical Assistant Professor, surgery: Systematic review and meta- months of surgery. In the case of type Department of Surgery, University analysis. Am J Med 2009;122:248-256. 2 diabetes, high rates of complete re- of British Columbia 10. Christou NV, Sampalis JS, Liberman M, et mission have been seen7,15,16 and this President, BC Obesity Society al. Surgery decreases long-term mortality, has led to use of the term “metabolic morbidity, and health care use in morbidly surgery,” which more appropriately References obese patients. Ann Surg 2004;240: encompasses the far-reaching impact 1. Nguyen NT, Paya M, Stevens CM, et al. 416-424. that bariatric surgery can have and The relationship between hospital volume 11. Sjöström L, Narbro K, Sjöström CD, et al. helps us better understand the com- and outcome in bariatric surgery at aca- Effects of bariatric surgery on mortality in plex relationships between obesity demic medical centers. Ann Surg 2004; Swedish obese subjects. N Engl J Med and its comorbidities. 240:586-594. 2007;357:741-752. In 2016, global guidelines were 2. Azagury D, Morton, JM. Bariatric surgery 12. Borisenko O, Adam D, Funch-Jensen P, et developed at the 2nd Diabetes Sur- outcomes in US accredited vs non- al. Bariatric surgery can lead to net cost gery Summit (DSS-II).17 Metabolic accredited centers: A systematic review. savings to health care systems: Results surgery should be considered for pa- J Am Coll Surg 2016;223:469-477. from a comprehensive European decision tients with type 2 diabetes and BMI 3. Courcoulas A, Schuchert M, Gatti G, analytic model. Obes Surg 2015;25:1559- of 30.0 to 34.9 kg/m2 if hyperglyce- Luketich J. The relationship of surgeon 1568. mia is inadequately controlled despite and hospital volume to outcome after 13. Horerger TJ, Zhang P, Segel JE, et al. Cost- optimal treatment with either oral or gastric bypass surgery in Pennsylvania: effectiveness of bariatric surgery for se- injectable medications. These BMI A 3-year summary. Surgery 2003;134: verely obese adults with diabetes. Diabe- thresholds should be reduced by 2.5 613-621. tes Care 2010;33:1933-1939. kg/m2 for Asian patients as this pop- 4. Sacks FM, Bray GA, Carey VJ, et al. Com- 14. Sampalis JS, Liberman M, Christou NV. ulation is prone to complications of parison of weight-loss diets with different The impact of weight reduction surgery obesity at a lower BMI. compositions of fat, protein, and carbohy- on health-care costs in morbidly obese The DSS-II guidelines are sup- drates. N Engl J Med 2009;360:859-873. patients. Obes Surg 2004;14:939-947. ported by multiple RCTs looking at 5. Perrone F, Bianciardi E, Ippoliti S, et al. 15. Schauer PR, Bhatt DL, Kirwan JP, et al. bariatric surgery to treat diabetes in Long-term effects of laparoscopic sleeve Bariatric surgery versus intensive medical patients with a BMI greater than 35.0 gastrectomy versus Roux-en-Y gastric by- therapy for diabetes—3-year outcomes. kg/m2.16 I believe that “metabolic” pass for the treatment of morbid obesity: N Engl J Med 2014;370:2002-2013. will eventually replace “bariatric” A monocentric prospective study with 16. Cummings DE, Cohen RV. Bariatric/meta- when we describe weight-loss sur- minimum follow-up of 5 years. Updates bolic surgery to treat type 2 diabetes in gery and this will make it easier for Surg 2017;69:101-107. patients with a BMI < 35 kg/m2. Diabetes patients to access surgical resources 6. Matthew B, Flesher M, Sampath S, et al. Care 2016;39:924-933. appropriately. The effect of intensive preconditioning 17. Rubino F, Nathan DM, Eckel RH, et al. This theme issue tackles some of and close follow-up on bariatric surgery Metabolic surgery in the treatment algo- the major considerations for weight- outcomes: Does multidisciplinary care rithm for type 2 diabetes: A joint statement loss surgery, whether the term “bar- contribute to positive results whether a by international diabetes organizations. iatric” or “metabolic” is used. These gastric bypass or sleeve gastrectomy is Diabetes Care 2016;39:861-887. considerations include the surgical performed? BCMJ 2015;57:238-243. options, the clinical assessment pro- 7. Schauer PR, Bhatt DL, Kirwan JP, et al. cess, and the prevention and man- Bariatric surgery versus intensive medical

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 147 Ekua Yorke, MD, FRCSC

Bariatric surgical options and future directions

Many patients with obesity-related comorbidities meet the criteria for bariatric surgery but do not pursue treatment, even though excellent outcomes are possible with procedures such as the laparoscopic vertical sleeve gastrectomy and Roux-en-Y gastric bypass.

ABSTRACT: Bariatric surgery is he adverse effects of obesity malabsorptive, or a combination of now accepted as a safe and effec- impact every aspect of the both. Restrictive procedures reduce tive procedure for severe obesity. T health care system. Studies the storage capacity of the stomach Despite excellent outcomes with have demonstrated that diet, lifestyle and lead to decreased caloric intake. current procedures, most patients modifications, and currently available Malabsorptive procedures reduce the with obesity-related comorbidities pharmaceutical agents are relatively functional length of the small intes- who meet the criteria for surgery ineffective in treating severe obesity tine and lead to decreased absorption do not pursue treatment. Common in the long term.1 Bariatric surgery is of nutrients. Evidence is emerging bariatric procedures performed in the only evidence-based approach for that another mechanism involving Canada are vertical sleeve gastrec- sustainable weight loss in patients with gut hormones plays a significant role, tomy and Roux-en-Y gastric bypass. severe obesity. It is proven to be safe an understanding that is reducing the A less common procedure is bilio- and effective for comorbid disease utility of the traditional classification pancreatic diversion with a duode- resolution and to reduce health care system. nal switch. All of these procedures costs.2 A consensus statement updating Regardless of which surgical op- are performed laparoscopically and an earlier statement from the National tion is chosen, success requires diet­ require dietary and behavior modifi- Institutes of Health supports bariatric ary and behavior modification as cation along with education and sup- surgery for those who strongly desire well as education and support from port from a multidisciplinary team substantial weight loss and have obe- a multidisciplinary team of experts. of experts. Patients face some chal- sity-related comorbidities.3 The 2nd The two most common bariatric pro- lenges in accessing bariatric surgery Diabetes Surgery Summit (DSS-II) cedures in Canada are vertical sleeve that could be addressed by increas- guidelines state that bariatric surgery gastrectomy (VSG) and Roux-en-Y ing awareness of surgical options. should be considered for patients with gastric bypass (RYGB), all of which Efforts should be made in BC to type 2 diabetes and a BMI of 30.0 kg/ are performed laparoscopically support bariatric surgery programs m2 to 34.9 kg/m2 if hyperlycemia is ( Figure ). Laparoscopic adjustable that are accessible to both referring inadequately controlled despite opti- gastric band (AGB) is still offered, physicians and patients. mal treatment with either oral or in- but is no longer being performed as jectable medications.4 Despite such frequently as it once was due to poor recommendations and the excellent outcomes with current procedures, Dr Yorke is a general and laparoscopic sur- most obese patients with obesity-relat- geon practising at Richmond Hospital and ed comorbidities who meet the criteria in the Richmond Metabolic and Bariatric for surgery do not pursue treatment. Surgery program. She is also a clinical in- Bariatric procedures have tradi- structor in the Deparment of Surgery at the This article has been peer reviewed. tionally been classified as restrictive, University of British Columbia.

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long-term success rates. In British to removal of the band. The removal Roux-en-Y gastric bypass Columbia, RYGB and VSG are cov- rate can be up to 4% per year, and at 15 Roux-en-Y gastric bypass is the most ered by MSP, while AGB is not. An- years almost half of all gastric bands studied of all the bariatric surgeries. A other procedure also available, but have been removed.8 AGB is the least gastric pouch is created and separated used less commonly and not yet be- common of the procedures currently from the remainder of the stomach. ing done in British Columbia’s is the performed in Canada. A gastrojejunostomy is performed to biliopancreatic diversion with a duo- connect the gastric pouch with the ali- denal switch (BPD-DS). Vertical sleeve mentary (Roux) limb. This alimentary gastrectomy limb is then anastomosed to the bilio- Adjustable gastric banding The vertical sleeve gastrectomy was pancreatic limb at a distance ranging Adjustable gastric banding is not cov- initially introduced as the first stage from 100 to 150 cm of the gastroje- ered by MSP and has largely been in the two-stage process for bilio- junal anastomosis to form a common abandoned by bariatric surgeons in pancreatic diversion with duodenal limb. RYGB can achieve an average Canada. We include it primarily be- switch. The VSG is now an important EWL of between 60% and 70% and cause many medical tourism patients stand-alone procedure that involves have an impact on diabetes, hyperten- have this procedure done abroad. removing a portion of the stomach to sion, dyslipidemia, and obstructive AGB is a restrictive procedure that leave behind a banana-shaped gastic sleep apnea. In one meta-analysis, partitions the stomach to create a small pouch with a capacity of between 60 diabetes was resolved or improved gastric pouch that empties slowly to and 100 mL. While VSG is primar- in 86% of patients.2 Although RYGB prolong satiety. An inflatable silicon ily a restrictive procedure, there is is a restrictive procedure, alterations gastric band is placed around the prox- evidence that it leads to a decrease in are also seen in gut hormones such imal part of the stomach and adjusted levels of ghrelin—a peptide hormone as ghrelin, incretins, and peptide YY. gradually by accessing a subcuta- produced in the fundus of the stom- These key contributors to clinical effi- neous port. AGB-induced weight loss ach that has been linked with hunger cacy are not fully understood. RYGB is slow and steady over 1 to 2 years, control.9 A reduction in hunger thus is currently the most common bariat- and typically averages between 22 and augments the restrictive effect of ric surgery performed in Canada. 27 kg. At the ideal restriction, the pa- VSG, which can achieve an average tient should lose between 0.5 and 1.0 excess weight loss (EWL) of between Biliopancreatic diversion kg per week without any vomiting.5-7 56.3% and 62.3% at 5 years pos- with a duodenal switch Some patients cannot tolerate the opti- toperatively.10 Although further stud- Biliopancreatic diversion with a mal restriction without nausea and ies are needed, current reports note duo­denal switch is a more complex, vomiting, which can also be an indica- a 66.2% remission rate for diabetes11 higher-risk surgery that combines tion of complications or lifestyle/nu- and a hypertension resolution rate both restrictive and malabsorptive tritional struggles. Complications and that ranges from 42.0% to 88.8%.12-15 components. The malabsorptive com­ failure to sustain weight loss may lead VSG is becoming increasingly popular. ponent is achieved by construct­ing

Adjustable gastric banding Roux-en-Y gastric bypass Vertical sleeve gastrectomy Biliopancreatic diversion with (AGB) (RYGB) (VSG) a duodenal switch (BPD-DS)

Figure. Bariatric surgical options.

Image courtesy of Walter Pories, MD (East Carolina University, Greenville, NC).

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a long-limb Roux-en-Y anastomosis the general public about the health 5. Steffen R. The history and role of gastric with a short common channel of ap- impact of obesity and the need for banding. Surg Obes Relat Dis 2008;4:S7-13. proximately 50 cm. BPD-DS tends to medical management. 6. Chapman AE, Kiroff G, Game P, et al. Lap- be reserved for patients with “super aroscopic adjustable gastric banding in the obesity” (usually meaning a BMI Summary treatment of obesity: A systematic litera- greater than 50.0 kg/m2). Although Surgery has consistently proven to be ture review. Surgery 2004;135:326-351. BPD-DS may be superior to RYGB the most effective long-term therapy 7. Kuzmak LI. A review of seven years’ ex- in long-term weight loss, direct com- for treating obesity. Despite excellent perience with silicone gastric banding. parative studies have been difficult to outcomes with current procedures, Obes Surg 1991;1:403-408. perform.16 Associated complications including biliopancreatic diversion 8. Carandina S, Tabbara M, Galiay L, et al. such as intestinal obstruction, nutri- with duodenal switch, vertical sleeve Long-term outcomes of the laparoscopic tional deficiencies, and foul smelling gastrectomy, and Roux-en-Y gastric adjustable gastric banding: Weight loss stools have limited the use of BPD- bypass, most obese patients with obes- and removal rate. A single center experi- DS in clinical practice and extensive ity-related comorbidities who meet ence on 301 patients with a minimum long-term follow-up is needed. BPD- criteria for surgery do not pursue treat- follow-up of 10 years. Obes Surg 2016; DS is performed at only a few centres ment. This is likely due to a combina- 9. Langer FB, Reza Hoda MA, Bohdjalian A, in Canada. tion of poor access to bariatric surgery et al. Sleeve gastrectomy and gastric programs and a lack of patient aware- banding: Effects on plasma ghrelin levels. Future directions ness of surgical options. A bariatric Obes Surg 2005;15:1024-1029. There is an urgent need to address surgery program that employs a multi- 10. Diamantis T, Apostolou KG, Alexandrou A, the obesity epidemic given the sig- disciplinary approach will promote et al. Review of long-term weight loss re- nificant individual and societal costs. better outcomes and quality of life for sults after laparoscopic sleeve gastrecto- Preventing and managing obes- patients. Efforts should be made in BC my. Surg Obes Relat Dis 2014;10:177- ity requires acknowledging that it is to support bariatric surgery programs 183. a disease and improving access to that are accessible to both referring 11. Gill RS, Birch DW, Shi X, et al. Sleeve gas- treatment. physicians and patients. trectomy and type 2 diabetes mellitus: A Therapies and initiatives for pre- systematic review. Surg Obes Relat Dis venting obesity should be differenti- Competing interests 2010;6:707-713. ated from those for managing obesity None declared. 12. Prasad P, Tantia O, Patle N, et al. An analy- through weight loss and weight-loss sis of 1-3-year follow-up results of laparo- maintenance because the physiol- References scopic sleeve gastrectomy: An Indian per- ogy, behavioral issues, and treatment 1. Douketis JD, Feightner JW, Attia J, Feld- spective. Obes Surg 2012;22:507-514. goals of each are distinct. Also, be- man WF. Periodic health examination, 13. Sammour T, Hill AG, Singh P, et al. Lapa- cause severe obesity can begin early, 1999 update: Detection, prevention and roscopic sleeve gastrectomy as a single- prevention should focus on promot- treatment of obesity. Canadian Task Force stage bariatric procedure. Obes Surg ing a healthy lifestyle in the prenatal, on Preventive Health Care. CMAJ 1999; 2010;20:271-275. neonatal, and early childhood years 160:513-525. 14. Menenakos E, Stamou KM, Albanopou- when nutritional choices can affect 2. Buchwald H, Avidor Y, Braunwald E, et al. los K, et al. Laparoscopic sleeve gastrec- long-term chronic disease risk. Sur- Bariatric surgery: A systematic review and tomy performed with intent to treat mor- gical options should be reserved for meta-analysis. JAMA 2004;292:1724-1737. bid obesity: A prospective single-center weight loss and weight-loss mainte- 3. Buchwald H. Consensus conference study of 261 patients with a median nance, and further research into the statement: Bariatric surgery for morbid follow-up of 1 year. Obes Surg 2010; biology and psychology of weight- obesity: Health implications for patients, 20:276-282. loss maintenance should be under- health professionals, and third-party pay- 15. Weiner RA, Weiner S, Pomhoff I, et al. taken to develop more effective ers. Surg Obes Relat Dis 2005;1:371-381. Laparoscopic sleeve gastrectomy--influ- approaches. Finally, more intensive 4. Rubino F, Nathan DM, Eckel RH, et al. ence of sleeve size and resected gastric public health campaigns and train- Metabolic surgery in the treatment algo- volume. Obes Surg 2007;17:1297-1305. ing opportunities are needed to better rithm for type 2 diabetes: A joint statement 16. Hess DS, Hess DW. Biliopancreatic diver- inform providers, industry represen- by international diabetes organizations. sion with a duodenal switch. Obes Surg tatives, insurers, policymakers, and Diabetes Care 2016;39:861-887. 1998;8:267-282.

150 bc medical journal vol. 60 no. 3, april 2018 bcmj.org Ali Zentner, MD, FRCPC, Diplomate of the American Board of Obesity Medicine

Clinical assessment to determine a patient’s suitability for bariatric surgery

Screening for surgical safety, history taking, physical examination, laboratory investigations, and clinical interviews are all needed to establish whether a patient with obesity can benefit from a bariatric procedure.

ABSTRACT: Bariatric surgery is a Criteria for bariatric surgery By using a simple equation we safe and effective treatment for obe- Great strides have been made in the limit the overall understanding of obe- sity and its comorbidities. In order to field of bariatric surgery, with pro- sity-related risks in a patient. Women, qualify for bariatric surgery, a patient cedures that are relatively free of for example, tend to have more fat must have a BMI greater than 40.0 complications and provide effect- than men.9 As well, age plays a role kg/m2 or a BMI greater than 35.0 kg/ ive treatment for obesity and its in fat distribution, and BMI in isola- m2 with one or more obesity-related comorbidities.1-6 tion does not point to the location of comorbidities such as depression, The Canadian criteria for select- body fat. Intra-abdominal fat has been hypertension, or type 2 diabetes. ing patients to undergo either sleeve shown to be far more toxic metaboli- Clinical assessment should be done gastrectomy or gastric bypass are cally than subcutaneous fat.10 over a period of time by a multidis- not without limitations. In order to BMI is a simple and convenient ciplinary team and include screen- qualify for bariatric surgery, a patient tool that has its merits, but it should ing for surgical safety in accordance must have a BMI greater than 40.0 kg/ not be used in isolation when manag- with the literature as well as history m2 or a BMI greater than 35.0 kg/m2 ing patients with the disease of obe- taking, physical examination, and with one or more obesity-related co- sity. While BMI remains central to laboratory investigations. Interviews morbidities (e.g., depression, hyper- establishing eligibility for bariatric are needed to determine if the pa- tension, type 2 diabetes, obstructive surgery, clinicians can and should tient understands the procedure and sleep apnea, hyperlipidemia, coro- take obesity assessment beyond BMI postoperative demands involved and nary artery disease, arthritis, fatty in all clinical settings. to establish whether the necessary liver). social supports required by bariatric The limitations of these criteria Comorbidities procedures are in place or whether stem from the use of body mass in- Patients should be assessed for obesity- any psychiatric conditions exist that dex, a simple measurement of weight related comorbidities whether they are might impair the patient’s ability to against height.7 BMI is only a surro- pursuing bariatric surgery or not. The handle the surgery. Although 1 mil- gate measure of body fatness because Edmonton Obesity Staging System lion Canadians satisfy the criteria for it describes excess weight rather than bariatric surgery, only 6500 undergo excess body fat and does not take into Dr Zentner is the medical director of Live this treatment each year, suggesting account factors such as age, sex, eth- Well, a multidisciplinary medical fitness this surgery is far too limited in its nicity, and muscle mass or the patho- clinic with numerous sites in the BC Lower use. physiological effects that certain Mainland and elsewhere. She is also the fat tissue has in the development of medical director of the Island Health bar- This article has been peer reviewed. obesity-related comorbidities.8 iatric program.

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(EOSS)11 takes into account the sever- would make adherence to dietary or comorbidities preoperatively.13 ity of obesity-related comorbidities as lifestyle modifications a challenge. All patients should have a baseline well as the patient’s metabolic, func- • Inability to care for self. fasting glucose test, an HbA1c test, a tional, and psychological state: • Serious chronic disease where sur- full cholesterol panel, and testing for · Stage 0. No obesity-related comor- gery itself would be contraindicated. liver function, renal function, and thy- bidities. No effects on a patient’s • Active bulimia nervosa. roid function. Patients being consid- metabolic, functional, or psycho- ered for a gastric bypass should also logical state. Clinical assessment have vitamin B12, vitamin D, and • Stage 1. No obesity-related comor- The cornerstone of a bariatric sur- multivitamin baseline assessment. All bidities. Mild effects on a patient’s gery program is clinical assessment patients should have an electrocardio- metabolic, functional, or psycho- to determine if surgery is safe and ap- gram to screen for arrhythmias and logical state. For example, the pa- propriate for a particular patient with silent ischemia. Further cardiac and tient has metabolic syndrome and/ obesity. Clinical assessment should be pulmonary testing should be based on or mild anhedonia associated with done over a period of time and by a the patient’s specific clinical state and obesity. multidisciplinary team that includes a comorbidities. • Stage 2. Patient has an obesity- dietitian, a physician, a surgeon, and, related comorbidity such as diabe- when necessary, a psychologist or Obstructive sleep apnea tes, arthritis, or depression. psychiatrist. Ideally, some clinical as- All patients undergoing bariatric sur- • Stage 3. Patient has an obesity- sessment will have been done by a pri- gery should be screened for obstruct- related comorbidity with organ dys- mary care provider before the patient ive sleep apnea (OSA). This is done function such as type 2 diabetes with is referred to a bariatric program for by a polysomnography test. Untreat- renal dysfunction or obstructive surgery. A more in-depth assessment ed OSA remains one of the key con- sleep apnea with right heart failure. is then done by the bariatric team. tributors to perioperative mortality • Stage 4. Patient has end-stage co- Clinical assessment includes after bariatric surgery.14 In a pivotal morbidities associated with obesity. screening for surgical safety in accor- study of 359 bariatric patients evalu- Although the EOSS is not the dance with the literature, and involves ated for OSA preoperatively, 309 clinical standard for establishing a pa- history taking, physical examination, (86%) had positive test results. On the tient’s eligibility for bariatric surgery, laboratory investigations, and inter- basis of apnea-hypopnea index (AHI) it can be a useful clinical tool for de- views to determine a patient’s mo- scores, 18% of the 359 patients had termining the potential risk of obesity tivation for undergoing surgery and mild OSA, 17% had moderate OSA, and the potential benefit of bariatric how much the patient understands and 51% had severe apnea.15 An an- surgery. about the procedure and postopera- alysis of patients by preoperative tive demands. Clinical interviews BMI showed that the following tested Contraindications for bariatric also provide information about the positive for OSA: surgery patient’s weight-loss and weight-gain • 34 of 37 patients with BMI values Bariatric surgery is contraindicated12 history and current eating behaviors, of 35.0 to 39.9 kg/m2 (92%). if the patient presents with any of the and establish whether the patient has • 178 of 218 patients with BMI val- following: the necessary social supports bariatric ues of 40.0 to 49.9 kg/m2 (82%). • Cirrhosis. procedures require or any psychiatric • 78 of 85 patients with BMI values • Portal hypertension. conditions that might impair the pa- of 50.0 to 59.9 kg/m2 (92%). • Uncontrolled psychiatric disorder. tient’s ability to handle the surgery. • 19 of 19 patients with BMI values • Suicide attempt within the last 18 of 60.0 kg/m2 or greater (100%). months. Metabolic and other disorders It is because of studies like this that • Uncontrolled inflammatory bowel All patients preparing for bariat- the American Society of Metabolic disease. ric surgery should undergo general and Bariatric Medicine recommends • Active substance abuse. metabolic screening. Many patients polysomnography for all patients un- • Active smoking (patients must be will have disorders such as diabetes, dergoing bariatric surgery.16 smoke-free for at least 6 months). hypertension, and dyslipidemia. • Chronic long-term steroid use. Screening for these allows the bariat- Psychological fitness for surgery • Mental or intellectual limitations that ric team to better manage a patient’s Best practice guidelines for assessing

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a patient’s psychological fitness for contraindication for surgery while concerned with being able to control surgery do not yet exist, although we binge-eating disorder is not.19 Un- the binges after surgery. do know that such an assessment can like bulimia nervosa, binge-eating rarely be done in a single visit. Not disorder does not involve purging af- Motivation for surgery all patients preparing for bariatric sur- ter eating. It is estimated that 10% to Patients should be asked the simple gery need to be evaluated by a psych- 25% of bariatric patients meet crite- question “Why have surgery?” to ologist or psychiatrist. However, the ria for BED, which involves the con- assess their readiness and suitabil- effect of certain critical psychosocial sumption of a large quantity of food ity for bariatric surgery. This allows changes resulting from weight loss in less than 2 hours, during which the clinician to determine patient ex- should be considered before surgery.17 the person feels a subjective loss of pectations of the procedure itself and

Weight-loss and weight-gain history A weight-loss and weight-gain his- It is imperative that clinicians gain a sense tory (weight cycling) should be ob- tained. This allows the clinician to of the patient’s social supports and find out screen for secondary causes of obes- whether the patient is aware of the potential ity and eating disorders. It can also help delineate physiological triggers social consequences of having the surgery. of weight gain such as medications and endocrinopathies. Not all patients need a complete hormonal workup for obesity.16 Baseline thyroid func- control.19Additionally, some patients overall motivation for having the sur- tion and screening for diabetes and report night eating syndrome, which gery. It is crucial to prevent patients dyslipidemia should be done in all is defined as the consumption of more from entering into the surgical pro- patients but not everyone pursuing than 35% of daily calories after din- cess lightly and without a good sense bariatric surgery needs to be screened ner, and disruption of sleep by epi- of the implications. No one can under- for Cushing syndrome or polycystic sodes of nocturnal eating. stand all the implications of a decision ovarian syndrome. This is where clin- Estimates of bariatric surgery in advance, but suitable patients will ical judgment is paramount. Focusing candidates with BED range from 5% understand the demands involved. on weight-loss and weight-gain his- to 50%, likely a gross overestimate. tory also allows a clinician to gauge a When patients are assessed using a Understanding the procedure patient’s readiness for surgery. structured clinical interview and strict and postoperative demands criteria, the prevalence rate ranges Patients should be asked to describe Current eating behaviors from 5% to 25%. the procedure, its risks and benefits, Patients should be questioned about Study results are mixed regard- and the preoperative and postopera- past and present patterns of eating, ing the effects of binge eating on a tive diet. Bariatric patients need to be timing of meals, and the presence of patient’s postoperative success. Some prepared for their “new normal.” They emotional triggers for eating. They studies find preoperative binge-eating must appreciate that they are essen- should be asked to keep a food diary disorder has no negative effects on tially trading one disease for another. and to record their eating patterns pre- outcomes after bariatric surgery, and A relatively healthy gut is being altered operatively. Patients should also be indicate that bingeing resolves post- anatomically to gain a therapeutic ad- screened for eating disorders. operatively as the neurohormonal me- vantage: a more favorable disease state Eating disorders are not uncom- diators of bingeing are corrected by that will require lifestyle changes. mon in bariatric surgery patients. Bu- the surgery itself. Other studies show A discussion about the procedure limia nervosa, binge-eating disorder that “grazing” behavior persists post- and postoperative demands can re- (BED), and night eating syndrome are operatively and becomes a barrier for veal any gaps in understanding and all clinically relevant when determin- weight loss. All patients are encour- allow the clinician to address these. ing suitability for surgery.18 aged to consider supportive counsel- If patients are unable to demonstrate Bulimia nervosa is an absolute ing when they binge frequently or are knowledge of what they are undertak-

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ing, they can be referred for further Psychiatric history • Is bariatric surgery appropriate for education about the role of surgery as Because psychiatric conditions can this patient? a treatment tool and the need to ad- impair a patient’s ability to handle the “Michelle” has carried extra here to lifestyle modification through- surgery, patients should be assessed weight for much of her life and tried out in order to garner the greatest for depression, anxiety, mania, psych- many weight-loss programs, all with benefit from this treatment as a whole. osis, suicidal ideation, substance limited success. She has never been The vast majority of bariatric patients abuse, history of abuse, family his- able to keep weight off for a consid- are enrolled in multidisciplinary pro- tory of mental health issues, and any erable time, even though she diets grams where most have attended sem- psychiatric treatment experiences. with vigor. She will embrace a new inars preoperatively and talked with Compared with the general popula- weight-loss program but inevitably people who have had the surgery. tion, patients affected by obesity have is challenged to continue with the re- Very infrequently, intellectual testing a higher rate of mental illness, addic- quired lifestyle modifications over the is needed to determine basic compe- tion, and sexual abuse. Depression long term. tence for informed consent. is especially common,20 and patients She had a deep vein thrombo- with a BMI above 40.0 kg/m2 are 5 sis in university that was thought Social supports times more likely to suffer from de- to be due to the birth control pill, Patients should be asked about who pression than those with a lower BMI. and 3 years ago she was diagnosed lives in their household, how these This can affect a patient’s adherence with type 2 diabetes. Her diabetes loved ones have reacted to the planned to preoperative and postoperative de- is well managed on oral hypoglyce- surgery, what the eating habits and/ mands. Anxiety can also affect a pa- mic agents, and her hypertension and or weight issues of other household tient’s ability to cope with the entire dyslipidemia are under control. She members are, and who will be avail- surgical experience.21 has never been screened for obstruc- able to help immediately after sur- Patients who are at higher risk of tive sleep apnea. She has mild arthri- gery. A variety of studies show that mental illness or who have a history tis in both knees. bariatric patients are more successful of uncontrolled mental illness should Michelle is interested in bariatric when they have supportive environ- undergo psychiatric screening.16 Ide- surgery. Her BMI of 38.0 kg/m2 and ments and that bariatric surgery in it- ally, bariatric surgery teams will in- her comorbidities alone qualify her self is a social stressor, which is seen clude a psychologist, a psychiatrist, for this surgery. She has an overall in the fact that divorce rates are higher or both. Further counseling should be EOSS risk profile of stage 2, which after surgery.20 mandated when clinically necessary. confirms that she is likely to be a suit- It is imperative that clinicians gain In patients with a history of psychiat- able candidate for this treatment. a sense of the patient’s social sup- ric illness it will be important to plan Michelle begins an in-depth as- ports and find out whether the patient for postoperative adjustments in med- sessment for surgery by undergoing is aware of the potential social con- ication in the short and long term. medical, metabolic, and psychiatric sequences of having the surgery by Although best practice guidelines screening. She is found to have a long asking appropriate questions: Have do not yet exist for psychological history of mild depression that has loved ones expressed negative opin- evaluation of the patient undergoing been well managed with antidepres- ions about the surgery or demonstrat- bariatric surgery, evidence is growing sants. She has a good understanding ed jealousy and discomfort when the with regard to the critical elements of the procedure proposed for her, a patient is losing weight? Have loved and domains for assessment and the sleeve gastrectomy. She has done on- ones tried to sabotage the patient’s various functions the assessment line research, attended an orientation weight-loss efforts in the past? What must serve.21 meeting, and joined a preoperative will meal arrangements look like support group. She has been exercis- when the patient is unable to eat and Example of clinical ing and keeping a regular food diary. drink in a fashion similar to others in assessment In short, she is adhering to lifestyle the household? Surgery can change The case of a fictional 36-year-old modifications that will be needed social dynamics and it is important woman with obesity illustrates how postoperatively. She has been seeing to prepare a patient for that when a comprehensive assessment can an- a psychologist for over a year as her necessary. swer two questions: husband does not support her having • Is bariatric surgery safe for this patient? the surgery.

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After several months of assess- suggests this surgery is far too limited population-representative cohort of peo- ment by the entire bariatric team, Mi- in its use. ple with overweight and obesity. CMAJ chelle is approved for surgery. 2011;183:e1059-e1066. Competing interests 12. Pories WJ. Bariatric surgery: Risks and Intervention needed None declared. rewards. J Clin Endocrinol Metab 2008; In October 2015, the Canadian Med- 93:s89-s96. ical Association acknowledged that References 13. DeMaria EJ, Portenier D, Wolfe L. Obesity obesity is a chronic disease requiring 1. Padwal R, Klarenbach S, Wiebe, et al. Bar- surgery mortality risk score: Proposal for a long-term therapeutic approaches. iatric surgery: A systematic review and clinically useful score to predict mortality One in four Canadians has obesity, network meta-analysis of randomized tri- risk in patients undergoing gastric bypass. and more than 3% of Canadians meet als. Obes Rev 2011;12:602-621. Surg Obes Relat Dis 2007;3:134-140. criteria for bariatric surgery. But al- 2. Flum DR, Dellinger EP. Impact of gastric 14. Dixon JB, Schachter LM, O’Brien PE. Poly- though 1 million Canadians meet bypass operation on survival: A popula- somnography before and after weight loss the criteria for bariatric surgery, only tion-based analysis. J Am Coll Surg 2004; in obese patients with severe sleep apnea. 6500 undergo this treatment each 199:543-551. Int J Obes 2005;29:1048-1054. year. This is not to say that all pa- 3. Christou NV, Sampalis JS, Liberman M, et 15. Bangura AS, Gibbs KE. Is routine preop- tients meeting the BMI criteria should al. Surgery decreases long-term mortality, erative polysomnography necessary in undergo bariatric surgery, but it does morbidity, and health care use in morbidly patients having bariatric surgery? Abstract suggest that this surgery is far too lim- obese patients. Ann Surg 2004;240:416- presented at 28th meeting of the Ameri- ited in its use. 423. can Society for Metabolic and Bariatric Our profession and our mandate 4. Zhang W, Mason EE, Renquist KE, Zim- Surgery, Orlando FL, 12-17 June 2011. demand that we pay attention to this merman MB. Factors influencing survival 16. Mechanick JI, Kushner RF, Sugerman HJ, global and national epidemic. Obesity following surgical treatment of obesity. et al. American Association of Clinical En- is the greatest public health crisis this Obes Surg 2005;15:43-50. docrinologists, The Obesity Society, and country has ever seen and as such re- 5. Sjöström L, Narbro K, Sjöström CD, et al. American Society for Metabolic & Bariat- quires intervention on all levels, from Effects of bariatric surgery on mortality in ric Surgery medical guidelines for clinical the bedside to the ballot. Swedish obese subjects. N Engl J Med practice for the perioperative nutritional, 2007;357:741-752. metabolic, and nonsurgical support of the Summary 6. Adams KF, Schatzkin A, Harris TB, et al. bariatric surgery patient. Obesity (Silver Bariatric surgery has been shown Overweight, obesity, and mortality in a Spring) 2009;17(suppl 1):S3-S72. to be a safe and effective procedure large prospective cohort of persons 50 to 17. Bocchieri LE, Meana M, Fisher BL. A re- for the treatment of obesity. As with 71 years old. N Engl J Med 2006;355:763- view of psychosocial outcomes of surgery any treatment, screening and assess- 778. for morbid obesity. J Psychosom Res ment are needed to determine a pa- 7. Prentice AM, Jebb SA. Beyond body 2002;52:155-165. tient’s suitability for surgery. After mass index. Obes Rev 2001;2:141-147. 18. Herpertz S, Kielmann R, Wolf AM, et al. initial assessment by the referring pri- 8. Haslam DW, James WP. Obesity. Lancet Do psychosocial variables predict weight mary care provider, clinical assess- 2005;366(9492):1197-1209. loss or mental health after obesity sur- ment should be done over a period 9. Price GM, Uauy R, Breeze E, et al. Weight, gery? A systematic review. Obes Res of time by a multidisciplinary team shape, and mortality risk in older persons: 2004;12:1554-1569. that includes a dietitian, a physician, Elevated waist-hip ratio, not high body 19. Wadden TA, Faulconbridge LF, Jones- a surgeon, and, when necessary, a mass index, is associated with a greater Corneille LR, et al. Binge eating disorder and psychologist or psychiatrist. Patients risk of death. Am J Clin Nutr 2006;84:449- the outcome of bariatric surgery at one year: should be screened for metabolic and 460. A prospective, observational study. Obesity other disorders, including obstructive 10. Frankenfield DC, Rowe WA, Cooney RN, (Silver Spring) 2011;19:1220-1228. sleep apnea, and interviewed about et al. Limits of body mass index to detect 20. Sarwer DB, Fabricatore AN. Psychiatric their understanding of the procedure obesity and predict body composition. considerations of the massive weight loss and the postoperative demands in- Nutrition 2001;17:26-30. patient. Clin Plast Surg 2008;35:1-10. volved. The relatively small number 11. Padwal RS, Pajewski NM, Allison DB, 21. Yen YC, Huang CK, Tai CM. Psychiatric of eligible patients undergoing bari- Sharma AM. Using the Edmonton obesity aspects of bariatric surgery. Curr Opin Psy- atric procedures in Canada each year staging system to predict mortality in a chiatry 2014;27:374-379.

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 155 Jacqueline Chang, MD, CCFP, Diplomate of the American Board of Obesity Medicine, Nam Nguyen, MD, FRCSC, Sharadh Sampath, MD, FRCSC, Nooshin Alizadeh-Pasdar, RD, PhD

Prevention and management of complications after bariatric surgery

Patients undergoing sleeve gastrectomy or gastric bypass should be prepared to recognize complications such as anastomotic leak and dumping syndrome, and to follow instructions regarding dietary progression, nutritional supplementation, and exercise.

ABSTRACT: Patients undergoing As well as watching for such compli- atients who have undergone sleeve gastrectomy and gastric by- cations after surgery, patients must sleeve gastrectomy or gastric pass require support from health make adjustments regarding con- Pbypass are typically discharged care professionals so that they can stipation management, medication from hospital 1 to 2 days after surgery recognize complications and make use, alcohol consumption, nutrition- and followed closely by a multidis- appropriate postsurgical lifestyle al supplementation, contraception, ciplinary team of health care profes- adjustments. After surgery, patients and lifestyle behaviors. Failure to sionals. Before surgery, patients will must follow a postoperative dietary follow dietary guidelines and a lack have been counseled extensively on progression that begins with liq- of exercise can be reasons for re- recognizing complications such as uids for 3 weeks and continues with gaining weight or not losing enough anastomotic leak, internal hernia, ul- pureed and then soft solids before weight after surgery. With a change cer, dumping syndrome, and gallstone concluding at 10 weeks with a tran- in lifestyle and successful weight formation. They will have received sition to very small amounts of reg- loss after surgery, patients can re- information about constipation man- ular food. Possible complications duce obesity-related comorbidities agement, medication use, alcohol after surgery include anastomotic and increase their overall energy and consumption, nutritional supplemen- leak, internal hernia, ulcer, dumping confidence. tation, contraception, and lifestyle syndrome, and gallstone formation. behaviors. As well, patients will have been prepared for the following post- operative dietary progression: 1. Liquid diet (no caffeinated, car- bonated, or alcoholic drinks) for 3

Dr Chang is a family physician who pro- program. He is also a clinical associate Columbia and president of the BC Obesity vides postoperative long-term follow-up professor in the Department of Surgery Society. Dr Alizadeh-Pasdar is a bariat- for sleeve gastrectomy patients treated at the University of British Columbia. Dr ric clinical dietitian at Vancouver Coastal in the Richmond Metabolic and Bariatric Sampath is head of the Division of General Health’s Garratt Wellness Centre and ses- Surgery program. Dr Nguyen is a general Surgery at Richmond Hospital and director sional lecturer in the Food, Nutrition, and surgeon at Richmond Hospital and in the of the Richmond Metabolic and Bariatric Health program of the Faculty of Land and Richmond Metabolic and Bariatric Surgery Surgery program. He is also a clinical Food Systems at the University of British assistant professor in the Department Columbia. This article has been peer reviewed. of Surgery at the University of British

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weeks; hydrate first before adding els because the obstruction is proxim- Dumping syndrome protein. al, CT can reveal the subtle rotation Dumping syndrome occurs when a 2. Pureed diet for 2 weeks. of mesenteric vessels (whirl sign) meal is ingested and a hypertonic 3. Soft and moist solids for 4 weeks. that suggests an internal hernia. Al- carbohydrate load empties rapidly 4. Transition to regular food in very though internal hernia occurs after into the small intestine. Symptoms small amounts at week 10. RYGB with a reported incidence rate include abdominal pain, cramping, For the long term, patients are ad- of 4.5%,3 the risk can be reduced if vomiting, diarrhea, flushing, palpita- vised to use a small plate and to sepa- the mesenteric defects are closed tions, tachycardia, and hypotension. rate their intake of solids and liquids with running sutures.4 Treatment for These gastrointestinal and vasomotor by 30 minutes. internal hernia is laparoscopic sur- symptoms result when excess insulin gery with hernia reduction and defect is produced in response to the rapid Possible complications closure. entry of food and fluids into the small Patients need to be aware of compli- cations that can occur after bariatric surgery.

Anastomotic leak If an anastomotic leak occurs, it usu- Before surgery, patients will have been ally happens within the first few days of surgery and rarely after 2 weeks. counseled extensively on recognizing Symptoms include tachycardia, complications such as anastomotic worsening abdominal pain, leukocyt- osis, fever, and oliguria. Anastomotic leak, internal hernia, ulcer, dumping leaks occur after sleeve gastrectomy syndrome, and gallstone formation. with a reported incidence rate of 1.06%1 and after Roux-en-Y gastric bypass (RYGB) with a reported in- cidence rate of 1.10%.2 The most common site for a leak is the prox- imal end of the stapler line near the gastroesophageal junction. A CT scan Ulcer intestine. Early dumping syndrome with oral contrast or an upper gastro- Ulcers are common after bariatric occurs less than 1 hour after eating intestinal series can be used to inves- surgery. To minimize the risk of ulcer with distention of the small bowel. tigate an anastomotic leak. formation and gastroesophageal re- Late dumping syndrome occurs 1 to flux symptoms, a proton pump inhib- 3 hours after eating with symptoms Internal hernia itor (PPI) is prescribed at the time of similar to those of low blood glucose Internal hernia occurs when the discharge. Typically, sleeve gastrec- levels. Dumping syndrome can usual- bowel protrudes through one of the tomy patients use a PPI for 6 weeks ly be prevented and treated by avoid- surgically created mesenteric defects. and gastric bypass patients use a PPI ing simple carbohydrates and eating The creation of space with weight for 6 months. If a patient has persis- protein-based meals. loss may contribute to internal her- tent reflux symptoms, a PPI may be nia, which often presents in a delayed used on a long-term basis. NSAID Gallstone formation fashion and can result in small bowel use is contraindicated after RYGB be- Gallstone formation can occur obstruction, ischemia, or infarction. cause of the increased risk of margin- with rapid weight loss. A Swedish With presenting features that in- al ulcers between the stomach pouch population-based study noted the in- clude abdominal pain, nausea, vomit- and the Roux limb. NSAID use is also creased incidence of cholecystectomy ing, and nonspecific gastrointestinal discouraged after sleeve gastrectomy after bariatric surgery. While 8.5% symptoms, diagnosis can be difficult. because of ulceration risk and the lim- of the study cohort underwent chole- While abdominal X-ray (three views) ited opportunity for surgical interven- cystectomy with a standardized inci- may not show the classic air fluid lev- tion with the smaller gastric pouch. dence ratio of 5.5, 3.2% of the cohort

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underwent emergency cholecystec- lower absorption rates for orally ad- not only on acidity but on intrinsic tomy with a standardized incidence ministered drugs may occur, although factor, a glycoprotein produced in the ratio of 5.2.5 The study authors sug- empirical evidence on this is limited. bypassed part of the stomach. gest that the increased incidence may Many patients will experience Recommended supplementation be due to detection bias rather than rapid resolution of obesity-related co- includes: an elevated risk of symptomatic gall- morbidities such as diabetes, hyper- · Multivitamin with minerals (con- stones. Nonetheless, biliary complica- tension, and dyslipidemia, and will taining iron, folate, thiamine), 1 to 2 tions are more common after RYGB. require less insulin and reduced doses tablets daily (minimal requirement). Endoscopic retrograde cholangiopan- of oral hypoglycemic, antihyperten- • Elemental calcium, 1200 to 1500 creatography for common bile duct sive, and lipid-lowering agents. Pa- mg daily, in diet and in citrated stones is a very difficult procedure tients will require regular follow-up supplement in divided doses (cal- after RYGB because access to the to monitor medication adjustments. cium citrate does not require acid duodenum through the mouth is not for absorption). easy with the partition in the stomach. Alcohol consumption • Vitamin D, at least 3000 IU daily Concurrent cholecystectomy may be Weight loss following bariatric sur- (titrate to > 30 ng/mL). recommended for select patients. gery and the rapid emptying of alco- • Vitamin B12 (as needed for normal hol from a gastric pouch contribute to range levels). Postsurgery adjustments faster abosorption of alcohol, lower • Iron, 45 to 60 mg via multivitamins As well as recognizing and address- metabolic clearance, and higher blood and additional supplements (needed ing any postoperative complications, alcohol content for each alcoholic most commonly after gastric bypass patients must be prepared to make drink consumed.7 Patients should be procedures).7 other adjustments. strongly discouraged from drinking alcohol during the rapid weight loss Contraception Constipation management period after surgery. In the long term, Contraception is recommended for Constipation is experienced by many increased sensitivity to alcohol has female patients of childbearing age patients after bariatric surgery. Ideal- ramifications for operating a motor for 2 years after surgery. This gives ly, patients will drink small amounts vehicle and heavy equipment; doing sufficient time to ensure nutritional of water frequently to ensure adequate so after drinking even a small amount adequacy before patients embark on hydration, which requires more than of alcohol is not recommended. pregnancy. 1.5 L/day PO. Prune juice, docusate, Furthermore, alcohol is a source of and polyethylene glycol (PEG) laxa- empty calories and can contribute to Lifestyle behaviors tive are recommended to treat and the development of marginal ulcers. Bariatric surgery in itself does not prevent constipation. guarantee success. The window of Nutritional supplementation opportunity for establishing bene- Medication use After bariatric surgery nutritional ficial lifestyle behaviors is the first Postsurgical weight loss will alter supplementation is required indefin- 12 months after surgery, when peak water and fat body composition and itely to address deficiencies in iron, weight loss occurs. Some of the rea- change the absorption and distribu- vitamin D and other fat-soluable vita- sons for regaining weight or losing tion of drugs in the patient’s system. mins A, E, and K (most common after insufficient weight (defined as less In addition, a restrictive proced- RYGB), vitamin B12, folate, calcium, than 40% to 50% of excess body ure such as sleeve gastrectomy may and other micronutrients. Reduced weight) include: change gastric emptying time, pH, gastric acid production affects the ab- • Failure to follow dietary guidelines and mucosal exposure.6 Patients who sorption of calcium and this in turn (e.g., consuming high-calorie liquid undergo a procedure such as Roux- increases a patient’s risk of osteopor- meals or snacks; “grazing”; eating en-Y gastric bypass, which has both osis. Reduced gastric acid production starches and carbohydrates; drink- restrictive and malabsorptive effects, also affects the absorption of iron. As- ing liquids with meals or drinking may experience a reduction in drug corbic acid (vitamin C) can be taken liquids right after eating, which absorption with the decreased func- to acidify the stomach and increase flushes food out of the gastric pouch tional length of the intestine and de- absorption of iron and vitamin B12, before it can stretch and send satiety creased absorptive surface.6 Higher or although absorption of B12 depends signals).

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• Lack of exercise. • Psychiatric issues (e.g., depression, After a sleeve gastrectomy or gastric anxiety, binge eating). bypass, patients must follow a • Postsurgical issues (e.g., large or di- lated gastric pouch, dilated gastro- postoperative dietary progression jejeunal anastomosis). that begins with liquids and According to the National Heart, Lung, and Blood Institute website,8 concludes with a transition to very people who want to maintain their small amounts of regular food. weight loss, as well as people who want to lose a large amount of weight (more than 5% of their body weight), may need to be physically active for more than 300 minutes a week (e.g., 1 hour of moderately intense activ- ity for 5 days a week). While not ev- eryone has the time or the financial to initiate and maintain lifestyle chan- Feder D. The use of drugs in patients who resources to work out at a gym, add- ges coupled with support from health have undergone bariatric surgery. Int J ing steps to each day whenever and care professionals will ensure suc- Gen Med 2014;7:219-224. wherever possible may be enough cessful weight loss after surgery. 7. Mechanick JI, Youdim A, Jones DB, et al. to initiate change. Encouragement Clinical practice guidelines for the periop- and support from health care profes- Competing interests erative nutritional, metabolic, and nonsur- sionals can go a long way toward None declared. gical support of the bariatric surgery pa- helping patients lose weight and im- tient—2013 update: Cosponsored by the prove their metabolic abnormalities, References American Association of Clinical Endocri- reduce obesity-related comorbidities, 1. Rosenthal RJ, International Sleeve Gas- nologists, the Obesity Society, and Amer- and increase their overall energy and trectomy Expert Panel, Diaz AA, et al. In- ican Society for Metabolic & Bariatric confidence. ternational sleeve gastrectomy expert Surgery. Endocr Pract 2013;19. panel consensus statement: Best prac- 8. National Heart, Lung, and Blood Institute. Summary tice guidelines based on experience of Be physically active. Accessed 15 January After a sleeve gastrectomy or gastric >12,000 cases. Surg Obes Relat Dis 2018. www.nhlbi.nih.gov/health/educa bypass, patients must follow a pos- 2012;8:8-19. tional/lose_wt/physical.htm. toperative dietary progression that be- 2. Jacobsen HJ, Nergard BJ, Leifsso BG, et gins with liquids and concludes with al. Management of suspected anasto- a transition to very small amounts of motic leak after bariatric laparoscopic regular food. Possible complications Roux-en-Y gastric bypass. Br J Surg 2014; after surgery include anastomotic 101:417-423. leak, internal hernia, ulcer, dumping 3. Garza E Jr, Kuhn J, Arnold D, et al. Internal syndrome, and gallstone formation. hernias after laparoscopic Roux-en-Y gas- Patients must be prepared for adjust- tric bypass. Am J Surg 2004;188:796-800. ments that involve constipation man- 4. Paroz A, Calmes JM, Giusti V, Suter M. agement, medication use, alcohol Internal hernia after laparoscopic Roux-en- consumption, nutritional supplemen- Y gastric bypass for morbid obesity: A tation, contraception, and modifica- continuous challenge in bariatric surgery. tion of lifestyle behaviors. Inadequate Obes Surg 2006;16:1482-1487. weight loss and weight regain will 5. Plecka Ostlund M, Wenger U, Mattsson occur if patients fail to make lifestyle F, et al. Population-based study of the changes regarding diet and physical need for cholecystectomy after obesity activity or if patients have psychiatric surgery. Br J Surg 2012;99:864-869. comorbidity. Patients’ determination 6. Geraldo Mde S, Fonseca FL, Gouveia MR,

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 159 Kevin Wing, MD, FRCSC, Alastair Younger, MD, FRCSC

Regional variations in access to orthopaedic care in BC

A study of wait times for a pathologically and geographically diverse group of patients found that the average journey from referral to surgery was worrisomely long at 59.5 weeks, and that more regional variation existed for consultation wait times than for surgery wait times.

ABSTRACT Results: Consultations were com- and Vancouver Coastal Health may Background: There has been long- pleted for 4100 patients and sur- be attributed to surgeon-led multi- standing concern among ortho- geries were completed for 1129 disciplinary clinics that utilize cen- paedic surgeons regarding timely patients during the study period. tralized intake and “first available access to consultation and, if war- Patients waited 19.5 weeks on av- surgeon” strategies to reduce wait ranted, surgery. On behalf of the erage for consultation, with signifi- times. We believe that standardized British Columbia Orthopaedic As- cant regional variation. All health recording of patient unavailability sociation, we sought to measure authorities had difficulties with long dates would help us better under- aspects of the patient journey from waits for consultation, with 10% of stand the situation of patients who referral to surgery, and to consider patients identified as long waiters. experience very long waits, and we regional variations in access. Patients waited 34.1 weeks on aver- remain committed to improving pa- age for surgery after consent. Less tient access to orthopaedic care by Methods: Currently, 49 orthopaedic regional variation was seen for av- promoting best practices that match surgeons from five BC health author- erage surgery wait times (between the right patient with the right sur- ities contribute anonymized sched- 29.4 and 36.3 weeks) than for aver- geon at the right time. Greater focus uling data to a secure server that age consultation wait times (between on the experience of patients ac- aggregates information about key 15.7 and 31.0). Among patients who cessing orthopaedic care is required time points: the date a patient is re- had surgery, the average time from in all regions of BC. ferred for surgical consultation, the referral to surgery was 59.5 weeks, date consultation occurs, the date a with regional variation between 49.5 Dr Wing is an orthopaedic surgeon at the decision is made regarding surgery, and 66.5 weeks. St. Paul’s Hospital Foot and Ankle Clinic and and the date of surgery. Data col- past president of the British Columbia Or- lected for consultations and surger- Conclusions: All health authorities thopaedic Association. He is also a clinical ies occurring between 1 May and 31 in BC have on average long waits professor in the Department of Orthopae- July 2017 were analyzed to establish for consultation and surgery. Re- dics at the University of British Columbia. wait times for patients seen or treat- gional variation in access to ortho- Dr Younger is an orthopaedic surgeon at ed in this 3-month period. paedic consultation exists in BC, the St. Paul’s Hospital Foot and Ankle Clinic and the average journey from refer- and president of the British Columbia Or- ral to surgery is worrisomely long. thopaedic Association. He is also a profes- Lower wait times for consultation sor in the Department of Orthopaedics at This article has been peer reviewed. in Island Health, Interior Health, the University of British Columbia.

160 bc medical journal vol. 60 no. 3, april 2018 bcmj.org Regional variations in access to orthopaedic care in BC

Background from the EMR systems of participat- During the study period, surgeons British Columbia, like other prov- ing surgeons. performed 1129 surgeries. Patients inces in Canada, continues to struggle Using the anonymized data, we waited 34.1 weeks on average after with poor access to orthopaedic care quantified wait times for patients who providing consent for surgery. Less as a result of rationing in the pub- were either seen in consultation or regional variation was noted for the licly funded health care system.1-6 received surgery between 1 May and average wait from consent to surgery Moreover, it is difficult to obtain ac- 31 July 2017. Patients who waited than for consultation, with a range be- curate information regarding access less than 42 days for consultation or tween 29.4 and 36.3 weeks. to orthopaedic consultation and sur- gery in BC. Although a review of the Ministry of Health’s surgical patient registry website (https://swt.hlth.gov .bc.ca) would suggest access to sur- gery in BC takes only a few weeks, the British Columbia Orthopaedic BC, like other provinces in Canada, Association (BCOA) has long known that patients can wait up to 1 year for continues to struggle with poor access to nonemergency access to orthopaedic orthopaedic care as a result of rationing in consultation and care. On behalf of the BCOA, we sought the publicly funded health care system. to quantify wait times for consultation and surgery in BC, paying special at- tention to regional variations in ac- cess to care. Data analyzed were from a BCOA wait times initiative (http:// bcoa.ca/information-for-patients/ wait-times-for-surgery/) that began surgery were excluded in order to Once again however, each region after a detailed privacy impact assess- avoid analyzing data for patients seen had difficulty with long waiters from ment was performed in collaboration rapidly after urgent referral from the consent to surgery with 10% of pa- with Doctors of BC and the Specialist emergency department while a sur- tients waiting between 68.0 and 95.1 Services Committee. geon was on call. weeks for surgery. For patients who had surgery dur- Methods Results ing the study period, the time from Currently, 49 orthopaedic surgeons During the study period, surgeons referral to surgery was 59.5 weeks on from five BC health authorities con- completed consultations with 4100 average, with regional variation be- tribute anonymized scheduling data patients seen on a nonemergency tween 49.5 and 66.5 weeks. from their electronic medical record basis. Patients waited 19.5 weeks on (EMR) systems to a secure server that average for consultation. There was Conclusions aggregates information about wait significant regional variation, with a To obtain evidence regarding wait times. These surgeons represent ap- low of 15.7 weeks in Island Health times for consultation and surgery, proximately 25% of all the full-time and a high of 31.0 weeks in Northern the BCOA executive determined they orthopaedists in the province. Key Health. would need the accurate and nuanced time points in the data they contrib- All health authorities had difficul- data available in the EMR systems ute are the date a patient is referred ties with long waits for consultation, surgeons use to manage their wait for surgical consultation, the date with 10% of patients identified as lists and book patients. A data-col- consultation occurs, the date a deci- “long waiters.” The wait for consulta- lection initiative for measuring wait sion is made regarding surgery, and tion in this group was 59.6 weeks on times was originally funded by the the date of surgery. A high level of average. Regional variation was also Specialist Services Committee and is accuracy is assured with the auto- significant, with a range between 38.1 now funded solely by the BCOA on mated extraction of scheduling dates and 84.5 weeks. behalf of its surgeon membership.

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We believe that the relatively low nonemergency orthopaedic surgery, fracture and the patient who has wait- wait time of 15.7 weeks on average and have every reason to believe that ed 2 years for an ankle replacement. for consultation in Island Health can patients are sustaining mental, physi- In this study we attempted to avoid be largely attributed to the positive cal, and financial harm as a result of blending data for two very different effect of the RebalanceMD clinic in these lengthy waits.7-13 The BCOA patient populations by excluding all Victoria. We note that both Interior also believes that wait time report- patients who received consultations Health, with a consultation wait time ing should be more transparent in all in less than 42 days. of 17.8 weeks, and Vancouver Coastal health authorities, and that more pa- Health, with a consultation wait time tient-focused research is required to Impact of wait times This study captured wait times for a pathologically and geographically di- verse group of patients, including pa- tients waiting for hip replacement in The BCOA remains very concerned Prince George, knee surgery in Trail, or shoulder surgery in New Westmin- that British Columbians are waiting 59.5 ster. For orthopaedic patients, long weeks on average for nonemergency wait times can have a significant im- pact on quality of life and mental and orthopaedic surgery... Patients are emotional well-being.1,7-9,11 The litera- sustaining mental, physical, and financial ture suggests that the impact of wait- ing varies by condition. For cancer harm as a result of these lengthy waits. and conditions involving the circula- tory system, including the heart, long wait times can lead to sudden adverse events, disability, or death.14-16 Our daily hospital experience indicates of 25.2 weeks, also have surgeon-led better quantify patient experience. that many other procedural specialties multidisciplinary clinics that utilize In the United Kingdom, the Na- are significantly affected by long wait centralized intake and “first available tional Health Service has set a wait- times for care. surgeon” strategies to reduce wait time target of 18 weeks from general times for consultation. practice referral to surgery for 92% of Study limitations Less variation was noted between patients. In BC, hospitals try to have The limitations of this study are those regions from the time consent was patients treated within 1 year of the inherent to any study that attempts to provided for surgery to the date of date the surgeon’s office submits the quantify the experience of an entire surgery. We note with interest that de- surgical booking card to the hospi- provincial population while sampling spite having the lowest wait times for tal. However, we have observed that only a portion of it. We believe this consultation, Island Health had the when this 1-year target for surgical to be especially true for Fraser Heath, highest wait times for surgery. It is care is missed, only the patient feels where our sampling rate was the low- our understanding that Island Health the negative repercussions. est. We anticipate that the BCOA will is bringing significantly increased Orthopaedic surgeons provide have more surgeons participating in surgical capacity on line to deal with both urgent care at the request of an this data collection and analytic pro- this backlog of surgical cases. Im- emergency room physician, and non- cess in the near future. proved real-time and cost-effective emergency care, most commonly at We believe that standardized re- collaboration between the office of the request of a patient’s family phy- cording of patient unavailability dates the nonhospital-based surgeon and sician. For example, hip fracture pa- would help us better understand the the hospital surgical booking office is tients are commonly treated within 48 situation of patients who experience clearly desirable. hours of admission. Wait list findings very long waits. The BCOA remains very con- for both consultation and surgery can The BCOA remains committed to cerned that British Columbians are be confused by EMR-based data that improving patient access to orthopae- waiting 59.5 weeks on average for capture both the patient who has a hip dic care by reporting on wait times

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and promoting best practices that will Regional variations in access to help match the right patient with the right surgeon at the right time. orthopaedic consultation exist in BC.

Summary Regional variations in access to ortho- paedic consultation exist in BC. While there is less variation in wait times for surgery than for consultation, the aver- JM. Patient-reported outcomes and surgi- able loss in quality time and preventable age journey from referral to surgery cal triage: A gap in patient-centered care? deterioration. J Arthroplasty 2004;19:302- is worrisomely long at 59.5 weeks. Qual Life Res 2016;25:2845-2851. 309. Greater focus on the experience of 6. Canadian Institute for Health Information. 12. Mahon JL, Bourne RB, Rorabeck CH, et patients accessing orthopaedic care is Wait times for priority procedures in Can- al. Health-related quality of life and mobil- required in all regions. ada, 2017. Accessed 6 February 2018. ity of patients awaiting elective total hip www.cihi.ca/en/wait-times-for-priority arthroplasty: A prospective study. CMAJ Competing interests -procedures-in-canada-2017 2002;167:1115-1121. None declared. 7. Desmeules F, Dionne CE, Belzile E, et al. 13. Nilsdotter A-K, Lohmander LS. Age and The burden of wait for knee replacement waiting time as predictors of outcome af- References surgery: Effects on pain, function and ter total hip replacement for osteoarthritis. 1. Garbuz DS, Xu M, Duncan CP, et al. De- health-related quality of life at the time of Rheumatology (Oxford) 2002;41:1261- lays worsen quality of life outcome of pri- surgery. Rheumatology 2010;49:945-954. 1267. mary total hip arthroplasty. Clin Orthop 8. Braybrooke J, Ahn H, Gallant A, et al. The 14. Chester M, Chen L, Kaski JC. Identifica- Relat Res 2006;447:79-84. impact of surgical wait time on patient- tion of patients at high-risk for adverse 2. Siciliani L, Moran V, Borowitz M. Measur- based outcomes in posterior lumbar spi- coronary events while awaiting routine ing and comparing health care waiting nal surgery. Eur Spine J 2007;16:1832- coronary angioplasty. Br Heart J 1995; times in OECD countries. Health Policy 1839. 73:216-222. 2014;118:292-303. 9. Fielden JM, Cumming JM, Horne JG, et 15. Fairhead JF, Mehta Z, Rothwell PM. 3. Thomson S, Osborn R, Squires D, Jun M. al. Waiting for hip arthroplasty: Economic Population-based study of delays in ca- International profiles of health care sys- costs and health outcomes. J Arthroplasty rotid imaging and surgery and the risk of tems, 2012. New York: Commonwealth 2005;20:990-997. recurrent stroke. Neurology 2005;65: Fund; 2012. 10. Derrett S, Paul C, Morris JM. Waiting for 371-375. 4. Mossialos E, Wenzl C, Osborn R, Ander- elective surgery: Effects on health-related 16. Kulkarni GS, Urbach DR, Austin PC. Lon- son C. International profiles of health care quality of life. Int J Qual Health Care 1999; ger wait times increase overall mortality in systems, 2014. New York: Common- 11:47-57. patients with bladder cancer. J Urol 2009; wealth Fund; 2015. 11. Ostendorf M, Buskens E, van Stel H, et al. 182:1318-1324. 5. Crump RT, Liu G, Chase M, Sutherland Waiting for total hip arthroplasty: Avoid-

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Managing type-III acromioclavicular joint injuries

etween 2009 and 2016, Work- Clinical evaluation were performed. These are not re- SafeBC accepted almost 1880 Patients typically present with the quired, as they are generally painful claims for acromioclavicular injured arm in an adducted and sup- and have no impact on clinical deci- B 1-3 (AC) joint injuries. More than 80% ported position. Pain will localize to sion making. of injured workers were males in the the AC joint on palpation and can be construction, service trades, or transit accentuated with abduction and cross- Classification operator sectors. Only 1% required sur- body adduction of the arm, though AC joint injuries are classified ac- gical correction, while others received this is usually challenging, given the cording to the Rockwood Classifica- appropriate rehabilitation. Treatment acuity of the injury. Tenting of the tion ( Table ). of type-III (completely displaced) AC skin may also be present, depending joint injuries ( Figure ) has been con- on the degree of displacement.3 The Management of type-III troversial. In the 1970s, treatment was authors’ practice is to clinically at- AC joint injuries generally surgical, and while this has tempt a reduction of the AC joint to Management of type-III injuries has changed to some extent, the debate re- help discern a type-III from a type- been controversial, a major reason be- garding surgical and nonsurgical treat- V injury ( Table ). Done carefully, this ing the introduction of arthroscopic ment persists.1 can result in minimal discomfort to innovation. Unfortunately, no com- the patient. parative data on minimally invasive Mechanism of injury versus nonsurgical management of The most common mechanism of AC Imaging this injury currently exists. The Can- joint injury is direct trauma to the lat- Radiographs are the initial and fre- adian Orthopedic Trauma Society per- eral aspect of the shoulder, when the quently only investigations required formed the most useful randomized arm is in an adducted position. The for AC joint injuries. The anteropos- controlled trial, which centred on plate direct force drives the acromion in- terior (AP), axillary, and Zanca (AP fixation versus nonoperative manage- teriorly while the clavicle remains with 10- to 15-degree cephalad tilt) ment.4,5 This study and its follow-up, in place, leading to disruption of the are the recommended views. The AP reported in 2017, failed to show a acromioclavicular and coracoclivicu- and Zanca views identify the amount benefit to the acute surgical manage- lar ligaments.1-3 Indirect mechanisms of superoinferior displacement, and ment of these injuries. Other studies of injury resulting from a fall on an the axillary view evaluates antero- in this area include a series of patients outstretched arm or elbow have also posterior displacement. The AP and with AC joint injuries who were treat- been reported.1,3 Zanca views should be performed bi- ed with hook plate fixation.6 This ser- laterally to allow for comparison to ies had a small sample size and lacked This article is the opinion of WorkSafeBC the uninjured side.1-3 a comparative nonoperative group. and has not been peer reviewed by the Historically, stress views with the Several studies have questioned BCMJ Editorial Board. patient holding weights in each arm the benefit of hook plate fixation. A

A B

Figure. Two cases of type-III AC joint injuries. A. Type-III AC disruption. B. Postoperative repair of type-III AC disruption.

164 bc medical journal vol. 60 no. 3, april 2018 bcmj.org

Figure. worksafebc

retrospective cohort study compared sociated with nonsurgical treatment et al. Acromioclavicular joint injuries: the clinical outcomes between hook are development of late AC joint Diagnosis and management. J Am Acad plate fixation and conservative man- arthrosis and persistent instability. Orthop Surg 2009;17:207-219. agement, using quality-of-life mea- Surgical options for these late com- 2. Stucken C, Cohen SB. Management of sures and patient questionnaires.7 plications include distal clavicle re- acromioclavicular joint injuries. Orthop The operative group consisted of 5 section and ligament reconstruction, Clin North Am 2015;46:57-66. type-III injures and 6 type-V injuries depending on the exact complaint 3. Li X, Ma R, Bedi A, et al. Management of treated with hook plates. The conser- and degree of displacement.1 Identi- acromioclavicular joint injuries. J Bone vative group included 4 type-III and fying the correct patient for chronic Joint Surg Am 2014;96:73-84. 17 type-V. Mean follow-up time for AC joint reconstruction remains a 4. Canadian Orthopaedic Trauma Society. the surgical group was 32.4 months, challenge. Multicenter randomized clinical trial of and for the conservative group, 34.77 nonoperative versus operative treatment months. No difference was noted in Summary of acute acromio-clavicular joint disloca- SF36, VAS, DASH, Constant, or At this time, evidence supports the tion. J Orthop Trauma 2015;29:479-487. Global Satisfaction scores. With ra- nonsurgical treatment of acute type- 5. Mah JM, Canadian Orthopaedic Trauma diographic follow-up, a significant III AC joint injury. Although signifi- Society (COTS). General health status af- difference in persistent AC joint dis- cant innovation toward minimally ter nonoperative versus operative treat- location (100% of the conservative invasive techniques has been made, ment for acute, complete acromioclav­ group versus 36.36% of the operative the literature supporting its use is icular joint dislocation. J Orthop Trauma group, P =0.0001) was noted. Despite lacking. 2017;31:485-490. the difference in radiographic out- 6. Salem KH, Schmelz A. Treatment of come, there seemed to be no differ- For assistance Tossy III acromioclavicular joint injuries ence in functional outcomes. For assistance with an injured worker using hook plates and ligament suture. J Several studies support the acute patient with a type-III AC joint injury, Orthop Trauma 2009;23:565-569. management of AC joint stabilization please contact a medical advisor in 7. Natera Cisneros LG, Sarasquete Reiriz J. arthroscopically.8-10 The one major your nearest WorkSafeBC office. Acute high-grade acromioclavicular joint limitation of these studies is the lack —Ben Jong, MD injuries: Quality of life comparison be- of comparison to a nonoperatively Resident, UBC Department of tween patients managed operatively with treated cohort. Given the superior Orthopaedic Surgery a hook plate versus patients managed outcomes following nonsurgical care, —Danny P. Goel, MD, non-operatively. Eur J Orthop Surg Trau- caution must be exercised when per- MSc, FRCSC matol 2017;27:341-350. forming an acute stabilization with WorkSafeBC Visiting Specialist 8. Menge TJ, Tahal DS, Katthagen JC, Millett an innovative procedure that has not Clinical Associate Professor, PJ. Arthroscopic acromioclavicular joint been shown to be superior to nonop- UBC Department of reconstruction using knotless coracocla- erative care. Orthopaedic Surgery vicular fixation and soft-tissue anatomic coracoclavicular ligament reconstruction. Complications References Arthrosc Tech 2017;6:e37. The most common complications as- 1. Simovitch R, Sanders B, Ozbaydar M, 9. Spoliti M, De Cupis M, Via AG, Oliva F. All arthroscopic stabilization of acute acro- Table. Rockwood Classification of AC joint injuries. mioclavicular joint dislocation with fiber- wire and endobutton system. Muscles Direction of clavicle Type Radiographic findings displacement Ligaments Tendons J 2014;4:398-403. 10. Pühringer N, Agneskirchner J. Arthroscop- I None No increase in coracoclavicular (CC) interspace ic technique for stabilization of chronic II Superior CC interspace increase of < 25% acromioclavicular joint instability with cor- acoclavicular and acromioclavicular liga- III Superior CC interspace increase of 25% to 100% ment reconstruction using a gracilis ten- IV Posterior Axillary view necessary to diagnose. Distal clavicle displaced don graft. Arthrosc Tech 2017;6:e175- posteriorly through trapezius. e181. V Superior CC distance > 100% of contralateral (clavicle herniated through deltotrapezial fascia)

VI Inferior Distal clavicle is subacromial or subcoracoid. Rare injury.

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Dr Charles Rally thoughtful nature were displayed to cousins speak to the success of family 1928–2017 all he met. Being a quiet man, he nev- life at the Rallys’. er presented an overbearing approach, Charlie had many other activities but whatever he said was notable and at which he excelled. He was an expert well thought out. gardener, superior wallpaper hanger, Charlie was involved in the Di- bird-watcher, and traveler. He loved vision of Cardiology at Vancouver tennis and routinely dismissed my ef- General Hospital, but he also worked forts. Monday nights were reserved at Shaughnessy Hospital and taught for a bridge group that started in 1966 medical students at UBC. Other work and continued until 2001. One of activities involved being the medical the best players, and Charlie’s dear- director or underwriter for many of est friend, was David Bachop. After Canada’s insurance companies. The David’s death in 1988, Charlie, along knowledge gained from this work with John Ankenman and Don Farqu- made him an expert in life expectancy har, was instrumental in setting up the statistics, and he was frequently con- Dr David M. Bachop Gold Medal for Dr Charles Rally, known to all as Char- sulted in this area. Distinguished Medical Service given lie, passed away from surgical compli- Despite his dedication to medi- out by Doctors of BC to a BC doc- cations on 16 November 2017. Charlie cine, Charlie always found time for tor who has made an extraordinary was born on 1 September 1928 in his family. In Montreal he met Rose, contribution in the field of organized North Vancouver. Some years before, the true love of his life, and she re- medicine and/or community service. his parents had emigrated from France mained so until his recent death. She Fishing, too, was a passion since and set up homestead near Savona, told me the following story, which childhood. Visits to Bella Coola, dur- BC. They moved to the Lower Main- speaks to his medical expertise. ing which he often included his chil- land prior to Charlie’s birth. His early A short time after being intro- dren who also loved to fish, allowed schooling was at St. Edmonds in North duced to Charlie, Rose was walk- Charlie to combine his talents as a Vancouver and later at Kitsilano High ing down a street in Montreal when physician with those as a fisherman, School, where he graduated at the ten- she ran into him. Charlie was then a and gave him some valuable dad-time der age of 15. He attended UBC for third-year medical student at McGill. as well. With these visits, he provided undergraduate work and considered They started discussing the unusually expert medical care to this underser- becoming an optometrist. His father, hot weather and the fact, she felt, that viced area, while reaping the benefits thinking that optometry required go- it had given her a heat rash. Charlie of well-stocked streams. ing to medical school, sent him to immediately said, “That is not a heat Traveling was also important to McGill where he graduated second in rash; you have chicken pox.” He Charlie and Rose, but not to popular his class in 1952. Postgraduate work was correct. Whether that encounter and frequented places: they visited in Montreal and Vancouver resulted sealed the deal or not, they eventually countries most would not consider. in his entering practice in Vancouver married and remained so for 64 years. As Rose will tell you, she has been to with G.F. Strong, Don Monroe, and Charlie and Rose had four chil- the Khyber Pass in Afghanistan and Bruce Paige. Cardiology was his spe- dren: Anne, Charles Jr., Elisabeth, and to West Africa, slept in yurts in Uz- cialty, but he excelled in all fields of David. From them came 14 grand- bekistan, and ridden up winding roads internal medicine. children and one great-grandchild. in Yemen, but she has never been to In the practice of medicine, Char- The family was a unit and even after Paris. lie’s clinical acumen was outstand- the children grew up and had progeny With Charlie’s passing, we have ing, as many can attest. I personally of their own, Saturday night always lost an intelligent, passionate, caring remember discussing with him a com- meant dinner at the Rallys’. Each physician: one of the old-fashioned plex case that had me puzzled. In a summer was spent in Vernon with types who was loved by patients, col- short few minutes of consideration, children and grandchildren. In 1999, leagues, and friends. I feel privileged he presented a clear and precise so- a property was purchased on Kala- to have known him. lution. His dedication to and respect malka Lake where all could vacation —Michael Moscovich, MD for all his patients and his gentle and together. The bonds formed with the Campbell River

166 bc medical journal vol. 60 no. 3, april 2018 bcmj.org gpsc

A mental health resource for all communities: The Salt Spring Island Youth Suicide Intervention Toolkit hen a child or youth ap- • A Suicide Intervention Toolkit for cians, Island Health program leader- pears to be struggling with Professionals on Salt Spring Island ship, and youth from the community. W suicidal ideation, talking • A Suicide Intervention Toolkit for Once the kits were finalized, Dr Ryan with them about it can be difficult— Parents and Caregivers on Salt worked with physician colleagues to for physicians, parents, teachers, and Spring Island champion distribution of the kits in friends alike. But as physicians know, All versions of the toolkit provide hospital and clinic settings on Salt these conversations are important: information on supports and resourc- Spring Island. statistics show that suicide is the sec- es in the community, crisis lines and ond highest cause of death for youth apps, self-management strategies, A resource for all age 10 to 24 in Canada.1 Suicide inter- and ways to identify risk factors. In- BC communities vention is a particularly pressing is- formation included is practical and The Salt Spring Island LAT and the sue for rural physicians: BC Coroners evidence-based, using language that Rural and Remote Division of Family Service data on suicide deaths in BC is simple and jargon-free. Answers Practice have made the toolkit con- between 2006 and 2015 show that sui- are provided to difficult questions tent and design files available to other cide rates in Vancouver Island Health such as, “How do you talk to a youth BC LATs so they can customize them and Northern Health regions are 34% who has suicidal thoughts?” “What with their own local information. For and 68% higher (respectively) than in do you say or not say?” “Will talking information on accessing the custom- the Vancouver Coastal Health region.2 about suicide cause more harm than izable toolkit design files, contact A provincial youth suicide pre- good?” Questions are answered from [email protected]. vention guide created by the Ministry different perspectives geared toward The kits have now been repur- of Children and Family Development the toolkits’ three different audiences. posed and distributed in 11 communi- in 20163 provides provincial-level re- The professional version of the ties throughout BC. sources and supports conversations toolkit also includes risk assessment —Afsaneh Moradi from a practitioner perspective. Rec- and universal precautions, while the Acting Director, Community ognizing that doctors, caregivers, and youth version incorporates stories Partnership & Integration, youth in their region needed access to from other teens who have experi- Doctors of BC local suicide intervention resources, enced suicidal ideation and are now the Local Action Team (LAT) of the on the road to recovery. References Child and Youth Mental Health and Funding from the Shared Care 1. Canadian Children’s Rights Council. Youth Substance Use (CYMHSU) Collab- Committee was the key enabler in Suicide in Canada. Who is at risk? Ac- orative—with the Salt Spring Island creating the toolkit. The Salt Spring cessed 7 February 2018. https://canadian Chapter of the Rural and Remote Di- Island LAT contracted two local crc.com/Youth_Suicide_in_Canada.aspx. vision of Family Practice as a key part- CYMHSU clinicians to compile base 2. BC Coroners Service. Suicide Deaths in ner—created a grassroots solution: content for the toolkits, which were BC 2006–2015. Rate of Suicide Deaths in the Salt Spring Island Youth Suicide then revised as part of a team effort by BC by Health Authority per 100 000 per- Intervention Toolkit. To support con- the LAT to shape it into the final docu- sons, 2006–2015. Accessed 7 February versations from several different per- ment. Salt Spring Island Chapter phy- 2018. www2.gov.bc.ca/assets/gov/pub spectives, three versions of the toolkit sician lead Dr Paula Ryan guided the lic-safety-and-emergency-services/death are available: one for youth and their content creation process, and the LAT -investigation/statistical/suicide.pdf. friends, one for professionals, and one hired a project lead whose experience 3. White, J. Ministry of Children and Family for parents and caregivers: includes working as the executive di- Development. Preventing youth suicide: • Salt Spring Island Youth Suicide In- rector for NEED2—a not-for-profit A guide for practitioners. July 2016. Ac- tervention Toolkit organization that works on suicide cessed 7 February 2018. www2.gov prevention and education, and runs a .bc.ca/assets/gov/health/managing-your This article is the opinion of the GPSC and youth crisis hotline. -health/mental-health-substance-use/ has not been peer reviewed by the BCMJ Feedback on the kits was provided child-teen-mental-health/preventing Editorial Board. by LAT members—clinicians, physi- _youth_suicide_practitioners_guide.pdf.

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 167 news

Facility Engagement: Relationships drive change PVD: It’s not in your head The Facility Engagement Initiative ment for change, but it will continue On 6 October 2017 the Women’s continues to gain momentum with to take effort on the part of physi- Health Research Institute (WHRI) 69 hospital-based physician groups cians and health authorities. in Vancouver located on the BC now organized and leading more How will we know if it is work- Women’s Hospital campus helped to than 500 projects across BC. So ing? When doctors are able to priori- launch an awareness campaign titled what is energizing this activity? tize the issues most important to them #ItsNotInYourHead. This campaign, Mainly, it’s relationships. My and discuss them with the health au- championed by Dr Lori Brotto, a father, who was an obstetrician, thority, and say, “We’re organized women’s health researcher, clin- worked at the tertiary care teach- now. We’d like to be involved.” And ician, and executive director of the ing hospital in Edmonton. He used when the health authority comes to WHRI, centres on a chronic genital to say he would not infrequently see physicians to ask for input about their pain condition called provoked ves- Dr Snell—the CEO of the hospital 10-year plan or important clinical de- tibulodynia (PVD). at the time—in the hallway. If there cisions before they make them, and PVD is a type of localized vulvo- was an issue to discuss, the two of says, “We should talk to these doc- dynia (pain in the vulva). The esti- them would just talk about it. tors. They know what they’re doing.” mated prevalence of this condition is Today, doctors may never see That doesn’t mean that every about 12% in the general population the CEO or other senior executives. doctor will get what they want. But and approximately 20% of women There’s not a one-on-one relation- if physicians have a chance to weigh under the age of 19. It is character- ship anymore, for a variety of rea- in and be involved, we will make ized by intense pain provoked with sons. The pressure on resources, some progress. direct contact to the vulvar vestibule staff, and the whole system is so We also realize that doctors need (located at and around the entrance much greater. We can’t expect to be to do a better job of talking to each of the vagina). This can happen able to stop Dr Snell in the hallway other about their issues. Through during sex, when attempting to use and talk to him about our issues. this initiative they are doing more of menstrual products, during physical As a result, for the past few de- that, and I hear they are enjoying it. medical exams, when wearing tight cades, physicians have felt that In my previous role as head of clothing, or even when sitting (to they’ve lost their voice. They are surgery, my colleagues and I agreed name a few examples). not always asked about critical de- to reallocate some OR time from one Many women who live with cisions that impact patients. When surgical service to another, based on PVD suffer in silence for years. The concerns arise, often physicians don’t information that we discussed openly. average length of time it takes to re- know whom to contact in the health The group that gave up the OR time ceive an accurate diagnosis spans 3 authority structure. After asking the realized it was not right that cancer to 7 years, and that’s with multiple same question over and over, nothing patients from the other service were visits to a variety of health care pro- changes, and they stop engaging. I waiting longer than their own pa- fessionals. This is, unfortunately, experienced this personally, and have tients who had less-serious problems. because PVD is difficult to diagnose heard it consistently in surveys and in- Supported by good information, based on a physical exam as there terviews with hospital-based doctors. we simply talked, and our patients is no physical sign of pain, infec- That’s why we introduced Facil- benefited, which, in the end, is the tion, abrasions, or trauma. In addi- ity Engagement. It specifically aims whole point. tion, most of the symptoms (intense to remove this barrier that doctors Facility Engagement is sponsored itching, stabbing pains, burning) are feel so discouraged about. It encour- by the Specialist Services Commit- similar to those of other common ages health authorities and doctors tee, one of four committees represent- conditions, such as yeast infections. to talk to each other and build rela- ing a partnership of Doctors of BC All of these factors often result in tionships, and gives physicians time and the BC Government. Read more women being told that their pain is and more opportunity to influence about Facility Engagement progress in their head, which can lead to feel- decisions affecting their workplace at www.facilityengagement.ca. ings of isolation, anxiety, depres- and patient care. —Sam Bugis, MD sion, and distress. We’re optimistic that Facility Executive Director, Physician and One way that PVD can be di- Engagement is creating an environ- External Affairs, Doctors of BC agnosed is with a cotton swab test:

168 bc medical journal vol. 60 no. 3, april 2018 bcmj.org news a clinician uses a moistened cotton WHO conducted a review across 34 to have low MORi scores. Women swab to lightly touch around the vul- countries of documented claims of with midwifery care reported higher var vestibule. A touch on the wom- human rights abuses in childbirth but MADM and MORi scores compared an’s thigh is felt but does not provoke was left to conclude there is no con- with women with just physician care. pain; a touch on the vulvar vestibule, sensus on how to measure disrespect —J. Stewart however, produces immediate sharp, in maternity care practices. However, Senior Director Communications shooting, and stinging pain. Rec- the work of Dr Saraswathi Vedam, and Media Relations, BC Women’s ommending patients to a gynecolo- principal of the University of BC’s Hospital Foundation gist who specializes in vulvovaginal Birth Place Lab and associate pro- health or sexual medicine is also in- fessor of midwifery at BC Women’s Stories for Caregivers: strumental to receiving diagnosis. Hospital, is changing that. Finding solace in a The #ItsNotInYourHead cam­ Funding from partners at the Van- social platform paign is bringing attention to evidence- couver Foundation, BC Women’s The role of the caregiver is crucial to based psychological treatment options Hospital Foundation, and the Michael the physical and mental health of out- for PVD: mindfulness meditation, Smith Foundation for Health Re- patients. However, those providing and cognitive behavioral therapy. search enabled Changing Childbirth essential support are often desperate- The cause of PVD is unknown and in BC, a community-led research ly in need of help themselves. There likely multifactorial, but thankfully project, and led to the development are approximately 1 million care- these treatments have shown to be of the MADM (Mother’s Autonomy givers in BC, and research1 from the effective in managing pain for many in Decision Making) scale and MORi Office of the Seniors Advocate indi- women in clinical trials carried out at (Mothers on Respect index). These cates that 30% of them feel distressed UBC and with funding from the Ca- tools recently received an Innovation and, therefore, unable to continue in nadian Institutes of Health Research. Award from the National Quality Fo- their caring activities. The research With the help of a patient collabora- rum. With new tools in place to quan- also found that the support available tor, Dr Brotto commissioned a short tify a patient’s experience, this data to unpaid caregivers is less access- video that follows one woman’s jour- could now be used to measure current ible now than it has been in previous ney from the onset of PVD through practices and inform new ones. years. It’s estimated that to replace to her diagnosis. The video also de- More than 4000 women across BC family caregivers with paid employ- scribes the findings from the research were surveyed about their childbirth ees would cost BC $3.5 billion a year, and lets others who are suffering from experiences and reported variations which would place increased strain the condition know that they are not in respect and autonomy during preg- on a health care system already under alone, and that their pain is real. nancy depending on their health sta- immense pressure. To learn more about PVD, check tus and preferences for care, as well as To combat the issues of distress, out the campaign on Twitter, Facebook, where and how they gave birth. Over- anger, and depression within the care- and Instagram at @NotInYourHead17. seen by Dr Vedam, the project is run giving community, Vancouver-based through a steering group of women Coup Group has created a new not-for- Respect in the from different cultural and socioeco- profit social platform: www.stories maternity ward nomic backgrounds. Despite the di- forcaregivers.com. The anticipation, the excitement, the versity of the participants, Dr Vedam Stories for Caregivers aims to unknown, and the unrelenting des- says they all raised similar concerns. improve the quality of life for fam- peration to deliver a healthy baby Women who were dissatisfied ily caregivers through emotional sup- are shared by every woman in preg- with their role in decision making port, access to free resources—such nancy. Respect and the opportunity to had very low MADM scores, indicat- as educational videos and webinars— participate in one’s own decisions in ing a lack of autonomy. Dr Vedam’s and a website for users to share their childbirth are likely assumed as auto- research also found women with advice and experiences. matic. But according to the World higher medical or social risks during Dr Yvette Lu, a family physician Health Organization (WHO), that is pregnancy were four times as likely from Burnaby, also hosts an educa- not necessarily so. to have low MORi scores, indicating tional video series called House Call In response to WHO’s report on the they felt less respected by their care on the site. In the series, she visits mistreatment of women during child- providers. Recent immigrants and caregivers and finds practical solu- birth in health facilities, childbearing refugees, or women with a history of tions to the daily challenges they women in BC have created a new tool substance use, incarceration, poverty, face. to measure respectful maternity care. or homelessness were twice as likely Continued on page 171

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 169 council on health promotion

Is current medical training preparing physicians to prescribe exercise to their patients? o reduce the pandemic of cise prescriptions. The most common All patients are impacted by phys- chronic disease, the World barriers, however, among medical ical activity. This underscores the uni- T Health Organization implores students, residents, and clinicians are versal importance of doctors having physicians to target physical inactiv- lack of knowledge, training, and com- foundational knowledge in exercise ity as a key risk factor. Chronic dis- petence in exercise prescriptions. medicine. Physicians and trainees ease causes the majority of Canadian The importance of preparing phy- are currently insufficiently prepared deaths, and if physical inactivity, poor sicians to counsel and prescribe exer- to discuss physical activity and pre- diet, and smoking were eliminated, cise to patients is widely recognized scribe exercise to their patients. Ad- 80% of all heart disease, stroke, and outside the medical community. Edu- dressing this deficiency at all stages of type 2 diabetes, and 40% of cancers cation, training, and the clinical prac- medical training is urgent, given the would be prevented.1 Physical activ- tice of writing exercise prescriptions increasing prevalence of chronic dis- ity is effective treatment and preven- ease and its unprecedented health and 2 tion in 25 chronic conditions. [Small] amounts of physical economic implications on our society. Exercise follows a dose response BC has an opportunity to challenge activity also provide curve, with greater health benefits ac- the status quo, create educational op- crued by those who attain higher lev- substantial health benefits. portunities in exercise medicine, and els of fitness, with 50% reduced risk of improve the health and lives of our all-cause mortality and cardiovascu- have been identified in global strate- patients and our communities. lar disease death compared with those gies and national policies, including A CME-accredited half-day with the lowest fitness.3 If Canadians the Canadian Senate’s report, Obe- workshop in exercise prescription is attained the physical activity guide- sity in Canada, which makes recom- coming to Vancouver on Saturday, line level of 150 minutes of moderate mendations to “encourage improved 28 April, at VGH. For more informa- to vigorous physical activity (MVPA) training for physicians regarding diet tion and to register, visit http://casem per week, premature deaths of Cana- and physical activity” and “promote -acmse.org/event/eimc or email eimc dians would decrease 30%.2 From a the use of physician physical activity [email protected]. population health perspective, sig- counseling, including the use of pre- —Kara Solmundson, MD, CCFP nificantly smaller amounts of physi- scriptions for exercise.”6 (SEM), Sport Med Dip, MSc cal activity also provide substantial UBC undergraduate medical edu- health benefits. Inactive patients can cation has started to incorporate ex- References: lower their mortality risk by 10% by ercise medicine into the curriculum, 1. World Health Organization. Overview – simply walking 10 minutes a day.2 yet most residency training pro- Preventing chronic diseases: A vital in- Despite the irrefutable benefits of grams have not. In a recent study of vestment. Accessed 22 February 2018. exercise, only 17.6% of Canadians at- 396 UBC family medicine residents, april-wrap-combined-1.docxwww.who tain guideline levels of physical ac- 95.6% indicated prescribing exercise .int/chp/chronic_disease_report/part1/en/ tivity,4 and only 15.8% of Canadian will be important in their future prac- index11.html. physicians provide patients with ex- tice, yet only 14.9% perceived their 2. Warburton DE, Charlesworth S, Ivey A, et ercise prescriptions.5 Why this dis- training in exercise prescriptions as al. A systematic review of the evidence connect? Physicians cite lack of time adequate.7 Furthermore, 91% of these for Canada’s Physical Activity Guidelines and remuneration as barriers to exer- future physicians indicated they want- for Adults. Int J Behav Nutr Phys Act ed more training in exercise medi- 2010;7:1-220. This article is the opinion of the Athletics cine and exercise prescribing.7 Such 3. Blair SN, Kohl HW, Paffenbarger RJ, et al. and Recreation Committee, a subcommit- training can impact behavior, with Physical fitness and all-cause mortality. A tee of Doctors of BC’s Council on Health Canadian doctors reporting great- prospective study of healthy men and Promotion, and is not necessarily the opin- er confidence discussing exercise women. JAMA 1989;262:2395-2401. ion of Doctors of BC. This article has not and providing more written exercise 4. Statistics Canada (2015). Table 117-0019– been peer reviewed by the BCMJ Editorial prescriptions 3 months following a Distribution of the household population Board. 1-day workshop.8 meeting/not meeting the Canadian physi-

170 bc medical journal vol. 60 no. 3, april 2018 bcmj.org cohp cme calendar

cal activity guidelines, by sex and age group. Accessed 22 February 2018. www5.statcan.gc.ca/cansim/a26?lang =eng&id=1170019#F1. 5. Petrella RJ, Lattanzio CN, Overend TJ. Physical activity counseling and pre- MOVEMENT IS MEDICINE ditions, urogenital symptoms of scription among Canadian primary care Vancouver, 28 Apr (Sat) menopause, sexual health concerns, physicians. Arch Intern Med 2007; Few doctors feel comfortable pre- vulvar pain conditions, and recur- 167:1774-1781. scribing exercise to their patients— rent vulvovaginal infections. The 6. Report of the Standing Senate Commit- do you? Movement is Medicine: focus will be on practical diagnosis tee on Social Affairs, Science, and Tech- What’s Your Patients’ Best Exer- and management. Target audience: nology. Obesity in Canada: A whole-of- cise Prescription, is an interactive family physicians, gynecologists, society approach for a healthier Canada. half-day workshop designed to em- dermatologists, nurse practitioners, March 2016. Accessed 22 February power primary health care provid- residents, medical students. Pres- 2018. https://sencanada.ca/content/ ers with the skills, confidence, and entation by invited speaker Lynne sen/committee/421/SOCI/Reports/ tools to provide exercise counsel- Margesson, MD, Geisel School of 2016-02-25_Revised_report_Obesity ling and prescription to patients of Medicine, Dartmouth, on Vulvar _in_Canada_e.pdf. all ages. Learning objectives: review Ulcers Update and Office Manage- 7. Solmundson K, Koehle M, McKenzie D. evidence for the harms of physical ment of Hidradenitis Suppurativa of Are we adequately preparing the next inactivity and benefits of physical the Vulva. Conference information, generation of physicians to prescribe ex- activity; understand the Canadian program details, and online regis- ercise as prevention and treatment? Physical Activity Guidelines for pa- tration: ubccpd.ca/course/vulvar Residents express the desire for more tients of all ages; learn to incorpor- -health-2018. Tel 604 875-5101, fax training in exercise prescription. CMEJ ate the Exercise Vital Sign into your 604 875-5078, email cpd.info@ubc 2016;7:e79-e96. office visits in 1 minute, or less; use .ca; web https://ubccpd.ca. 8. Fowles JR, O’Brien MW, Solmundson simple motivation interview strat- Continued on page 172 K, et al. Exercise is medicine Canada egies to reframe barriers and en- physical activity counselling and exer- hance behavioral change; is exercise cise prescription training, improves safe? Do I need to medically clear counselling, prescription and referral patients for exercise? Learn what practices among physicians across Can- the best approach is for your pa- ada. Appl Physiol Nutr Metab 2018;doi: tients with pre-existing chronic dis- 10.1139/apnm-2017-0763. ease.Credits: 7 Mainpro+ credits. To register and for more information, visit casem-acmse.org/event/eimc/ news or email [email protected]. Continued from page 169 The creator of Stories for Care- VULVOVAGINAL HEALTH givers, Bannister Bergen, says that UPDATE nearly 30% of Canadians over the Vancouver, 3 May (Thu) age of 15 care for a family member UBC CPD is excited to announce or loved one, but they receive a lack the first BC conference addressing Doctors Helping of attention and support. Stories for vulvar health! We expect a strong Doctors Caregivers is there to let them know regional interest as vulvovaginal that they are not alone. disorders are one of the top rea- Anonymous, confidential help sons women seek help from their and support 24 hours a day, seven days a week. Reference family doctors. To be held at UBC 1. Office of the Seniors Advocate of BC. Robson Square, this unique confer- Call 1-800-663-6729 Caregivers in distress, a growing prob- ence was planned with women’s or visit physicianhealth.com lem. Accessed 16 February 2018. www health care providers in mind and .seniorsadvocatebc.ca/app/uploads/ will provide education in vulvov- sites/4/2017/08/Caregivers-in-Distress aginal disorders. Areas that will be -A-Growing-Problem-Final.pdf addressed include: vulvar skin con-

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Continued from page 171 on preparation and risks before trav- CME listings TROPICAL AND GEOGRAPHIC elling; Herpes zoster: A review on MEDICINE vaccines and avoiding disease com- rates and details Vancouver, 7–11 May (Mon–Fri) plications; Worm infestations: Risk The University of British Columbia assessment, diagnosis, and manage- Rates: $75 for up to 150 words Faculty of Medicine is pleased to ment. 8 Jun (MSK, sports medicine, (maximum),­ plus GST per month; once again offer this short intensive and rheumatology). To register, and course for health care providers who for more information visit ubccpd. there is no partial rate. If the seek an update on infectious tropical ca, call 604 875-5101, or email cpd. course or event is over before diseases and determinants of health in [email protected]. an issue of the BCMJ comes these geographic settings. This course out, there is no discount. Visa runs 8 a.m. to 5 p.m. and is especially DIABETES DIRECTORS and Master­Card accepted. useful for those who intend to practise SEMINAR in areas endemic for these diseases. Vancouver, 11 May (Fri) Deadlines: Material to be covered includes clin- The Endocrine Research Society is Online: Every Thursday (list­ings ical descriptions and approaches to pleased to present the 30th Diabetes are posted every Friday). evaluation and treatment of tropical Directors Seminar, an annual, UBC- diseases, strategies for infection con- accredited gathering of leading dia- Print: The first of the month 1 trol within communities, and a focus betes experts and caregivers across month prior to the issue in on infections whose management British Columbia. Join us at The Sand- which you want your notice to makes a critical difference to sur- man Vancouver City Centre Hotel for appear, e.g., 1 February for the vival. Participants will gain practical a full day presentation series covering March issue. The BCMJ is dis- experience through laboratory and the latest and most pertinent aspects problem-solving exercises. Nearly of diabetes therapeutics and clinical tributed by second-class mail in 250 physicians, nurses, pharmacists, care. Target audience: specialists and the second week of each month and other health professionals have family physicians with an interest in except Jan­uary and August. successfully completed this course. diabetes care, nurses, dieticians, phar- Send material by email to Spaces filled quickly in each of the macists, and other diabetes educators past 4 years since this course was first responsible for diabetes management [email protected]. Tel: offered in Canada. Register early. For within their own groups and com- 604 638-2815. Please provide course details and to register: http:// munities. To register, and for more the billing address and your spph.ubc.ca/continuing-education/ information, please contact Aria Jaz- com­plete contact information. tgm2018. Contact: [email protected]. darehee at the Endocrine Research Tel: 604 822-9599. Society, Endocrine.Research.Soc Planning your CME listing: [email protected]; 604 689-1055. Planning to advertise your CME CME ON THE RUN event several months in ad- VGH and various videoconference PRACTICE SURVIVAL SKILLS vance can help improve atten- locations, 11 May–8 Jun (Fri) Vancouver, 9 Jun (Sat) dance. Members need several CME on the Run sessions are held at UBC CPD’s 11th annual Practice Sur- weeks to plan to attend; we the Paetzold Lecture Hall, Vancouver vival Skills—What I Wish I Knew in General Hospital, and there are op- My First Years of Practice will be held suggest that your ad be posted portunities to participate via video- at UBC Robson Square. This course 2 to 4 months prior to the event. conference from various hospital will emphasize practical, nonclinical sites. Each program runs on Friday knowledge crucial for your career, afternoons from 1 p.m.–5 p.m. and with topics such as billing, navigating includes great speakers and learning through the medical organizations, materials. Topics and dates: 11 May accreditation, practice audits, med- (Infectious Disease & Travel). Topics icolegal advice and report writing, Continued on page 172 include: Zika update; c. difficile man- job finding, office skills and manage- agement update; HIV 2018 update: ment, physician resources, practice PrEP; STI update; Managing skin management, and avoiding physician infections: Best treatments options; burnout. Target audience: family Practice tips: Advising our patients physicians, specialty physicians, lo-

172 bc medical journal vol. 60 no. 3, april 2018 bcmj.org cme calendar cums, IMGs, physicians new to BC, for local cancer patients and their us on the pristine Hawaiian island of family practice and specialty resi- families. Following the introductory Moloka’i for this 7-day meditation dents, physicians working in episodic session, participants complete a fur- retreat for physicians. Learn mindful- care settings. Course format: Collab- ther 30 days of customized clinic ex- ness and meditation for deep relaxa- orative didactic lectures and inter- perience at the cancer centre where tion and healing; connect with fellow active small group workshops; plenty their patients are referred. These can physicians; and bring a restored per- of networking opportunities; prac- be scheduled flexibly over 6 months. spective and vitality into your per- tice-based exhibits. Join us at the end Participants who complete the pro- sonal and professional lives. This of the day for a job fair and network- gram are eligible for credits from the retreat will offer instruction in basic ing reception to meet with colleagues College of Family Physicians of Can- and more advanced meditation skills and make career connections! Con- ada. Those who are REAP-eligible interspersed with small group discus- ference information, program details, receive a stipend and expense cover- sion and sharing, as well as opportun- and online registration: ubccpd.ca/ age through UBC’s Enhanced Skills ities for self-reflection and deep rest. course/practice-survival-skills-2018. Program. For more information or to Please see www.livingthismoment. Tel 604 875-5101; fax 604 875-5078; apply, visit www.fpon.ca, or contact ca for more information and to regis- email [email protected]; web https:// Jennifer Wolfe at 604 219-9579. ter. This retreat only has room for 18 ubccpd.ca. participants so please register today. MINDFULNESS IN MEDICINE Contact [email protected] FERTILITY & REPRODUCTIVE Molokai, HI, 13–20 Oct (Sat–Sat) for more information. MEDICINE SYMPOSIUM The culture and practice of medi- Vancouver, 13 Jun (Wed) cine offers unique challenges to This symposium is hosted by the physicians in terms of self-care and Pacific Centre for Reproductive Medi- wellness. This can lead to unhealthy cine and will be held at the Chan Cen- stress, mood disorders, relation- tre for Family Health, 950 W 28 Ave. ship challenges, and burnout. Join The program starts with breakfast and registration at 7:30 a.m., includes a refreshment break at 9:45 a.m., lunch at 12:15 p.m., and ends with a recep- tion at 5 p.m. Excellent local faculty featuring Drs Caitlin Dunne, Jeff Roberts, Jon Havelock, Ken Poon, Rebecca Warburton, Sabrina Gill, Sheona Mitchell, Tim Rowe, and Ken Seethram. Admission is compliment- ary. RSVP [email protected]. Check out our physician resources page at pacificfertility.ca.

GP IN ONCOLOGY TRAINING Vancouver, 10 Sep–21 Sep and 18 Feb–1 Mar 2019 (Mon–Fri) The BC Cancer Agency’s Family Practice Oncology Network offers an 8-week General Practitioner in Onc- ology training program beginning with a 2-week introductory session www.johnson.ca/doctorsofbc every spring and fall at the Vancouver Centre. This program provides an op- portunity for rural family physicians, with the support of their community, to strengthen their oncology skills so that they may provide enhanced care

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 173 billing tips

Audit red flag: Treating a family member or yourself, and billing for it n 2014 the Patterns of Practice 1. Services are not benefits of MSP member is in contravention of the Committee published the follow- if a medical practitioner provides CMA Code of Ethics, which states: I ing information about physicians them to the following members of “Limit treatment of yourself or mem- billing for family members or them- the medical practitioner’s family: bers of your immediate family to mi- selves. Despite this, there continue a. a spouse nor or emergency services and only to be incidents of physicians treating b. son or daughter when another physician is not readily and billing for family members or c. a step-son or step-daughter available; there should be no fee for themselves. d. a parent or step-parent such treatment.” Furthermore, physi- Physicians are reminded of Pre- e. a parent of a spouse cians whose family billings exceed amble C. 19 of the MSC Payment f. a grandparent $1000 are now being reported to the Schedule and the Doctors of BC g. a grandchild College of Physicians and Surgeons Guide to Fees, which states: h. a brother or sister, or of British Columbia. i. a spouse of a person referred to in Billing for family members rais- This article is the opinion of the Pat- paragraph (b) to (h) es an ethical flag, which can lead to terns of Practice Committee and has not 2. Services are not benefits of MSP if a increased attention from the Billing been peer reviewed by the BCMJ Edito- medical practitioner provides them Integrity Program—something most rial Board. For further information contact to a member of the same household doctors would like to avoid. Juanita Grant, manager, audit and billing, as the medical practitioner. —Lorne Verhulst, MD Physician and External Affairs, at 604 638- Physicians should also be aware Chair, Patterns of Practice 2829 or [email protected]. that billing for services to a family Committee

Updates to the Federal Government’s Proposed Tax Changes Professional Cycle Understanding the Impact on Your Practice DELIVERING MORE AT EVERY STAGE.

Sweeping federal tax rule changes and proposed changes could signifi cantly change how you plan your tax strategies to maximize your practice. An update released in December 2017 by the federal government provided more clarity around what will be excluded from the tax on split income. For the latest information on how these proposed tax changes could impact your business, as well as your options to minimize the effect if the legislation moves forward, go to www.MNP.ca/en/professionals Contact your local MNP business advisor or Don Murdoch, B.C. Leader, Professionals Services, at 1.877.766.9735 or [email protected]

174 bc medical journal vol. 60 no. 3, april 2018 bcmj.org college library

Finding clinical practice guidelines

linical practice guidelines CPG Infobase provides a link to the please contact the College of Physi- are “statements that include online full-text version or contact cians and Surgeons of BC library at Crecommendations intended information for the producer. 604 733-6671 or [email protected] or to optimize patient care and are in- view a list of guideline sources on our formed by a systematic review of Practice Guidelines page. For guideline suggestions evidence and an assessment of the —Karen MacDonell, PhD, MLIS or assistance locating benefits and harms of alternative care Director, Library Services options.”1 Their utility and limitations copies of guidelines, have recently been well described please contact the References by D. Etches in This Changed My College of Physicians and 1. Institute of Medicine (US) Committee on 2 Practice. Surgeons of BC library. Standards for Developing Trustworthy Given that many guidelines are Clinical Practice Guidelines; Graham R, created outside of the scholarly pub- Mancher M, Miller Wolman D, et al., edi- lishing industry, these documents are • The National Guideline Clearing- tors. Clinical practice guidelines we can not necessarily indexed in databases house4 (NGC) is an American di- trust. Washington (DC): National Acade- such as Medline. This creates a chal- rectory of guidelines with an inter- mies Press (US); 2011. lenge to locate and access current national scope including Canadian 2. Etches D. Guidelines. This Changed My guidelines. Fortunately, the two other guidelines and those from SIGN Practice. 21 Feb 2018. Accessed 7 March directories make finding guidelines and NICE in the UK. The NGC pro- 2018. http://thischangedmypractice.com/ easy: vides remarkably detailed summa- guidelines. • The Canadian Medical Association ries and links to the full text where 3. CPG Infobase: Clinical practice guidelines. maintains CPG Infobase,3 a directo- available. Criteria for inclusion in Canadian Medical Association. Accessed ry of guidelines produced in Canada this directory are more rigorous 7 March 2018. www.cma.ca/En/Pages/ by health organizations, societies, than the CPG Infobase, requiring clinical-practice-guidelines.aspx. governments, or expert panels or systematic literature reviews and 4. National Guideline Clearinghouse. Agen- by similar non-Canadian groups. explicit reflections on benefits and cy for Healthcare Research and Quality These guidelines have been created harms. (US). Rockville, MD. Accessed 7 March or reviewed within the last 5 years For guideline suggestions or as- 2018. www.guideline.gov. and are based on literature1/3 searches. horizontal sistance locating copies of guidelines,6.625 2.75

Specializing in: Infertility IVF and related technologies “Mini-IVF” • Egg freezing Genetic screening (PGS, NIPT) Polycystic Ovary Syndrome (PCOS) 604-558-4886 West Broadway and Ash St., Vancouver FERTILITYWITHGRACE.COM

bc medical journal vol. 60 no. 3, april 2018 bcmj.org 175 classifieds

practices available VANCOUVER—FP BREASTFEEDING ARMSTRONG—FT FAMILY MEDICINE PHYSICIAN N VANCOUVER—PRACTICE The Vancouver Breastfeeding Centre is look- Haugen Medical Group, located in the heart of TAKEOVER OPPORTUNITY the North Okanagan, is in need of a full-time Permanent physician or long-term locum re- ing for an enthusiastic physician with a special family physician to join a busy family practice quired to take over a well-established and high- interest in breastfeeding medicine to join the clinic. The retiring MDs will offer mentorship group. Flexible hours, congenial peers, and revenue family practice in North Vancouver— competent nursing and MOA staff will pro- an area known for its great lifestyle, outdoor as needed. Maternal and child health experi- ence and IBCLC qualification are assets. Visit vide exceptional support with very competitive pursuits, and wonderful community. This is a overhead rates. Obstetrics, nursing home, and latchkey practice with group support and an as- www.breastfeedingclinic.com for further in- formation. inpatient hospital care are not required, but re- sociated walk-in clinic. There is an established main optional. Payment schedule: fee for ser- base of 2800 patients with the current physi- vice. If you are looking for a fulfilling career cian billing $300K-plus per year working 4.5 VICTORIA—OPPORTUNITY: JOIN OR balanced with everything the Okanagan life- days per week. There is the opportunity to buy BUY style has to offer, please contact Maria Varga into the clinic if desired. Experienced MOAs, Well-established, busy walk-in clinic with for more information at [email protected]. electronic records, and well-set-up supportive family practices on site. Looking to add more and harmonious working environment. Con- owners or to sell clinic outright. Attractive BURNABY—FP/WALK-IN, FT OR tact Dr Rockford Samborski at lvclinic@telus business/practice opportunity. Reply to victoria LOCUM .net. [email protected]. Canway Medical Centre, Burnaby, is seeking an associate to join their team of family phy- QUADRA ISLAND—PRACTICE FOR sicians. Clinic has diverse patient population SALE employment (ages and genders). We have OSCAR EMR; Family practice for sale: $1.00! The right friendly, knowledgeable, and skilled staff. doctor for this clinic wants a low-stress, no- ABBOTSFORD—LOCUMS Flexibility to work full- or part-time, walk-ins hospital, full- or part-time practice with nurse Full-service East Abbotsford walk-in clinic re- or build your own practice. This clinic is bright practitioner support and rural CME and locum quires locum physicians for a variety of shifts, and spacious, situated in a Burnaby neighbour- funding in an amazing, beautiful, small island including weekends and evenings. Generous hood close to businesses, BCIT, and Burnaby community a short ferry ride from Vancouver split; pleasant office staff and patient popula- Hospital. We have a pharmacy and free park- Island. Call Mary at 250 285-3540 or email tion. Please contact Cindy at 604 504-7145 if ing on site. We have an overwhelming flow of [email protected]. you are interested in obtaining more info. patients. If interested or for more information, call 604 428-8123, email canwaymedical@ shaw.ca, or visit our website: www.canway medicalcentre.ca.

KELOWNA—FAMILY PHYSICIAN Busy family practice clinic centrally located in Canada’s four-season playground look- ing to add a third family physician. Modern, spacious, recently renovated clinic; congenial staff; fully computerized; EMR. Opportunity to branch into residential care, immigration medicine, medical arts research. Hospital op- tional. Contact [email protected].

KELOWNA—LOCUM NEEDED Locum needed for solo practice in Lower Mis- sion any part or all of 29 April to 20 May 2018. Brand-new office with beautiful facilities and great MOAs. If you wish to work FT hours there is plenty of work; I usually only work T-W-Th and cover about 20 nursing home pa- tients. No obs, no inpatients. Call Pam at 250 863-8456 or email [email protected].

KELOWNA—RADIOLOGIST LOCUM Our busy hospital and community clinic prac- tice is in need of locum coverage from mid- March to the end of December 2018 due to ma- ternity leave. Short and longer terms available. Modalities covered include fluoroscopy and DR, US with procedures, CT with biopsies, MRI, mammography and stereo biopsies. NM, angio/interventional available but not required. Contact Dr Mike Partrick at michael.partrick@ interiorhealth.ca.

176 bc medical journal vol. 60 no. 3, april 2018 bcmj.org classifieds

NANAIMO—GP Classified advertising (limited to 700 characters) General practitioner required for locum or Rates: Deadlines: Ads must be submitted or can- permanent positions. The Caledonian Clinic Doctors of BC members: $50 + GST per celled by the first of the month preceding the is located in Nanaimo on beautiful Vancou- month for each insertion of up to 350 char- month of publication, e.g., by 1 November ver Island. Well-established, very busy clinic acters. $75 + GST for insertions of 351 to for December publication. Please call if you with 26 general practitioners and 2 specialists. Two locations in Nanaimo; after-hours walk-in 700 characters. We will invoice on publication. have questions. Tel: 604 638-2858. clinic in the evening and on weekends. Com- Non-members: $60 + GST per month for puterized medical records, lab, and pharmacy each insertion of up to 350 characters. $90 Submit requests at www.bcmj.org/classi on site. Contact Ammy Pitt at 250 390-5228 or + GST for insertions of 351 to 700 charac- fied-advertising-submission-form. e-mail [email protected]. Visit ters. We will invoice on publication. our website at www.caledonianclinic.ca. able 7 days a week (7 a.m. to 7 p.m.). MOA and NORTH DELTA—GP TERRACE—FAMILY PHYSICIAN, NEW support staff provided. Clinic has many unat- Very busy, established family practice located CLINIC tached patients looking for a family doctor, and on Scott Road. The practice consists mainly Join our new primary care office opening in of Punjabi-speaking patients. Two spacious is accompanied with available VDofP supports Terrace, BC. Only 80 minutes north of Vancou- to help build a practice. Offering 70/30 split. exam rooms plus a private office available for ver. Opening in August 2018, the HG Health Email [email protected]. the physician. Underground parking. No set- Centre offers complete provision of medical up fees or equipment required. Everything is office infrastructure to operate your own pro- included in the billing split (80/20). Potential fessional family practice. Outstanding special- VANCOUVER—PSYCHIATRIST to earn 400K per year. Physician may decide ist support: gen surg, int med, peds, OBGYN, NEEDED their own schedule. Each exam room is fully psych, ENT, urology, ophthalmology, and on- Together We Can Drug & Alcohol Addiction equipped with everything required. EMR: Med cology. Obstetrics and ER available, not man- and Education Society is looking to contract a Access. Very friendly medical office assistant datory. ER: uniquely APP funded, and point- psychiatrist for our residential treatment pro- and office manager. For more information con- of-care diagnostics. DI dept includes MRI tact Dr Jagtar Rai at raimedicalclinic@gmail gram. Our clientele is composed of men enter- and on-site radiology. Expand your scope and ing recovery from substance misuse and who .com. vision in your own family practice, and sculpt struggle with concurrent mental health issues. your personal work-life-balance in this unique NORTH VAN—FP LOCUM opportunity. Please contact hermangreeff@ Please look at our website at TWCVancouver. Physician required for the busiest clinic/fam- gmail.com. org. Those who are interested can contact ei- ily practice on the North Shore! Our MOAs ther Matt Rands, reporting counselor, at 604 are known to be the best, helping your day run VANCOUVER/RICHMOND—FP/ 358-7843, or Vince Pirozzi, resident services smoothly. Lucrative 6-hour shifts and no head- SPECIALIST manager, at 604 441-8988. aches! For more information, or to book shifts We welcome all physicians, from new gradu- online, please contact Kim Graffi at kimgraffi ates to semiretired, either part-time or full- VICTORIA—GP/WALK-IN @hotmail.com or by phone at 604 987-0918. time. Walk-in or full-service family medicine Shifts available at three beautiful, busy clinics: and all specialties. Excellent split at the busy Burnside (www.burnsideclinic.ca), Tillicum POWELL RIVER—LOCUM South Vancouver and Richmond Superstore (www.tillicummedicalclinic.ca), and Uptown The Medical Clinic Associates is looking for medical clinics. Efficient and customizable (www.uptownmedicalclinic.ca). Regular and short- and long-term locums. The medical OSCAR EMR. Well-organized clinics. Please community offers excellent specialist backup contact Winnie at medicalclinicbc@gmail occasional walk-in shifts available. FT/PT GP and has a well-equipped 33-bed hospital. This .com. post also available. Contact drianbridger@ beautiful community offers outstanding out- gmail.com. door recreation. For more information contact VANCOUVER—FP Laurie Fuller: 604 485-3927, e-mail: clinic@ Mainland Medical Clinic is seeking a fam- VICTORIA—PERMANENT/P-T FP tmca-pr.ca, website: powellrivermedicalclinic ily doctor for our modern, multidisciplinary Experienced family physician wishing to ex- .ca. street-level clinic in Yaletown, downtown pand medical team at Mattick’s Farm in beau- Vancouver. We have been operating for over tiful Cordova Bay. Fully equipped office, OS- S SURREY/WHITE ROCK—FP 13 years in a comfortable setting shared with CAR EMR, congenial staff, close to schools. Busy family/walk-in practice in South Surrey a chiropractor, massage therapists, and a nutri- Contact [email protected], phone requires GP to build family practice. The com- tionist to complement our three family doctors. 250 658-5228. munity is growing rapidly and there is great Ideally seeking someone with an existing prac- need for family physicians. Close to beaches tice—perhaps relocating or cutting back. We and recreational areas of Metro Vancouver. serve a broad spectrum of patients, both walk- ABBOTSFORD—NEW CONSTRUCTION OSCAR EMR, nurses/MOAs on all shifts. ins and appointments. Excellent revenue split. PRACTICE SPACE CDM support available. Competitive split. The clinic offers a pleasant work environment Move-in ready. New physicians or relocating, Please contact Carol at Peninsulamedical@ in an upbeat, fun neighborhood. Contact Dr we would make your transition seamless and live.com or 604 916-2050. Brian Montgomery at brian@mainlandclinic take care of advertising and chart transfers. We .com or 604 240-1462, or just drop by. could discuss a signing bonus to help with your SURREY/DELTA/ABBOTSFORD—GPs/ move to Abbotsford. If you are looking for SPECIALISTS VANCOUVER—FT/PT FAMILY space, come and take a look. OSCAR EMR, Considering a change of practice style or loca- PHYSICIANS & PSYCHIATRISTS online appointment booking, and telemedicine. tion? Or selling your practice? Group of seven New medical office in the Fairmont Medical locations has opportunities for family, walk-in, Building is looking for family physicians who We take care of all administration. Located on or specialists. Full-time, part-time, or locum want to move or start a practice. Office features Sumas Way at Marshall Road. Visit our website doctors guaranteed to be busy. We provide four fully furnished exams rooms; able to ac- at www.healthvue.ca. Contact us at manager administrative support. Paul Foster, 604 572- commodate both paper and EMR (Accuro) @healthvue.ca or 604 670-8762. 4558 or [email protected]. practices. Office hours are flexible and avail- Continued on page 178

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Continued from page 177 offices are suitable for psychiatrists, psycholo- at www.2ascribe.com, [email protected], or gists, or counselors. New furniture, including toll free at 1 866 503-4003. in the waiting area. Customize your office and medical office space bring in your phone, fax machine, etc. Offices FREE MEDICAL RECORD STORAGE VANCOUVER (BRDWY & CAMBIE)— are available immediately on a 1-year lease ba- Retiring, moving, or closing your family prac- MED OFFICE SPACE FOR SALE OR sis; however, will consider other options. Ne- tice? RSRS is Canada’s #1 and only physician- LEASE gotiable and reasonable rent. Call or text 604 managed paper and EMR medical records stor- Highly desirable Broadway and Cambie loca- 970-6600 or e-mail [email protected]. age company. Since 1997. No hidden costs. tion, minutes walk to VGH and Broadway- Call for your free practice closure package: City Hall Canada Line station. Underground everything you need to plan your practice clo- visitors’ parking for patients’ convenience. sure. Phone 1 866 348-8308 (ext. 2), e-mail Medical office space for sale or lease: vacation properties [email protected], or visit www.RSRS.com. 500 to 600 sq. ft.; lease: 3162 sq. ft. Visit PROVENCE, FRANCE—YOUR VILLA www.550WestBroadway.com or call 604 505- Les Geraniums, a luxury 3-bedroom, 2½ bath PATIENT RECORD STORAGE—FREE 6810 for more details. villa, is your home in the heart of Provence. Retiring, moving, or closing your family or Expansive terrace with pool and panoramic general practice, physician’s estate? DOCU- VANCOUVER (MAIN STREET)—2 MED views. New kitchen and bathrooms. Walk to davit Medical Solutions provides free storage for your active paper or electronic patient re- OFFICE SPACES FOR LEASE lovely market town. One hour to Aix and Nice. cords with no hidden costs, including a patient Two separate second-floor office spaces for Come and enjoy the sun of southern France! mailing and doctor’s web page. Contact Sid lease: 650 and 600 sq. ft. Both set up as general 604 522-5196. [email protected]. medical. Established pharmacy on main floor. Soil at DOCUdavit Solutions today at 1 888 Unit 1: $1500/month, waiting room, three 781-9083, ext. 105, or e-mail ssoil@docudavit.­ exam or office rooms. Unit 2: $1400/month, com. We also provide great rates for closing waiting room, two exam rooms, one small miscellaneous specialists. office. No elevator access. Utilities and unit CANADA-WIDE—E TRANSCRIPTION cleaning included, property tax $5800/year. VANCOUVER—TAX & ACCOUNTING SVCS SVCS E Transcription Services allows hospitals, VANCOUVER (W BROADWAY)— Rod McNeil, CPA, CGA: Tax, accounting, clinics, and specialists to outsource a critical and business solutions for medical and health FURNISHED SPACE business process, reduce costs, and improve Fully furnished space for one or multiple doc- professionals (corporate and personal). Spe- the quality of medical documentation. By out- tors. Space can be used part-time or full-time cializing in health professionals for the past 11 sourcing transcription work you will be able to with short- or long-term arrangement possible. years, and the tax and financial issues facing increase the focus on core business activities Use some or all of the large space. MOA pro- them at various career and professional stages. The tax area is complex, and practitioners are vided if needed. Extraordinary views. Con- and patient care. Our goal is to exceed your ex- often not aware of solutions available to them crete professional building with elevators, pectations. Call for free trial 1 877 887-3186. and which avenues to take. My goal is to help underground parking, and three restaurants. www.etranscription.ca. you navigate and keep more of what you earn Available immediately. Please call Neil at 604 by minimizing overall tax burdens where pos- 644-5775. CANADA-WIDE—MED sible, while at the same time providing you TRANSCRIPTION with personalized service. Website: www. Medical transcription specialists since 2002, VANCOUVER—TWO RENOVATED rwmcga.com, e-mail: [email protected], OFFICES CLOSE TO VGH Canada wide. Excellent quality and turn- phone: 778 552-0229. Two fully renovated office spaces available around. All specialties, family practice, and close to VGH with city views. Close to the IME reports. Telephone or digital recorder. Broadway–City Hall Canada Line station on Fully confidential, PIPEDA compliant. Dicta- Cambie for your patients’ convenience. The tion tips at www.2ascribe.com/tips. Contact us

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