IN THIS ISSUE: April 2019; 61:3 Cardiac auscultatory teaching and its Pages 101–148 role alongside echocardiography The value of independent drug assessment BC’s Tuberculosis Strategic Plan: Refreshed and focused on TB Falling through the cracks: How service gaps leave children with neurodevelopmental disorders and mental health difficulties without the care they need

www.bcmj.org 2019 Winner

102 bc medical journal vol. 61 no. 3, april 2019 bcmj.org bc medical journal vol. 61 no. 3, april 2019 bcmj.org 103 April 2019 Volume 61 • Number 3 contents Pages 101–148

106 Editorials Langley City family practice, David R. Richardson, MD (106) Reflections on my first year of independent practice, so far, Yvonne Sin, MD (107)

109 President’s Comment Are doctors territorial? When it comes to quality care, we better be Eric Cadesky, MD

110 Letters to the Editor Re: Cannabis use by adolescents, Ian Mitchell, MD (110) On the cover Author replies, A.M. Ocana, MD (110) MyoActivation for the treatment of pain & disability, Suzanne There is a lack of specialized Montemuro, MD (111) mental health services for chil- dren with a dual diagnosis, and To sleep or not to sleep, George Szasz, CM, MD (111) the resulting inadequate level of community support has placed the burden of care on families. Article begins on page 114. Clinical Article

114 Falling through the cracks: How service gaps leave children with neurodevelopmental disorders and mental health difficulties without the care they need Erika Ono, MSW, Robin Friedlander, MD, Tamara Salih, MD The BCMJ is published by Doctors of BC. The journal provides peer-reviewed clinical and review articles written 125 Premise primarily by BC physicians, The value of independent drug assessment for BC physicians, along with James M. Wright, MD, Ken Bassett, MD, Thomas L. Perry, MD, Aaron M. Tejani, debate on medicine and medical politics in editorials, letters, and PharmD essays; BC medical news; career and CME listings; physician profiles; and regular columns. 128 BCMD2B Print: The BCMJ is distributed Modern-day cardiac auscultatory teaching and its role alongside monthly, other than in January and August. echocardiography Caleb A.N. Roda, BSKin Web: Each issue is available at www.bcmj.org. Subscribe to print: Email 131 [email protected]. WorkSafeBC Single issue: $8.00 Indoor air quality Canada per year: $60.00 Sami Youakim, MD Foreign (surface mail): $75.00 Subscribe to notifications: To receive the table of contents by email, visit www.bcmj.org and click on “Free e-subscription.” Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org for submission requirements.

104 bc medical journal vol. 61 no. 3, april 2019 bcmj.org contents

BC Medical Journal Vancouver, Canada 604 638-2815 132 News [email protected] Changes to the Editorial Board (132) www.bcmj.org Read the quarterly GPSC newsletter online (132) GPSC article update (132) Compass program (132) Editor Online sexually transmitted infection testing offers many benefits(133) David R. Richardson, MD Tool to help with early detection of melanoma (133) Editorial Board Pre- and postnatal nutrition program in Victoria (134) Jeevyn Chahal, MD (134) David B. Chapman, MBChB Protein “switch” could be key to controlling blood poisoning Brian Day, MB David Esler, MD Amanda Ribeiro, MD 135 Council on Health Promotion Yvonne Sin, MD Cynthia Verchere, MD Canadian physicians support mandatory alcohol screening Roy Purssell, MD, Robert Solomon, LLB, Erika Chamberlain, PhD Managing editor Jay Draper Associate editor 136 BC Centre for Disease Control Joanne Jablkowski

Senior editorial and British Columbia’s Tuberculosis Strategic Plan: Refreshed and focused production coordinator on TB elimination Kashmira Suraliwalla Shaila Jiwa, RN, Victoria Cook, MD Copy editor Barbara Tomlin

Proofreader 137 College Library Ruth Wilson DynaMed Plus: Updated point-of-care tool now available Web and social media Robert Melrose coordinator Amy Haagsma Design and production 138 CME Calendar Laura Redmond Scout Creative

Cover concept & art direction 143 Guidelines for Authors (short form) Jerry Wong Peaceful Warrior Arts Printing 144 Classifieds Mitchell Press

Advertising Kashmira Suraliwalla 146 Back Page 604 638-2815 [email protected] Proust Questionnaire: Dr Caitlin Dunne

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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, 2019. 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.

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 105 editorials

Langley City family practice

have spent over 25 years of my life working at Langley Hospital, where worried, because this environment as a family physician in Langley I have fostered excellent relationships fostered closeness and sharing. There I and have seen many changes in with many physicians and staff. is always someone around to bounce my community during this time. The Speaking of relationships, one ideas off and listen to concerns about population has more than doubled, re- constant during all of this growth has this patient or that issue. Complaints sulting in increased traffic congestion, been the welcome presence of the are shared, lightening the burden each commercial areas, infrastructure, and physicians with whom I work closely of us carries throughout our busy recreational facilities. Langley now in our clinic. I feel so lucky and have practices. We also regularly laugh and has every big-box retailer known to been blessed to have shared these joke with one another. Fridays after Western civilization, including Cost- years with these quality individuals. work are one of my weekly highlights co, Walmart, Home Depot, and the Four became five, and now we are six. as we settle into the weekend by shar- Real Canadian Superstore. What was When I first joined the original three, ing some drinks and snacks. previously a quiet drive into the cen- I was surprised to find that our office We have seen each other through tral core is now a stop-and-go traffic desks were in the same room without illnesses, accidents, tragedies, divorc- light adventure. Despite this, Langley any physical barriers to separate them. es, aging parents, and so much more. has been good to me. My two children I found this lack of privacy unnerving These people are my rocks and I know were raised here and I have made many and was concerned about confidenti- they have my back through thick and good friends over the years. I also met ality, interruptions, and noise levels. I thin. Now don’t get me wrong; we’ve my wife here, twice.* I managed to wondered how work would get done had our disagreements over the years, build a busy family practice while in this open space. I shouldn’t have but they have been handled with mu- tual respect and care. We hear about practices that have disbanded as a re- sult of differences and disputes. I’m Travel insurance not sure if it was by luck or some un- “I’ll stop seen force, but I couldn’t have chosen that’ll get chasing mine” a better group of work colleagues. I have spent more time with these peo- tails wagging. ple than I have with most of my fam- ily and friends, yet I don’t tire of their wit, humor, compassion, caring, and support. Perhaps I have become more sentimental as I begin to think about retirement, but it has been a wonder- Get a quote & you’ll be ful journey working with these excel- entered for a chance to lent physicians whom I am proud to WIN call my friends. $25,000† Joining a practice is like a mar- Get hassle-free travel insurance at a great riage in many ways, so to those phy- price with MEDOC® Travel. Insurance. sicians considering joining a practice, 1-855-473-8029 I encourage you to choose wisely. I know I did. johnson.ca/doctorsofbc TRAVEL —DRR Johnson Inc. (“Johnson”) is a licensed insurance intermediary. MEDOC® is a Registered Trademark of Johnson. MEDOC® is underwritten by Royal & Sun Alliance Insurance Company of Canada (“RSA”) and administered by Johnson. Valid provincial or territorial health plan coverage required. The eligibility requirements, terms, *The first time we met there was an conditions, limitations and exclusions, which apply to the described coverage are as set out in the policy. Policy instant connection and a feeling of wordings prevail. Johnson and RSA share common ownership. Call 1-855-473-8029 for details. †NO PURCHASE NECESSARY. Open January 1, 2019 –April 30, 2020 to legal residents of Canada (excluding NU) electricity passing between us . . . that who have reached the age of majority in their jurisdiction of residence and are a member of a recognized group of JI with whom JI has an insurance agreement. One (1) available prize of $25,000 CAD. Odds of winning apparently only I felt as she doesn’t depend on the number of eligible entries received. Math skill test required. Rules: www1.johnson.ca/cash2019 remember the interaction.

106 bc medical journal vol. 61 no. 3, april 2019 bcmj.org editorials

Reflections on my first year of independent practice, so far

hen 1 July 2018 came genuine surprise, but some can come thought that if I passed the exam then around, I had done the across as judgmental. One patient all the knowledge I needed for family W countless paperwork and even talked to me for a good 10 min- medicine would be there, and, miracu- paid my dues. I finally got the okay to utes before he finally asked, “When lously, between 30 June and 1 July I venture into the world of family medi- am I going to see the real doctor?” I would become the wise, all-knowing cine on my own. It was, and still is, could only reply, “Sorry, Mr S., I am doctor I strived to be. But I woke up an exciting time, but also a terrifying who you are seeing today.” on 1 July feeling like the same person time. I spent the first few weekends of I was the day before. this monumental year thinking about There are still many things I do I am able to share quite a all the cases I had seen the week prior not know, so I ask for help from col- bit of knowledge and pearls and second guessing myself about leagues, check resources, and consult some. I ended up calling several pa- I have gained along the way, specialists. I also look back and realize tients to check on how they were despite only having been in how much more I do know compared doing, and most of them were, first, practice for a short time. to only several months ago. I am more surprised I called and, second, usually confident dealing with cases and mak- doing better, and if not, there was a There will come a time when these ing decisions. I was hesitant at first to plan of what to do next. This put my remarks no longer occur. I’m not sure teach medical students and residents mind at ease somewhat. The unknown if I’m looking forward to that or not. because I thought I would not have is still scary, but I know it is a part of Nonetheless, I remind myself that my much knowledge to share, but in re- the growing pains and transition. I’m training has enabled me to help pa- ality, I am able to share quite a bit of also happy to say that my weekends tients, so being the most professional knowledge and pearls I have gained are generally getting better. and knowledgeable that I can be is the along the way, despite only having Another thing I’ve noticed is the best response. In the meantime, I may been in practice for a short time. many remarks on my age and expe- as well take them as a compliment. This period of transition is an ex- rience. The remarks I most often get The one thing I did not truly come citing time. There are finally no resi- are, “Oh, I thought I would be see- to understand fully until recently is that dency requirements to fulfill but we ing someone . . . older,” or, “You look the learning never stops in medicine. in turn become fully accountable for like you are in high school!” I have Yes, mentors and teachers told me that our patients. To my fellow colleagues not yet come up with a good response they are constantly learning something who have also recently ventured into to these remarks, so it usually ends new. But for some reason, when I was practice, let’s continue to learn and with an awkward laugh and shrug. I in residency, the end goal seemed to be grow together. I look forward to what think most of the remarks come from passing the CCFP. A small part of me lies ahead in our careers. —YS

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Are doctors territorial? When it comes to quality care, we better be

Being a doctor is chelation therapy, or consuming herbs our communities, we fiercely protect no walk on the such as kava kava. (On a side note, against wasteful investigation, sha- beach. Certainly although language is important and manistic treatments, and fear-pro- it’s rewarding there are historical reasons for its use, voking propaganda. And if doing that work and it’s we ought to find another term for al- makes us territorial, then let me be the a privilege to ternative medicine, because the alter- first to draw a line in the sand. serve others, but native to medicine is not medicine.) —Eric Cadesky, MDCM, recent headlines We are also territorial in advo- CCFP, FCFP suggest that we cating for our health care system,6 Doctors of BC President have had sand thrown in our faces: or at least some improved form of it. • The public is told that nurse practi- Through initiatives like the Guide- References tioners can provide the same care as lines and Protocols Advisory Com- 1. Henning C. Nurse practitioners fill gaps as family doctors.1 mittee,7 continuing education, and family doctor shortage grows. CBC News. • Naturopaths are legitimized through many quality-focused organizations, Accessed 4 March 2019. www.cbc.ca/ funding to treat patients after a car we do not have space for those who news/canada/british-columbia/nurse accident.2 promote unnecessary tests8 or incor- -practitioners-filling-gaps-family-doctor • Some pharmacists want to give a di- rect or imaginary diagnoses.9 We rec- -shortage-1.4565750. agnosis and then sell the treatment.3 ognize cultural humility10 but strive 2. ICBC. Focusing on care, not legal costs. Given the expected pushback to balance that with science, even as Accessed 4 March 2019. www.icbc from our profession, I was recently movements with malicious intent11 .com/about-icbc/changing-auto-insur asked by a reporter why doctors are aim to erode our societal constructs of ance-BC/Pages/focus-on-care-not-legal so territorial. My initial thought was, science and medicine. -costs.aspx. who is more collaborative than doc- It is through this lens of advocat- 3. Ireland N. Pharmacies want to give $15 tors? We work (most importantly) ing for our patients that we can under- strep throat tests—but pediatricians say with our patients and their families, stand recent actions. We are happy to they’re not accurate enough for kids. CBC but also with pharmacists, kinesi- work with nurse practitioners and do News. Accessed 4 March 2019. www. ologists, physio- and occupational so in many settings, but the skills— cbc.ca/news/health/canadian therapists, social workers, speech and and, quite frankly, the value—of doc- -pharmacies-strep-throat-tests-second language therapists, administrators, tors are unparalleled. Pharmacists are -opinion-1.4902431. staff, and many other health care pro- our medication experts and an im- 4. GPSC. Team-based care. Accessed 4 fessionals. We are asking for support portant part of the health care team, March 2019. www.gpscbc.ca/our-im to develop team-based care4 so we but the question of conflict of inter- pact/team-based-care. can work together complementarily est12 diverges from the principle of 5. The College of Family Physicians of Can- and practice to scope.5 patient-centredness. ada. Best advice: Team-based care in the But I have further reflected on And although much online de- patient’s medical home. Accessed 4 this question. While we aren’t neces- bate eventually degrades to prove March 2019. https://bccfp.bc.ca/wp sarily territorial over who provides Godwin’s Law, we as doctors cannot -content/uploads/2015/06/Team-based care to our patients, happily sharing stand by while some naturopaths and -Care-in-PMH.pdf. it with other health care professionals functional medicine doctors encour- 6. Nguyen N, Xu Y. Healthy Debate, Opin- in team-based settings, we are protec- age people to pressure medical doc- ions. Why doctors must be advocates. tive of our patients and of the health tors to order tests13 so that insurance Accessed 4 March 2019. https:// care system we work in. We are ardent will pay for it. healthydebate.ca/opinions/doctors about giving the best care—one need We enjoy serving our patients -must-advocates. only look at the many online forums and putting them first. We want bet- 7. Government of BC. Guidelines and Proto- to see how passionately doctors advo- ter ways to collaborate in teams where cols Advisory Committee (GPAC). Ac- cate to protect patients from unproven each health care professional works cessed 4 March 2019. www2.gov.bc or unlikely investigations and treat- to their full scope. But when it comes .ca/gov/content/health/practitioner ments such as magnetic field therapy, to the well-being of our patients and Continued on page 112

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 109 letters to the editor

We welcome original letters of less than 300 words; they may be edited for clarity and length. Letters may be emailed to [email protected], submitted online at bcmj.org/submit-letter, or sent through the post and must include your mailing address, telephone number, and email address. All letter writers will be required to disclose any competing interests.

Re: Cannabis use are absolutely not saying that mari- Author replies by adolescents juana killed that child.”3 I thank Dr Mitchell for his opinion and This article [BCMJ 2019;61:14-19] As Dr Ocana notes, it can be dif- for standing behind the quote, “There would be the first in the literature to ficult to deal with misinformation; are biochemically distinct strains establish different clinical effects this is magnified when it is published of cannabis, but the sativa/indica from C. sativa and C. indica strains. in a medical journal. The three most distinction as commonly applied in While Dr Ocana insists that clinical commonly held misbeliefs among the lay literature is total nonsense and research supports separating these physicians are that cannabis overdose an exercise in futility.”1 strains because of their different ef- can be fatal, that cannabis is often In effect, Dr Mitchell is saying fects (stimulating vs sedating), the contaminated with fentanyl, and that “strain does not matter.” I can’t say reference he provided does not sup- there are differences in effect between Dr Mitchell is wrong, but it does not port this or even use these differing C. indica and C. sativa strains. align with the data we collected. strain names. Recent chemical analy- —Ian Mitchell, MD, FRCP Dr Mitchell proposes that my ob- sis of cannabis strains from Washing- Clinical Associate Professor, UBC servations should be viewed more as ton State argues against differences in Department of results of the placebo effect in combi- CBD and THC between these strains.1 Emergency Medicine nation with observer bias, especially Other cannabis scientists are in agree- Site Scholar, Kamloops Family given the lack of quantification of the ment that these terms are better suited Medicine Residency Program cannabis used. to marketing than clinical use: “There I respectfully disagree. This is not are biochemically distinct strains of References a placebo effect. The data are based on Cannabis, but the sativa/indica dis- 1. Jikomes N, Zoorob M. The cannabinoid a retrospective chart analysis of a het- tinction as commonly applied in the content of legal cannabis in Washington erogeneous population, in a naturalis- lay literature is total nonsense and an State varies systematically across testing tic setting, with no exclusion criteria. exercise in futility.”2 facilities and popular consumer products. Even after you remove the noise, our In Dr Ocana’s article, results are Scientific Reports. Accessed 26 February observations remained statistically presented from a cohort interviewed 2019. www.nature.com/articles/s41598 more likely than expected by chance. about their experiences with different -018-22755-2. It seems that Dr Mitchell is sug- strains; however, the results should 2. Piomelli D, Russo EB. The cannabis sativa gesting that our observations are mis- be viewed more as those of the pla- versus cannabis indica debate: An inter- information, worse because they are cebo effect in combination with ob- view with Ethan Russo, MD. Cannabis published in a peer-reviewed medical server bias, especially given the lack Cannabinoid Res 2016;1:44-46. journal. Here’s why I see it differently: of quantification of the cannabis used. 3. Silverman E. The truth behind the ‘first • Before our study, from reading the Dr Ocana also states that deaths marijuana overdose death’ headlines. The medical literature, I didn’t even have increased with cannabis legal- Washington Post. Accessed 26 February know there were two distinct strains. ization. The cited reference mentions 2019. www.washingtonpost.com/news/ • During our study, I was amazed only one death, that of a child who to-your-health/wp/2017/11/17/the-truth how strong the signal remained, died of myocarditis. This case was -behind-the-first-marijuana-overdose despite a possible placebo ef- controversial enough for the case re- -death/?utm_term=.5e8828886558. fect, observer bias, and regardless port’s authors to publicly clarify, “We of the dose. Not only are the strains

110 bc medical journal vol. 61 no. 3, april 2019 bcmj.org letters

different, they are opposites. needles with minute amounts of nor- To sleep or not to sleep • After our study, I shared my obser- mal saline, soft tissue contractures are One thing that endears me to the vations with every clinician at ev- released. BCMJ is the editor’s page. DRR ery conference and everybody said I am now pain free and back to do- writes thoughtful, often funny com- what Dr Mitchell said, “There is no ing all of the activities I love to do. ments about the world around us. strain difference.” Here are some interesting details His December 2018 editorial, “Sleep, In essence, what our patients that I picked up during my visits: when it no longer comes naturally,” consider a self-evident truth, that sa- • A detailed history of all past injuries [BCMJ 2018;60:478] was a bit of tiva stimulates and indica sedates, is is considered in terms of myofascial a departure from his usually joyful based on millennia of trial and error. It contractures and scars. character, and reading it filled me should not be a mystery to respected • A series of standardized movement with concern and empathy for him. cannabis scientists. But it is. That’s tests is used to define painful areas. It revealed his struggle with antici- why I knew we had to publish it. • The most painful sites are treated patory anxiety insomnia, wondering Whether this is a random finding first, followed by re-evaluation of each night if sleep is going to come to or whether it represents the first stone movements. Then the next painful him. The last line was: “…if anyone on the scale that measures the weight area is treated. has suggestions for some good book of evidence, only time will tell. • Multiple cycles of injections, fol- titles, please send them my way.” —A.M. Ocana, MD, CCFP, ABAM lowed by evaluation and further in- I asked myself, what would be North Vancouver jections, are carried out at each ap- a good book for someone awake pointment. enough in the middle of the night to Reference • Tissue realignment takes place the want to read, but anxious enough to 1. Piomelli D, Russo EB. The cannabis sativa first few days after treatment, fol- hope to get back to sleep? versus cannabis indica debate: An inter- lowed by stabilization. I scanned my list of 117 BC view with Ethan Russo, MD. Cannabis The technique was pioneered by physician authors on www.abcbook 1 Cannabinoid Res 2016;1:44-46. Dr Greg Siren, a family physician Continued on page 112 with a focused practice in chronic MyoActivation for the pain in Victoria, BC. treatment of pain & disability At the time I write this letter, myo- Chronic musculoskeletal pain is com- Activation is also available in Van- Seeing my data has mon in our society. One in five people couver at the CHANGEpain Clinic, given me confidence suffer with chronic pain in Canada. the Downtown Community Health and a sense of pride. We need alternatives to pharmaco- Centre (Downtown Eastside), and the DR STEPHANIE AUNG logic interventions that are cost ef- Complex Pain Service at BC Chil- Family Doctor, New Westminster fective, safe, and available to most dren’s Hospital. It has been shown to patients. Ideally, these alternatives be effective in treating chronic pain would be covered by MSP. Most im- originating in the soft tissues in the portantly, alternative treatments could elderly as well as children. decrease our reliance on opiates. I hope this letter raises awareness I am a retired family physician about this technique. It can be prac- who underwent right hip replacement tically delivered in primary care pa- surgery in 2018. I was skeptical when tient encounters and could be part of a colleague suggested I try myoAc- a multidisciplinary­ approach to treat- tivation during my rehabilitation. A ment of chronic musculoskeletal pain. compensatory flexion and adduction —Suzanne Montemuro, MD, CCFP contracture of my right hip was slow- Victoria ing my recovery. I also had weak hip Join physicians across BC who are using their EMR data for abductors, hamstrings, and gluteus Reference self-reflection. Learn more and muscles. 1. Lauder G, West N, Siren G. MyoActiva- enrol at hdcbc.ca/enrol. What is myoActivation? It is a re- tion: A structured process for chronic fined injection technique that targets pain resolution. IntechOpen. Accessed 5 damaged fascia, scars, and other trig- March 2019. www.intechopen.com/on ger points in the body. Using multiple line-first/myoactivation-a-structured-pro needling with hollow bore cutting cess-for-chronic-pain-resolution.

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 111 letters comment

Continued from page 111 Trip across Canada:1862–1863 Continued from page 109 world.com, and looked for diaries, Duncan AC. Medicine, Madams, -professional-resources/msp/commit novels, short stories, historical sto- and Mounties: Stories of a Yukon tees/guidelines-and-protocols-advisory ries, poetry, and theatrical plays Doctor -committee-gpac. published between the early 1800s Emmott K. How Do You Feel? 8. Carroll AE. The JAMA Forum. The high and recent times. I looked for read- (1992 poetry collection) costs of unnecessary care. Accessed 4 ing material that was relatively slow Karlinsky H. The Evolution of March 2019. https://jamanetwork.com/ paced, interesting but not exciting or Inanimate Objects: The Life journals/jama/fullarticle/2662877. anxiety provoking, and long enough and Collected Works of Thomas 9. Abassi L. American Council on Science to get sleepy—or bored—while Darwin (1857–1879) and Health. Your adrenals are not fa- reading it. Kenyon A. The Recorded History of tigued, you are. Accessed 4 March Here are 10 books I recommend, the Liard Basin, 1790–1910 2019. www.acsh.org/news/2017/09/05/ written by some of our physician Lee E. Scalpels and Buggywhips your-adrenals-are-not-fatigued-you colleagues, in alphabetical order by Leighton K. Oar and Sail: An -are-11782. author: Odyssey of the West Coast 10. Doctors of BC. Supporting cultural safe- Burris HL. Medical Saga: The Swan A. House Calls by Float ty for First Nations. Accessed 4 March Burris Clinic and Early Pioneers Plane: Stories of a West Coast 2019. www.doctorsofbc.ca/news/sup Cheadle WB. Cheadle’s Journal of Doctor porting-cultural-safety-first-nations. Tolmie WF. The Journals of 11. Griffin A. The Independent. Anti-vaccine William Fraser Tolmie: Physician myths are being promoted by social me- Doctors and Fur Trader dia bots and Russian trolls, study finds. Helping Dear Dr DRR, have a good read Accessed 4 March 2019. www.inde Doctors and a good sleep! pendent.co.uk/life-style/gadgets-and -tech/news/anti-vaccine-vaxx-bots 24 hrs/day, —George Szasz, CM, MD West Vancouver -russian-trolls-twitter-facebook-study 7 days/week -a8505271.html. Thank you for your concern, and 12. Wilson JA. Pharmacist prescribing: Call at I really appreciate your book Good medicine? BCMJ 2007;49:52-54. 1-800-663-6729 or suggestions.—Ed. 13. Cole W. Dr Will Cole: The future of natu- visit www.physicianhealth.com. ral healthcare. These are the 6 labs you This letter originally appeared as a BCMJ need to run if you are feeling off. Ac- blog post. Visit www.bcmj.org/blog to cessed 4 March 2019. https://drwillcole read all of our posts, and consider sub- .com/these-are-the-6-labs-you-need-to mitting your own. -run-if-you-are-feeling-off.

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112 bc medical journal vol. 61 no. 3, april 2019 bcmj.org EVERY DAY, THE CMA TAKES ACTION ON ISSUES LIKE PHYSICIAN WELLNESS, SENIORS CARE, EQUITY AND DIVERSITY.

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Be part of all we do. Join today at CMA.ca/join © 2019 Canadian Medical Association bc medical journal vol. 61 no. 3, april 2019 bcmj.org 113 Erika Ono, MSW, RSW, Robin Friedlander, MD, FRCPC, Tamara Salih, MD, FRCPC

Falling through the cracks: How service gaps leave children with neurodevelopmental disorders and mental health difficulties without the care they need

Four clinical vignettes illustrate the challenges faced by families of children with a dual diagnosis in British Columbia and demonstrate the need for a wraparound approach to service delivery.

ABSTRACT: Children with neuro- the specifics of the diagnoses, chil- he Diagnostic and Statisti- developmental disorders are at in- dren may be eligible for community cal Manual of Mental Disor- creased risk of developing mental support services, outpatient mental Tders (Fifth Edition) defines health difficulties, and when neu- health services, and inpatient psy- neurodevelopmental disorders as “a rodevelopmental and psychiatric chiatry services. However, because group of conditions with onset in the disorders do co-occur, children and of system fragmentation and insuf- developmental period. The disorders their families frequently face mul- ficient collaboration and commu- typically manifest early in develop- tiple barriers as they try to access nication, obtaining these services ment, often before the child enters services and resources. A literature can be challenging and many chil- grade school, and are characterized review indicates that there is a lack dren are falling through the cracks. by developmental deficits that pro- of specialized mental health servic- Four clinical vignettes illustrate how duce impairments of personal, social, es for patients with a dual diagnosis, children and their families trying to academic, or occupational function- and the resulting inadequate level of access support face barriers, includ- community supports has placed the ing bureaucratic processes, lack of Ms Ono is a PhD candidate and sessional burden of care on families. Services respite, out-of-home service obsta- lecturer in the School of Social Work at the for children in BC with a dual diagno- cles, and limited specialized training University of British Columbia, an evalua- sis are delivered by different agen- for care providers. Policy changes tion specialist at the Centre for Health Eval- cies and programs, primarily under are needed to ensure a wraparound uation and Outcome Sciences, and a social the Ministry of Children and Fam- approach to care based on integra- worker at BC Children’s Hospital Psychiatry ily Development and the province’s tive interagency and cross-agency Department. Dr Friedlander is clinical head health authorities. Depending on practices. of the Neuropsychiatry Clinic at BC Chil- dren’s Hospital. He is also a clinical profes- sor in the UBC Department of Psychiatry and director of the Developmental Disor- ders Program. Dr Salih is a psychiatrist in the Mood and Anxiety Disorders Clinic and the Neuropsychiatry Clinic at BC Children’s Hospital. She is also a clinical instructor in This article has been peer reviewed. the UBC Department of Psychiatry.

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ing. There is a wide range of de- disabilities in the community. In this In addition to making access to velopmental deficits that vary from process specialized psychiatric care specialized mental health services very specific limitations of learning diminished.4 Individuals with a co- difficult, the inadequate level of com- or control of executive functions to occurring neurodevelopmental dis- munity supports in general has placed global impairments of social skills or order and mental health difficulties the burden of care on families. “Car- intelligence.”1 Major neurodevelop- could only access generic mental ing for a child with a disability can be mental disorders include intellectual health services in a system not set up a demanding experience, taxing both disability (ID), autism spectrum dis- for easy access to these services. The the physical and emotional capacities order (ASD), fetal alcohol spectrum “generic [mental] health care model, of the caregiver, as well as the material disorder (FASD), and genetic condi- combined with no national guidelines resources of the family.”8 Challenges tions such as Prader-Willi, fragile X, and provincially determined services include increased caregiver physical and Down syndrome. Children with shared by two distinct ministries has and psychological stress, family dis- neurodevelopmental disorders are at translated into poorly coordinated tress, reduced marital satisfaction, increased risk of developing mental care for individuals with intellectual and inadequate social supports for health difficulties, with 39% of chil- disabilities and mental health needs parents of these children.9 Research dren with a neurodevelopmental dis- in Canada.”5 These systemic issues indicates the need for adequate re- order requiring mental health services have “led to misdiagnoses, inappro- spite (“short-break residential servic- compared with 14% of children in the priate treatments and over-reliance on es”); availability of additional respite general population.2 psycho-pharmacological interven- services in emergencies; accessible Children with a dual diagnosis tions.”6 As Ouelette-Kuntz states, out-of-home placements; flexibil- and their families frequently face “Individuals with mental health prob- ity in eligibility and service delivery; multiple barriers when trying to ac- lems and ID experience ‘double stig- shorter waiting lists; psychoeduca- cess support services. Service de- ma’. . . . Persons with ID and mental tional support groups for parents; livery in BC is fragmented, with health issues are often considered peer mentoring; on-site health clinics the health authorities and different inappropriate for traditional ID com- for caregiver accessibility, cultural agencies, programs, and contractors munity integrated services because sensitivity; and streamlining, coordi- providing various kinds of care and of their psychiatric difficulties but nation, and centralization of servic- funding, primarily through the Min- are also considered inappropriate for es.10-12 Furthermore, as Goddard and istry of Children and Family Devel- usual mental health services because colleagues note in their study of sto- opment (MCFD). Service gaps have of their low IQ. Adding to this stigma ries collected from parents, “Perhaps resulted from this model, similar to is the lack of knowledge of mental the most persistently troubling system those seen across Canada (oral com- health professionals with regard to for these parents was that of the bu- munication from V. Dua, psychia- this population because of deficien- reaucracy. . . . Parents expressed their trist-in-chief, Surrey Place [Toronto, cies in training and the existing barri- frustrations about how they have re- Ontario], 7 July 2017). ers to practice in this area.”6 ceived the bureaucratic ‘runaround,’ The attempt to integrate individu- especially from the social welfare Literature review als with neurodevelopmental disor- system. . . . They described a system In BC before the 1990s, children ders into their communities has led that compartmentalized, that regular- with neurodevelopmental disorders to them being “segregated once again ized, and that fostered fear, confusion, received services through three insti- by a failure to address their special- and frustration.”13 tutions: Woodlands, Tranquille, and ized medical needs.”6 Social margin- Glendale. In 1981 the BC government alization cannot be addressed solely Current services announced plans to close all three in- by a shift to community care. The Services for children in BC with a stitutions. This plan was implemented “work of deinstitutionalization does dual diagnosis are delivered by differ- over the next 15 years, with Wood- not stop at transferring participants ent agencies and programs. Children lands3 officially closing in 1996. into the community. . . unless relo- may be eligible for a variety of com- Following deinstitutionalization, cation brings with it a fundamental munity support services, outpatient services became de-medicalized and change in the [quality of life] of par- mental health services, and inpatient more importance was placed on inte- ticipants, it creates only an illusion of psychiatry services, depending on the grating individuals with intellectual deinstitutionalization.”7 specifics of their diagnoses.

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Assessment services for outpatient medical psychology de- is private fee-for-service psychology neurodevelopmental disorders partment. Some psychological assess- clinics. Assessments for genetic con- Regional health authorities in part- ments are also conducted in child and ditions are undertaken by hospital- nership with Provincial Health Ser- adolescent inpatient psychiatry units based services, including pediatrics, vices provide multidisciplinary across the province, and a smaller medical genetics, metabolic diseases, assessments for autism spectrum number in the BC Children’s Hospi- and neurology. disorder and fetal alcohol spectrum tal outpatient psychiatry clinics. As- disorder through the BC Autism As- sessment for intellectual disability is Community support services sessment Network (BCAAN) and done mainly through psychoeduca- The Ministry of Children and Family the Complex Developmental Be- tional assessments at schools; how- Development provides commun- havioural Conditions (CDBC) pro- ever, these resources are limited and ity support services for a range of gram ( Figure 1 ). In addition, a small many children with intellectual dis- neurodevelopmental and psychiatric number of children are assessed at ability are not assessed during child- disorders ( Figure 2 ). BC Children’s Hospital through the hood. The other option for assessment

Autism spectrum disorder Fetal alcohol spectrum Intellectual disability (ID) Genetic conditions (ASD) disorder (FASD) Psychoeducational Hospital-based assessment BC Autism Assessment Complex Developmental assessment at school or through pediatrics, medical Network (BCAAN) or private Behavioural Conditions private psychology clinic or genetics, metabolic psychology clinic (CDBC) Network as part of ASD or FASD diseases, or neurology assessment services

Figure 1. Assessment services for neurodevelopmental disorders.

Ministry of Children and Family Development (MCFD)

Key Worker and Parent Children and Youth with Special Needs (CYSN) division Support Program For children with a variety of needs, including autism For children with fetal alcohol spectrum disorder (ASD) and intellectual disability (ID) spectrum disorder (FASD)

Autism Funding ASD or ID services At Home Program program Respite resources, behavioral Medical and/or respite resources Behavioral consultant services, child and for children dependent in at least intervention youth care worker services three of four functional activities of resources (depending on need and availability daily living (eating, dressing, of resources in community) toileting, washing)

Figure 2. Community support services.

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Children and Youth with Special Funding program, which provides understand fetal alcohol spectrum Needs (CYSN). Most of the servi- support for intervention services: disorder by providing education and ces for children with autism spectrum $22 000 annually for children under information specific to the needs of disorder and intellectual disability are age 6 (early intervention) and $6000 the child and family. They also help delivered through the Children and annually for children age 6 to 18. families access support, health, and Youth with Special Needs division of education services for the child. Local MCFD.14 Services are often delivered At Home Program. The At Home parent support agencies provide par- by contracted agencies or individual Program provides medical and/or ent and grandparent FASD training care providers. Families receive sup- respite benefits to assist parents with and parent mentoring sessions, and port services for children with autism the costs of caring for a child with sponsor parent support groups. spectrum disorder and/or intellectual severe disabilities at home. To be eli- disabilities, which can include direct- gible for the program, children must Outpatient mental health funded respite, contracted respite, be dependent in at least three of four services respite relief, homemaker/home sup- functional activities of daily living Outpatient services are provided pri- port, behavioral support, child and (eating, dressing, toileting, washing), marily by divisions of the Ministry of youth care worker support, and parent have a palliative condition, or meet Children and Family Development support. The availability of services the requirements for direct nursing and the province’s health authorities is dependent on which programs are care provided by provincial Nursing ( Figure 3 ). In addition, some services running through contracted agencies, Support Services. are provided by private practitioners which varies from one location to such as psychologists and counselors. another. Children with ASD receive Key Worker and Parent Support additional services under the Autism Program. Key workers help families

Examples of challenges addressed: Private practitioners anxiety, depression, attention deficit hyperactivity disorder, Psychologists, counselors, aggression, self-injurious behavior, unsafe behavior psychiatrists, pediatricians, clinical social workers

Ministry of Children and Family Health authorities Development (MCFD)

Children and Family support Child and Youth Developmental Provincial Fraser Health Island Health Youth with and child pro­ Mental Health Disabilities Health Services Child and Youth Anscomb Special Needs tection services (CYMH) Mental Health Neuro­ Neuro­ Program Neuro­ (CYSN) Emergency Mental health Services psychiatry psychiatry development Additional respite if the services Services Clinic at BC Clinic at Surrey Team at Queen respite, child/youth is not specific to Children’s Memorial Alexandra overnight eligible through children with Hospital Hospital Centre for respite CYSN and there intellectual Children’s are safety disabilities Health concerns

Figure 3. Outpatient services for patients with mental health and/or behavioral challenges.

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Child and Youth Mental Health Developmental Disabilities Men­ Centre for Children’s Health (Island (CYMH). Child and Youth Mental tal Health Services. Developmental Health). The neuropsychiatry and Health delivers psychiatric services to Disabilities Mental Health Services neurodevelopment teams working at children up to age 18. However, this is operated by regional health author- these centres provide assessments and service does not provide specialized ities to provide specialized mental limited treatment. care for children with a dual diagno- health care for youth with co-occur- sis. If children with neurodevelop- ring intellectual disability and mental Inpatient psychiatry and mental disorders are assessed as “too health or behavioral challenges. This residential services severe” or “low functioning,” they are unique program offers psychiatric Inpatient psychiatry and residential often denied mental health services, assessments and treatment, clinical services are provided by the Ministry regardless of mental health concerns counseling, music and art therapy, of Child and Family Development, or diagnosed psychiatric comorbid- and case management. Eligibility health authorities, and Community ities. Since 2014 the referral process requirements include a diagnosis of Living BC (CLBC) ( Figure 4 ). Two for Child and Youth Mental Health intellectual disability accompanied child inpatient/day programs and sev- has changed to primarily self-refer- by severe mental health difficulties. eral adolescent inpatient psychiatry rals. Unfortunately, this has created Services are available to individuals units operate across the province. obstacles for many families who are in starting at age 12 in the Lower Main- However, there are no specialized in- crisis and find applying for services to land and Vancouver Island and age 14 patient psychiatry units for children be challenging. Moreover, most Child in the rest of the province. and youth with a dual diagnosis. and Youth Mental Health offices of- fer drop-in intake sessions for only Health authority neuropsychiatry Residential group homes. When a few hours 1 day a week. This can services. Outpatient child and youth families are struggling to care for create additional barriers for parents neuropsychiatry services are pro- their children, placement in a group of children with neurodevelopmental vided at clinics in three tertiary care home may be required. To obtain disorders, families with English as a centres: BC Children’s Hospital residential care, parents must apply to second language, working parents, (Provincial Health Services Author- the Ministry of Children and Family single parents, and families without ity), Surrey Memorial Hospital (Fra- Development. They must then sign a transportation. ser Health), and the Queen Alexandra Special Needs Agreement or a Volun-

Ministry of Children and Family Community Living BC Health authorities Development (MCFD) (CLBC)

Residential group homes Complex care program Child or adolescent Inpatient assessment Provided by contracted Provided at Maples inpatient psychiatry units facility agencies organized through Adolescent Treatment Centre Hospital-based services Provincial Assessment Children and Youth with for individuals age 7 to 18 with such as the Child and Centre (PAC) for individuals Special Needs or child health, developmental, and/or Adolescent Psychiatric age 14 and older with protection services under a behavioral needs that affect Emergency (CAPE) unit at intellectual disabilities and Voluntary Care Agreement or their ability to function in the BC Children’s Hospital mental health or behavioral Special Needs Agreement routine of daily life challenges

Figure 4. Inpatient psychiatry and residential services.

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tary Care Agreement, which places Alex tion program. The psychiatrist has the child in the care of the ministry. Alex is a 13-year-old male with fetal also recommended respite care and Families have no options for long- alcohol spectrum disorder, attention counseling for Alex’s mother. term out-of-home care that does not deficit hyperactivity disorder, post- require going through Children and traumatic stress disorder, and a specif- Gaps in services. Multiple obstacles Youth with Special Needs or child ic learning disorder in reading and have made it difficult to move for- protection services and giving up care written expression. Alex lives with ward with the psychiatrist’s recom- of their child. Group homes typically his adoptive mother, who is a single mendations. Because Alex has an do not have mental health staff.

Complex care program. The Maples Adolescent Treatment Centre of- fers residential care for children with mental health concerns and troubling behavior. A complex care program for There are two distinct patient populations: children age 7 to 18 includes individ- in one the children have few comorbidities ual treatment and service plans. and need limited specialized intervention Provincial Assessment Centre and support, while in the other the children (PAC). The Provincial Assess- ment Centre is a designated tertiary have significant mental health comorbidities psychiatric service under the Men- and sometimes extremely challenging tal Health Act, mandated to provide multidisciplinary assessment and behaviors that require intervention for treatment for individuals age 14 and which funding is not readily available. older with an intellectual disability and concurrent mental health and/or behavioral challenges. PAC is part of Community Living BC, the prov- incial Crown corporation that funds and supports services to adults with parent and has her own mental health IQ of 84 he is not eligible for servi- developmental disabilities, autism struggles. She currently receives in- ces through Children and Youth with spectrum disorder, and fetal alcohol come assistance as a person with dis- Special Needs, which requires an IQ spectrum disorder. abilities. Over time, the behavioral of 70 or less when defining intellec- difficulties stemming from Alex’s tual disability. Had he met this eligi- Clinical vignettes multiple diagnoses (temper outbursts, bility requirement, the family could The following clinical vignettes are aggression toward his mother and have benefited from respite care and fictionalized amalgamations of pa- peers, stealing) have led to caregiver the services of a child and youth care tient symptoms and systemic barriers burnout. worker and a behavioral consultant. commonly seen at tertiary outpatient Alex is also not eligible for care under neuropsychiatry clinics in British Services accessed and recom­ Developmental Disabilities Mental Columbia. The vignettes do not rep- mended. The family has access to a Health Services because he does not resent actual patients. They have been community key worker and a psych- meet that agency’s requirements for included to illustrate the recurring iatrist at a tertiary outpatient neuro- intellectual disability either. Alex’s issues and gaps in services that chil- psychiatry clinic. The psychiatrist has mother, supported by the neuropsych- dren with a dual diagnosis and their recommended Alex receive ongoing iatry clinic, had previously called the families experience. treatment in the community to mon- Ministry of Children and Family De- itor his medications and see a therapist velopment and asked to be considered for emotional regulation and a behav- for respite and other support services. ioral consultant to design an interven- She was told that because there were

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“no child protection concerns” the iatrist at a tertiary outpatient neuro- neuropsychiatry clinic and receives ministry would not open a file, even psychiatry clinic for consultation and benefits through the Autism Funding though the MCFD does open files short-term treatment. The psychiatrist program. Previously, community- for family support services as well has recommended that Leo receive based consultants who were not ex- as child protection services. She then support from a behavioral consultant perts in self-injurious behavior were used the self-referral intake process and behavioral interventionist and be contracted by Children and Youth for Child and Youth Mental Health started on medication and monitored with Special Needs to provide in- to access required mental health ser- in the community. home behavioral consultation and vices for ongoing therapy and medi- intervention. These interventions did cation management for Alex and was Gaps in services. Because Leo does not change Emily’s behaviors. For refused services. The reason given not have a diagnosis for autism spec- the past 2 years Emily’s psychiatrist was Alex’s diagnosis of fetal alcohol trum disorder he is not eligible for has been strongly recommending she spectrum disorder. Because of this the Autism Funding program, which see a behavioral consultant skilled diagnosis, Alex’s co-occurring men- would cover the cost of a behavioral in managing self-injurious behavior tal health conditions were discounted. interventionist to implement a treat- and be considered for placement in ment plan developed by a behavioral a residential facility specializing in Leo consultant. Leo cannot be referred to challenging behaviors. As the behav- Leo is an 11-year-old male with Pra- Child and Youth Mental Health to ad- iors continue and worsen, the mental der-Willi syndrome, a rare genetic dress his mental health concerns be- health of Emily’s parents is precipi- disorder affecting chromosome 15. cause his clinical needs require more tously declining and their marriage is Individuals with this diagnosis com- than the services of a general mental under heavy strain. One parent is un- monly have insatiable appetite, de- health clinician, and he cannot ac- able to continue working because of velopmental and cognitive delays, cess a psychiatrist through Child and the constant care Emily requires. hypogonadism, and behavioral and Youth Mental Health without seeing psychiatric difficulties. Leo has an IQ a clinician first. In addition, he is un- Gaps in services. Lack of communi- of 67, placing him in the mild intellec- able to access a psychiatrist through cation from Children and Youth with tual disability range. Leo engages in Developmental Disabilities Mental Special Needs initially delayed secur- chronic skin-picking and self-harm, Health Services because he is young- ing appropriate supports for Emily. typical of the behavioral phenotype er than 12, and a private child psych- While her family now receives bene- associated with Prader-Willi syn- iatrist will not accept the referral. fits through the Autism Funding pro- drome. He also inserts objects into gram, the $6000 per year provided his rectum and smears feces over his Emily does not cover the interventions she body, stabs his wounds with sharp Emily is a 9-year-old female with needs. Also, despite the very obvious objects, and fills them with dirt. His autism spectrum disorder, moderate challenges Emily’s parents face, they parents have often had to stay up all intellectual disability, separation anx- have had to continuously and tire- night to prevent him from worsening iety disorder, and Tourette syndrome. lessly assert their needs and advocate the multiple self-inflicted wounds on Emily must wear a helmet, gloves, for their child. An additional issue his body. Leo exhibits impulsive be- and knee pads because of her severe for this family has been the require- haviors and is a flight risk. Leo’s par- self-injurious behavior. Her parents ment to sign a Special Needs Agree- ents are overwhelmed by managing have had to stand by helplessly while ment for residential treatment, which the difficult behaviors associated with Emily bruises and batters her head involves relinquishing care of their his neurodevelopmental disorder and and face. Despite multiple trials of child to CYSN. This is a difficult step co-occurring psychiatric problems. medication by several psychiatrists for the family to take, but is the only and community-based behavioral way to access a specialized residential Services accessed and recom­ interventions, Emily’s self-injurious program. mended. The family has access to behavior is worsening. Children and Youth with Special Harpreet Needs services because Leo’s IQ is Services accessed and recom­ Harpreet is a 14-year-old female with less than 70. Leo has an education mended. Emily is under the care of moderate intellectual disability. Her assistant at school and sees a psych- a psychiatrist at a tertiary outpatient comorbidities include epilepsy, anx-

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iety, sleep disturbance, obsessive- with Special Needs. The parents are System fragmentation compulsive disorder, and episodes of exhausted and need appropriate res- Children with a dual diagnosis and major depression that have recurred pite to avoid burnout. Previously, the their families often do not obtain the over the past 2 years. She has irregu- neuropsychiatry clinic’s social worker support they need because services lar periods, constipation, and anemia. helped the family contact their Chil- are fragmented and there is insuffi- Harpreet squeezes, pinches, and grabs dren and Youth with Special Needs cient interagency collaboration and peers, teachers, and her parents. She social worker for assistance with communication. This system frag- is nonverbal and gets very upset if direct-funded respite, which requires mentation means that many children people talk about her in her presence. Harpreet is only allowed to attend school for half a day as the school staff report that they cannot manage her behaviors for longer. Harpreet is on high doses of antipsychotic medi- cations to manage her behaviors, keep Even when families do manage to her in school, and prevent her parents access some services, the care they from becoming completely over- whelmed to the point where they can receive does not always meet the no longer care for her. Harpeet is an complex needs of their children. only child and her parents are immi- grants who require an interpreter dur- ing appointments. Her mother suffers from depression caused by the stress of caring for Harpreet.

Services accessed and recom­ mended. Harpeet sees a psychiatrist advertising for and interviewing res- fall through the cracks. As seen in at a tertiary outpatient neuropsych- pite providers. Given the parents’ lim- some of the clinical vignettes, chil- iatry clinic. Her intellectual disabil- ited ability to communicate in English, dren are denied Child and Youth Men- ity makes her eligible for services these tasks were extremely challen- tal Health services because of their from Children and Youth with Spe- ging. While they did eventually man- neurodevelopmental disorder diag- cial Needs, but she does not qualify age to find someone, the caregiver quit noses, yet are not considered eligible for benefits under the Autism Funding after 1 week. The parents would still for mental health services through program. Harpreet is eligible for the like to find out-of-home respite for a Children and Youth with Special At Home Program and will be able to few days each month, but have been Needs. Even when families do man- receive medical and/or respite resour- told their only option for more respite age to access some services, the care ces once a referral from a physician is is to put Harpreet in care, which they they receive does not always meet completed. do not want to do. the complex needs of their children. These issues are particularly chal- Gaps in services. Numerous ob- Barriers lenging when families are faced with stacles are keeping Harpeet and her As the clinical vignettes illus- long waitlists and do not have a case family from receiving sufficient sup- trate, children and families trying manager or care coordinator to help port. Harpeet’s pediatrician has not to access services for co-occurring them navigate through the system and yet made the referral needed for her to neurodevelopmental and psychiat- advocate for them. The situation is receive At Home Program resources. ric disorders face a number of bar- especially difficult for single parents Her parents have difficulty communi- riers caused by system fragmentation, and families who are already chal- cating in English and do not know bureaucratic processes, lack of res- lenged by socioeconomic stressors, how to navigate in a system unfamil- pite, out-of-home service obstacles, previous negative experiences with iar to them or what services can be and limited specialized training for the Ministry of Children and Family provided through Children and Youth care providers. Development, and language barriers.

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Families new to British Columbia (or ers, and the need for parents to ad- ing. Another route to receiving out- Canada) have a particularly difficult vocate constantly for respite. When of-home treatment involves going time with unfamiliar social service parents do obtain funding for respite, through inpatient psychiatry. There and health care systems. the amount that CYSN provides for an are currently no specialized pediat- hourly wage is low and many families ric neuropsychiatry inpatient units in Bureaucratic processes cannot afford to top this up to make a BC. While the Provincial Assessment Parents of children with a dual diagno- reasonable wage for the respite pro- Centre can help individuals with in- sis often have to advocate for needed vider. The low wages, along with tellectual disability and co-occurring supports over many years in a system safety issues in many cases, make it mental health and/or severe behavior- that is hard to understand and to navi- very hard to retain respite providers. al concerns who are age 14 and older, gate. They have to endure bureaucrat- Additionally, there is a limited num- PAC is focused primarily on assess- ic processes, jump through hoops, and ber of skilled respite providers with ment and stabilization and does not of- fer services for children younger than 14, nor does it offer services to youth with neurodevelopmental disorders other than intellectual disability. Many children with neurodevelop- mental disorders who are referred to Adequate services are often put child or adolescent psychiatry units into place only after crises occur are declined service because the mi- lieu in these units is not suitable for and families are overwhelmed. children with a dual diagnosis.

Limited specialized training Specialized neuropsychiatry training is needed for those who provide care for children with neurodevelopment- wait for long periods of time for ser- specialized training and an under- al disorders and mental health issues, vices. They often experience parent- standing of both neurodevelopmental but a limited amount of this training blaming for the behavioral challenges disorders and mental health issues. is currently available. More training their children exhibit. Coping mech- is needed for psychiatrists, pediatri- anisms can fail and family breakdown Out-of-home service obstacles cians, general practitioners, nurses, becomes more likely when care is dif- The routes to receiving out-of-home social workers, counselors, psycholo- ficult to access. Adequate services are placement or residential treatment are gists, behavioral consultants, respite often put into place only after crises confusing and fragmented. One route providers, and group home workers. occur and families are overwhelmed. involves going through Children and Youth with Special Needs and sign- Recommendations Lack of respite care ing a Special Needs Agreement or a The way services for children with Many families of children with a Voluntary Care Agreement. In this a dual diagnosis are currently struc- dual diagnosis need respite to prevent case, parents relinquish care of their tured in BC does not involve a wrap- caregiver burnout. Despite this com- child to the Ministry of Children and around system of care approach.15 mon need, families still struggle to get Family Development for the duration Such an approach supports children sufficient respite. Difficulties include of the placement. The placement can and their families by using integra- inconsistent offerings of respite hours be in an existing group home or a tive interagency and cross-agency for families and communities, long home arranged specifically for the in- practices to ensure collaboration and waitlists for contracted respite provid- dividual child. Generally, these homes communication among child-serving ers recruited and monitored by Chil- are operated by agencies contracted agencies and programs. The current dren and Youth with Special Needs, by the ministry to provide care, and service delivery design in BC also the need for parents to independently are staffed with group home workers fails to ensure a continuum of care by recruit direct-funded respite provid- who do not have mental health train- providing a comprehensive range of

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health services spanning all levels of based on need rather than diagno- Family support and child protec­ intensity.16 sis—currently designated funding tion services Addressing the complex needs is only available to children with • Have family support services more of children with a dual diagnosis will autism spectrum disorder, regard- readily available when other sup- require ensuring a continuum of care, less of their level of functioning, ports are not yet put in place. improving Ministry of Children and mental health comorbidities, and Family Development services, improv- support needs. Improving health authority ing health authority services, and estab- • Develop separate funding models services lishing a wraparound system of care. for children and youth with autism Address limitations in specific service spectrum disorder and/or intellectu- areas: Ensuring a continuum of care al disability alone versus those with • Provide timely access to various dual diagnosis. Developmental Disabilities Mental levels of care. • If separate funding models are not Health Services • Provide community-based programs feasible, allocate distinct fund- • Provide services for children young- and outreach. ing for these complex cases to the er than age 12. • Provide intensive in-home support health authorities that frequently • Expand eligibility for services to (nurse, behavioral consultant, etc.) treat these children and have more include other neurodevelopmental for both prevention and step-down specialized training in psychiatric disorders such as autism spectrum care when children and youth are comorbidities and treatment. disorder and fetal alcohol spectrum discharged from inpatient psychia- • Include treatment teams (mental disorder rather than providing ser- try or residential treatment. health, specialist health care, pedi- vices only for youth with a diagno- • Provide more out-of-home tempo- atrics) in Ministry of Children and sis of intellectual disability. rary respite options for complex Family Development decision- cases to prevent caregiver burnout making processes such as residen- Outpatient tertiary neuro­­­­psy­ and safety concerns. tial placements. chiatry • Provide dedicated neuropsychiatry • Help families find skilled respite • Ensure that every health authority beds in current child and adolescent providers and behavioral interven- has a neuropsychiatry clinic. psychiatry units. tion services when they must do • Include a behavioral consultant on so under the terms of direct-funded the neuropsychiatry clinic team. Improving Ministry of Children respite and Autism Funding. • Provide outreach and more consul- and Family Development • Provide designated respite pro- tation to general practitioners and services grams for families of children with pediatricians in BC who are already • Provide integrated cross-agency dual diagnosis. prescribing extensively for children service delivery to families access- • Provide training in dual diagnosis with a dual diagnosis. ing mental health, special needs, to Children and Youth with Special child protection, and family support Needs social workers. Inpatient psychiatry services. • Provide more out-of-home respite • Establish designated neuropsychia- • Hold joint meetings to determine options for dual-diagnosis cases try beds. the most appropriate services for before resorting to ministry place- • Develop a specialized short-term referrals between each division, and ment. (3 to 6 months) neuropsychiatry regular meetings for all profession- intensive assessment and treatment als involved. Child and Youth Mental Health unit for children and youth staffed • Designate a case manager for chil- • Provide services to children with with mental health professionals, dren with a dual diagnosis and com- dual diagnosis. behavioral consultants, and behav- plex care needs. • Assign designated clinicians on ioral interventionists. • Address limitations in specific ser- teams for dual-diagnosis cases, • Provide more training on dual diag- vice areas: similar to concurrent disorder clini- nosis. cians on mental health teams. Child and Youth with Special Needs • Provide more staff training in spe- Physician training • Provide a program with funding cialized therapy for dual diagnosis. • Provide mandatory training on dual

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 123 Falling through the cracks: How service gaps leave children with neurodevelopmental disorders and mental health difficulties without the care they need

diagnosis for family medicine, pe- to take on a case manager role to ac- with intellectual disability: A review of the diatric, and psychiatry residents to cess appropriate resources. This role international literature. J Policy Pract Intel- increase community capacity. is usually not appropriate for parents lect Disabil 2011;8:256-265. • Provide ongoing funded opportu- whose children have a dual diagnosis 8. Doig JL, McLennan JD, Urichuk L. “Jump- nities for general practitioners, pe- and require guidance and additional ing through the hoops”: Parents’ experi- diatricians, and psychiatrists to in- support to access specialized services. ences with seeking respite care for chil- crease their knowledge and skill set BC needs policies and practices dren with special needs. Child Care Health in this area. that recognize and address the com- Dev 2009;35:234-242. plex needs of children with a dual di- 9. Lach LM, Kohen DE, Garner RE, et al. The Establishing a wraparound agnosis. health and psychosocial functioning of system of care caregivers of children with neurodevelop- • Support children and families by Competing interests mental disorders. Disabil Rehabil 2009; using integrative interagency and None declared. 31:606-618. cross-agency practices among child- 10. Emerson E. Mothers of children and ado- serving services provided by the References lescents with intellectual disability: Social Ministry of Children and Family 1. American Psychiatric Association. Diag- and economic situation, mental health Development and the province’s nostic and statistical manual of mental status, and the self-assessed social and health authorities. disorders. Fifth edition. Arlington, VA: psychological impact of the child’s difficul- • Provide a case manager to help American Psychiatric Publishing; 2013. ties. J Intellect Disabil Res 2003;47: families of children with a dual di- 2. British Columbia Ministry of Health. 385-399. agnosis navigate the system of care. Planning guidelines for mental health 11. McConkey R, Truesdale M, Conliffe C. • Provide care that is individualized and addiction services for children, The features of short-break residential and least restrictive. youth and adults with developmental services valued by families who have chil- • Ensure early identification and in- disability. March 2007. Accessed 2 Feb- dren with multiple disabilities. J Soc tervention. ruary 2019. www.health.gov.bc.ca/ Work 2004;4:61-75. • Organize transitions to adult ser- library/publications/year/2007/MHA 12. Olsson MB, Hwang CP. Depression in vices. _Developmental_Disability_Planning mothers and fathers of children with intel- • Provide culturally safe, trauma- _Guidelines.pdf. lectual disability. J Intellect Disabil Res informed, and clinically competent 3. Inclusion BC. Woodlands institution. Ac- 2001;45:535-543. services. cessed 2 February 2019. www.inclusion 13. Goddard JA, Lehr R, Lapadat JC. Parents In British Columbia the current bc.org/our-priority-areas/disability-sup of children with disabilities: Telling a differ- system of care for children with neu- ports/institutions/woodlands-insitution. ent story. Can J Counselling 2000;34: rodevelopmental disorders does not https://inclusionbc.org/our-resources/ 273-289. appear to recognize there are two dis- institutions. 14. Government of British Columbia. Special tinct patient populations: in one the 4. Nøttestad JA, Linaker OM. Psychiatric needs. Accessed 2 February 2019. children have few comorbidities and health needs and services before and af- www2.gov.bc.ca/gov/content/health/ need limited specialized interven- ter complete deinstitutionalization of peo- managing-your-health/healthy-women tion and support, while in the other ple with intellectual disability. J Intellect -children/child-behaviour-development/ the children have significant mental Disabil Res 1999;43:523-530. special-needs. health comorbidities and sometimes 5. Lunsky Y, Garcin N, Morin D, et al. Mental 15. Chenven M. Community systems of care extremely challenging behaviors that health services for individuals with intel- for children’s mental health. Child Adolesc require intervention for which fund- lectual disabilities in Canada: Findings Psychiatr Clin N Am 2010;19:163-174. ing is not readily available. Where this from a national survey. J Appl Res Intellect 16. Morrow M, Dagg PKB, Pederson A. Is second population is concerned, vig- Disabil 2007;20:439-447. deinstitutionalization a “failed experi- orous family advocacy is required to 6. Ouellette-Kuntz H. Understanding health ence”? The ethics of re-institutionaliza- access services and family breakdown disparities and inequities faced by indi- tion. J Ethics Ment Health 2008;3:1-7. can result. The Child and Youth with viduals with intellectual disabilities. J Appl Special Needs division of the MCFD Res Intellect Disabil 2005;18:113-121. operates on an underlying assump- 7. Chowdhury M, Benson BA. Deinstitution- tion that parents are able and willing alization and quality of life of individuals

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The value of independent drug assessment

Type 2 diabetes in British Columbia as a case study to explain the work of UBC’s Therapeutics Initiative.

James M. Wright, MD, PhD, Ken Bassett, MD, PhD, Thomas L. Perry, MD, Aaron M. Tejani, PharmD

he November 2018 issue of the founding principle and raison d’être not, indeed, unique. We consider the BCMJ included two articles was health professionals’ need for in- work of regulatory agencies such as Tabout diabetes management in dependent, unconflicted assessments the US FDA and European Medicines British Columbia and a guest editorial of new drug therapies to balance Agency, other independent drug bul- that referred to the Therapeutics Ini- drug industry–sponsored information letins, and other academic groups. tiative (TI). We would like to respond sources. Over the last 25 years, our Our analyses are often relatively con- to the information provided in that is- team has developed expertise in iden- cordant with those published by non- sue by clarifying our organization’s tifying and critically appraising both conflicted experts in diabetes.2-4 Our goals and processes and our role in published and unpublished sources of uncertainty about how to interpret the BC’s health care system. evidence. Taking the time and effort EMPA-REG OUTCOME trial, seen The TI was established in 1994 to apply these skills meticulously to by some as relatively controversial, by the Department of Pharmacology the review of clinical trial evidence was reflected in the narrow 12:11 ap- and Therapeutics in cooperation with distinguishes our approach from proval of its cardiovascular preven- the Department of Family Practice at many other groups. tion indication by the FDA’s advisory the University of British Columbia. In his guest editorial,1 Dr Ehud Ur committee and shared by an indepen- We are an independent academic unit, states that the TI “provides physicians dent assessment from Spain.5,6 separate from government and the with its own unique interpretation of The article by Dr Maureen Clem- pharmaceutical industry, funded by a the diabetes literature through bi- ent and colleagues,7 and Dr Ur’s grant to UBC from the BC Ministry monthly Therapeutics Letters that of- editorial note differences between of Health. ten cast doubt on the findings of robust some recommendations from Diabe- Our mission is to provide physi- trials and guideline recommendations tes Canada, the BC Guidelines and cians and pharmacists with up-to-date, issued by highly respected interna- Protocols Advisory Committee, and evidence-based, practical informa- tional organizations.” Our interpreta- certain conclusions drawn by the TI tion on prescription drug therapy. A tion of evidence from clinical trials is Continued on page 126

This article has been peer reviewed. research focuses on issues related to ap- interests are in the systematic review of propriate use of prescription drugs, clinical drug therapy and drug funding policy. Dr Dr Wright is a professor in the Department pharmacology, treatment of hypertension Perry is a general internist/clinical pharma- of Anesthesiology, Pharmacology, and Ther- and hyperlipidemia, clinical trials, system- cologist who chairs the Therapeutics Initia- apeutics and the Department of Medicine at atic review, meta-analysis, and knowledge tive Education Working Group. Dr Tejani is a the University of British Columbia and has translation. Dr Bassett is a professor of researcher with the Therapeutics Initiative worked in that role since 1977. He is also a medicine in the Department of Family Prac- and co-chairs the Education Working Group practising specialist in internal medicine and tice and the Department of Anesthesiology, and the Drug Assessment Working Group. clinical pharmacology at UBC Hospital, co- Pharmacology, and Therapeutics at UBC. He He is a clinical assistant professor with the managing director of the Therapeutics Initia- has directed the Drug Assessment Work- Faculty of Pharmaceutical Sciences at UBC, tive, editor-in-chief of the Therapeutics Let- ing Group of the Therapeutics Initiative since and a medication use evaluation pharmacist ter, and coordinating editor of the Cochrane 1993 and co-managed the Therapeutics with Lower Mainland Pharmacy Services Hypertension Review Group. His current Initiative since 2010. His ongoing research (Vancouver, BC).

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Continued from page 125 for glucose-lowering medications. control is a small absolute reduction from our evidence reviews. Dr Clem- If our results differ from recommen- in risk for microvascular surrogate ent and colleagues note that “general dations offered by pharmaceutical events, such as retinopathy detected practitioners and specialists looking manufacturers and industry-funded on ophthalmologic screening or ne- for guidance in the complex phar- thought leaders, it is likely because phropathy defined by development or macological management of type 2 our review process differs in a num- progression or albuminuria.”3 Simi- diabetes in BC can find themselves ber of ways. We start by defining the larly, the 2017 meta-analysis cited by frustrated by contradictory recom- outcomes of greatest importance to Dr Clement and colleagues did not mendations from these three bodies: patients, ranked in a standard hier- identify an effect of intensive glucose Diabetes Canada, the British Colum- archy derived from Cochrane Col- control on the risk of neuropathy, and bia Guidelines and Protocols Adviso- laboration methodology. Our reviews noted that effects on retinopathy and ry Committee, and the Therapeutics routinely attempt to include unpub- nephropathy were modest and deter- Initiative.” lished data available now from regu- mined by less-serious complications.9 It should not be surprising if latory reviews and from the detailed A founding policy of the TI in health care professionals and people clinical study reports compiled by 1994 was to ensure that members with type 2 diabetes are confused or clinical trial sponsors, and from trial of our academic group have no con- frustrated by the range of guidelines registry websites. Including regula- flicts of interest with manufacturers available, and their mutability over tory documents and clinical study of pharmaceuticals. This is neither be- time. This problem is hardly unique reports (when available) is critical, cause of antagonism to the important to diabetes care. Over the life of the rather than superfluous, to informing benefits of innovative pharmacothera- TI (and long before) there are numer- conclusions regarding a new drug or pies nor to the challenges of develop- ous examples of guideline recom- indication. This often involves very ing them. It is because we agree with mendations that were subsequently hard work. For example, the version those who have concluded that con- repudiated or superseded by objec- of the LEADER trial of liraglutide for flicts may introduce insidious biases tive evidence from clinical trials. This type 2 diabetes in the NEJM compris- with the potential to impair scientific applies to nephrology, cardiology, es 12 pages plus a 69-page appendix. judgment. It has been clear for years infectious diseases, intensive care, The corollary US FDA briefing docu- that conclusions and recommenda- pediatrics, many fields of surgery, and ment is 166 pages. The transcript of tions of clinical guidelines could be various types of screening and other the FDA advisory committee meet- strengthened greatly through atten- preventive interventions. ing is 382 pages, and the underlying tion to contemporary standards that Different organizations composed clinical study report for LEADER is increase their trustworthiness. The of specialists, patient advocates, or 3603 pages. It is not clear that Dia- 2011 report of the US National Acad- government officials have varying betes Canada’s Expert Committee has emies, “Clinical Practice Guidelines mandates and apply markedly differ- included this level of review to in- We Can Trust,”10 explores in depth ent processes to assess evidence. This form its most recent pharmacotherapy­ how guidelines should be developed can yield a broad spectrum of recom- recommendations.8 and what standards should be em- mendations, many of which will not Focusing on clinical outcomes ployed to ensure their reliability, in- look wise in retrospect. Were only the that are most relevant for patients cluding a foundation of transparency vagaries of human biology so simple accounts for many differences in in- and management of conflicts of inter- to understand and control as some terpretation of clinical trials. For ex- est. Its approach has been followed direct-to-consumer TV ads make it ample, Dr Clement and colleagues in some recent guidelines developed look: “I just love my numbers!” write that “Glycemic control is an in the US and Canada, yet such high The role of the TI is not to write important risk factor for microvascu- standards remain an exception rather guidelines for any disease. Our man- lar disease, including retinopathy, ne- than the rule in medicine. date is solely to assess randomized phropathy, and peripheral neuropathy. If BC clinicians feel confused by clinical trial evidence and to sum- Early improved glucose control slows guidelines that offer conflicting ad- marize our detailed assessments for progression to these endpoints.” Yet vice, the best remedy would be for clinicians to help them and their pa- considering the same clinical trial complex scientific research to be ana- tients make evidence-informed drug evidence, the 2018 American College lyzed free from pharmaceutical in- therapy decisions. of Physicians Guidance Statement on dustry funding, and then crafted into We employ a standardized, sys- HbA1c targets for type 2 diabetes ar- trustworthy recommendations that tematic, transparent process to all ticulates more clearly that “the main are relevant to individual patient care. drug assessments, including those effect of more intensive glycemic As others have pointed out, this is a

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more than Herculean endeavor; most potential public plan coverage. Most A1C the right outcome for studies of dia- clinical trials screen out the type of of the submissions are then reviewed betes? JAMA 2017;317:1017-1018. complex multimorbidity seen by doc- by the ministry’s Drug Benefit Coun- 3. Qaseem A, Wilt TJ, Kansagara D, et al. tors in everyday practice.11 cil (DBC) to contextualize CDR’s Hemoglobin A1c targets for glycemic con- We think that our careful and evidence syntheses and recommenda- trol with pharmacologic therapy for non- unconflicted scrutiny of research tions. Sometimes the ministry requests pregnant adults with type 2 diabetes mel- findings helps to produce succinct additional analysis from the TI. Our litus: A guidance statement update from Therapeutics Letters that physicians members may attend DBC meetings the American College of Physicians. Ann can trust as a resource to serve their when requested to explain evidence Intern Med 2018;168:569-576. patients. However, we have never and answer questions. However, TI 4. Rodriguez-Gutierrez R, Montori VM. Gly- claimed to have all the answers or members neither vote on nor make cemic control for patients with type 2 dia- recommended treatment paradigms funding decisions. We help to eluci- betes mellitus: Our evolving faith in the for individual patients. To suggest date and clarify available evidence, face of evidence. Circ Cardiovasc Qual that the TI is responsible for confus- typically from randomized controlled Outcomes 2016;9:504-512. ing and frustrating BC’s family phy- trials. The Pharmaceutical Services 5. Therapeutics Initiative. EMPA-REG OUT- sicians and specialists underrates Division then makes its funding deci- COME trial: What does it mean? Letter their intelligence, education, and sions after considering the recommen- 107. Accessed 8 February 2019. www judgment. We believe BC doctors dations of the CDR and DBC. .ti.ubc.ca/2017/11/20/107-empa-reg-out are capable of thinking critically for Over the past 25 years the TI has come-trial-what-does-it-mean. themselves and synthesizing infor- enjoyed international recognition for 6. Saiz LC. The EMPA-REG OUTCOME trial mation from different sources. This our consistently rigorous approach. (empagliflozin). A critical appraisal. The is especially so when they can access We have often been among the first power of truth, the truth of power. Drugs unbiased and rigorous evidence about to understand the real available evi- and Therapeutics Bulletin of Navarre, drug therapies, based on thorough and dence about drugs, and it is hardly Spain 2016;24:1-14. systematic reviews. Understanding surprising that this has frequently 7. Clement M, Paty B, Mancini GBJ, et al. the strengths and weaknesses of evi- proven controversial. If additional Challenges to managing type 2 diabetes dence about drugs for type 2 diabetes evidence changes our understanding in British Columbia: Discordant guidelines (or any other condition), combined of the merits of new diabetes drugs, and limited treatment options. BCMJ with clinical experience and willing- we will naturally welcome therapeu- 2018;60:439-450. ness to integrate their patients’ goals, tic approaches that are more success- 8. Diabetes Canada Clinical Practice Guide- provides the best foundation for opti- ful than the limited tools available to lines. Pharmacologic glycemic manage- mal care. This is really the definition doctors and patients since the discov- ment of type 2 diabetes in adults. Ac- of evidence-based medicine: “the ery of insulin. cessed 8 February 2019. http://guidelines conscientious, explicit and judicious We welcome challenges to our .diabetes.ca/cpg/chapter13. use of current best evidence in mak- interpretation of evidence and would 9. Zoungas S, Arima H, Gerstein HC, et al. ing decisions about the care of indi- be pleased to work with our critics to Effects of intensive glucose control on mi- vidual patients.”12 exchange ideas regarding literature crovascular outcomes in patients with BCMJ readers may also wish to review methods. As always, we look type 2 diabetes: A meta-analysis of indi- understand better the process used forward to hearing from BC doctors, vidual participant data from randomised by the Pharmaceutical Services Di- including those who are critical of our controlled trials. Lancet Diabetes Endocri- vision of the Ministry of Health to approaches or conclusions. nol 2017;5:431-437. decide on drug coverage. This is ex- 10. The National Academies of Sciences En- plained in detail at www2.gov.bc.ca/ Competing interests gineering Medicine. Clinical practice gov/content/health/health-drug-cov Drs Wright, Bassett, Perry, and Tejani re- guidelines we can trust. 2011. Accessed erage/pharmacare-for-bc-residents/ ceive part-time salaries from UBC via the 8 February 2019. http://nationalacade what-we-cover/drug-coverage/ Ministry of Health Contributory Agreement mies.org/hmd/Reports/2011/Clinical drug-review-process-results. (grant) to UBC to support TI. -Practice-Guidelines-We-Can-Trust.aspx. After Health Canada approves a 11. Greenhalgh T, Howick J, Maskrey N. Evi- drug for use in humans, the national References dence based medicine: A movement in Common Drug Review (CDR) of the 1. Ur E. Guest editorial: Diabetes in British crisis? BMJ 2014;348:g3725. Canadian Agency for Drugs and Tech- Columbia: Starvation in the midst of plen- 12. Sackett DL. Evidence-based medicine. nologies in Health reviews drug sub- ty. BCMJ 2018;60:436-438. Semin perionatol 1997;21:3-5. missions from drug manufacturers for 2. Lipska KJ, Krumholtz HM. Is hemoglobin

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Modern-day cardiac auscultatory teaching and its role alongside echocardiography

Maximizing physicians’ cardiac auscultatory abilities alongside use of advanced diagnostic technologies results in better diagnostic accuracy and increased patient interaction.

Caleb A.N. Roda, BSKin

Abstract: In the hands of a skilled Introduction Auscultation or user, the stethoscope is a quick, The stethoscope has been a part of the echocardiography? inexpensive, and readily available physician’s toolkit for over 200 years The decline in physicians’ ability way to screen and assess patients since its invention in 1816 by French to identify auscultated heart sounds for cardiac pathology at initial point physician Rene Laennec.1 Binaural, could be due, in part, to the wide- of care. Unfortunately, reliance on electronic, and more recently, iPhone spread introduction and reliance on sophisticated diagnostic technolo- stethoscopes with the ability to ampli- advanced diagnostic technologies gies such as echocardiography and, fy, record, and share heart sounds are such as echocardiography.10 The diag- more importantly, outdated auscul- options for health care professionals to nostic accuracy of echocardiography tatory teaching methods has led to use in their daily practice.2 Ausculta- is superior to auscultation when iden- a decline in practitioners’ ability tion serves as a quick and inexpensive tifying many subtle cardiac patholo- to correctly identify heart sounds way for the modern-day physician to gies, and has the capability to improve through auscultation. Current re- infer a variety of disease states about detection over cardiac auscultation search shows cardiac auscultatory the cardiovascular, respiratory, and alone.11-14 Relatively recent advances teaching should place more empha- gastrointestinal system, which al- in medical technology have led to sis on auditory repetition in conjunc- lows for streamlined diagnoses and the development of handheld ultra- tion with visual integration, testing, management. However, with long sound devices that can be used at the and scheduled refresher learning of patient lists, access to sophisticated initial point of care to assess cardiac heart sounds. This can be done in diagnostic technology, and stagnant function. Cardiologists using hand- an accessible, affordable, and self- auscultatory teaching methods, more held ultrasound outperformed cardi- paced manner through online or time is being spent combing through ologists using physical examination phone applications. Proficient car- patient electronic medical records with auscultation for identifying the diac auscultation and new diagnos- rather than examining and auscultat- majority of common cardiac patholo- tic technologies have the potential ing the patient. The identification of gies.15 Medical schools are beginning to work synergistically with one an- auscultated heart sounds among most to incorporate ultrasonography early other to improve patient outcomes. medical students,3-5 residents,4-6 and into their undergraduate curricu- physicians5,7-9 is poor. Practitioners at lum as a regular part of the physical all levels of training find it difficult to examination.16 Proponents of point- identify and distinguish pathological of-care ultrasound acknowledge the This article has been peer reviewed. from normal heart sounds, which can relatively high risk of misdiagnosis lead to delayed diagnoses and treat- among inexperienced practitioners.16 Mr Roda is a medical student in the Van­ ment, as well as unnecessary, poten- Even with experienced ultrasonog- couver Fraser Medical Program, class of tially harmful investigations. raphers, there are circumstances 2020, at the UBC Faculty of Medicine. where echocardiography misses car-

128 bc medical journal vol. 61 no. 3, april 2019 bcmj.org bcmd2b diac pathology that the stethoscope is able to pick up. Dr Valentine Fuster describes one of many such clinical situations, where a pericardial rub is heard through auscultation in a pa- tient with chest pain and fever, despite echocardiography’s inability to show any pericardial effusion.17 The exist- ence of better tests does not negate the stethoscope, but rather, pushes us to understand its limitations and value alongside cardiac auscultation in the physical examination.

Modern-day cardiac auscultatory teaching Apart from technological advances, a compelling reason for poor ausculta- and advanced murmurs after listen- computer or smart phone.28,29 Blaufuss tory heart sound identification is that ing to 400 repetitions of each murmur Medical Multimedia Laboratories has teaching methods for cardiac auscul- while viewing cardiac images.7 Audi- also created a free online platform tation among medical programs has tory training is a promising technique for learning four common valvular not changed much over the last half that should be paired with visual ani- lesions using auditory repetitions of century.18 Current evidence-based mations of the hemodynamics and val- heart sounds combined with inter- cardiac auscultatory teaching meth- vular actions of the given sound,24-26 active computer animations and de- ods involving online platforms and in addition to skill testing and sched- tailed text.30 In addition to the online phone applications have the poten- uled refresher learning.18,21,27 Such platforms, there are a variety of smart tial to revitalize cardiac auscultation training allows the learner to visual- phone applications available, such as in medical programs.19 The technical ize the flow of blood through the heart HeartMurmurs and Murmur Pro that auditory skill of recognizing abnor- and best understand the pathophysiol- offer auditory repetitions in combina- mal from normal heart sounds, extra ogy responsible for the given sound, tion with visual aids, descriptions, heart sounds, and common patho- extending retention.25 Testing and and quizzes to assess competence. logical murmurs during ausculta- periodic refresher learning ensure a The online platforms, and more spe- tion tends to be inadequately taught, high degree of competency has been cifically, the phone-based applica- and consequently, poorly understood reached and will be maintained over tions, offer a low-cost, flexible, and by medical students. Accurate heart time. effective medium for incorporating sound identification requires the brain evidence-based auscultatory teach- to be able to recognize the volume, Computers, smart phones, ing into the schedules of health care frequency, and timing of sounds.20 and heart sounds professionals. This skill can only be developed by Successfully incorporating the re- hearing many repetitions of the same, quired cardiac auditory repetition into Conclusion often subtle sound, in order to incor- the schedules of medical students and Cardiac auscultatory skills can work porate that new pattern of sound into practising professionals poses a chal- synergistically with new diagnostic long-term memory.20 Multiple stud- lenge. However, with the increasing technologies like point-of-care ultra- ies have shown that auditory train- range of Internet connectedness and sound. Cardiac auscultatory teach- ing, compared to traditional teaching use of cellphones, this challenge can ing methods should be modernized methods, can markedly advance a be overcome. The American College by incorporating auditory repetition learner’s ability to recognize abnor- of Cardiology and Teaching Heart to hone technical auscultation skills, mal from normal heart sounds, extra Auscultation to Health Professionals using concurrent visualizations to heart sounds, and common patho- websites offer free online auditory improve conceptual understanding logical murmurs.7,21-23 In addition to training programs with hundreds of of cardiac pathology, and employing benefiting novice and intermediate repetitions of various hearts sounds, testing and periodic refresher sessions learners, cardiologists significantly training assessments, and download- to ensure long-term knowledge re- improved their identification of basic able mp3 files for offline use on a Continued on page 130

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Continued from page 129 Methods for improving the practice of an 2017;25:205-210. tention. Online platforms and phone ancient but critical skill. Halifax, NS: Cana- 19. Mackie A. Auscultation: A review of applications offer a portable learn- dian Pediatric Cardiology Association; teaching methods. In: Finley J. Teaching ing medium that is affordable, read- 2011. heart auscultation to health professionals: ably accessible, and self-paced for 8. Vukanovic-Criley JM, Hovanesyan A, Cri- Methods for improving the practice of an mastering the technical and concep- ley SR, et al. Confidential testing of cardiac ancient but critical skill. Halifax, NS: Cana- tual aspects of cardiac auscultation, examination competency in cardiology dian Pediatric Cardiology Association; in addition to the basic foundational and noncardiology faculty and trainees: A 2011. knowledge and physical exam skills multicenter study. Clin Cardiol 2010; 20. Atienza M, Cantero JL, Dominguez-Marin already being taught in medical 33:738-745. E. The time course of neural changes un- schools and residency. Maximizing 9. Roy D, Sargeant J, Gray J, et al. Helping derlying auditory perceptual learning. cardiac auscultatory ability instills family physicians improve their cardiac Learn Mem 2002;9:138-150. confidence and encourages physic- auscultation skills with an interactive CD- 21. Finley JP, Caissie R, Nicol P, Hoyt B. Inter- al examination alongside advanced ROM. J Contin Educ Health Prof 2002; national trial of online auditory training pro- diagnostic technologies, resulting in 22:152-159. gramme for distinguishing innocent and better diagnostic accuracy, increased 10. Chizner MA. Cardiac auscultation: Redis- pathological murmurs. J Paediatr Child patient interaction, and more import- covering the lost art. Curr Probl Cardiol Health 2015;51:815-819. antly, human connection. 2008;33:326-408. 22. Barrett MJ, Kuzma MA, Seto TC, et al. The 11. Patel A, Tomar NS, Bharani A. Utility of power of repetition in mastering cardiac References physical examination and comparison to auscultation. Am J Med 2006;119:73-75. 1. Roguin A. Rene Theophile Hyacinthe echocardiography for cardiac diagnosis. 23. Barrett MJ, Lacey CS, Sekara AE, et al. Laennec (1781-1826): The man behind Indian Heart J 2017;69:141-145. Mastering cardiac murmurs: The power the stethoscope. Clin Med Res 2006; 12. Spencer KT, Anderson AS, Bhargava A, et of repetition. Chest 2004;126:470-475. 4:230-235. al. Physician-performed point-of-care 24. Moshman S. Teaching of Cardiac Auscul- 2. Patel RS, Schwarz J, Danesh V, et al. Clin- echocardiography using a laptop platform tation. Cardiol Rev 2017;25:203-204. ical performance of the HeartBuds, an compared with physical examination in 25. Vukanovic-Criley JM, Boker JR, Criley SR, electronic smartphone listening device, the cardiovascular patient. J Am Coll Car- et al. Using virtual patients to improve car- compared to FDA approved class I and diol 2001;37:2013-2018. diac examination competency in medical class II stethoscopes. J Mob Technol Med 13. Rahko PS. Prevalence of regurgitant mur- students. Clin Cardiol 2008;31:334-339. 2016;5:1:45-51. murs in patients with valvular regurgita- 26. Torre DM, Pfeifer KJ, Lamb GC, et al. An 3. Vukanovic-Criley JM, Criley S, Warde CM, tion detected by Doppler echocardiogra- assessment of the impact of multimedia, et al. Competency in cardiac examination phy. Ann Intern Med 1989;111:466-472. technology-based learning tools on the skills in medical students, trainees, physi- 14. Jaffe WM, Roche AH, Coverdale HA, et cardiac auscultation skills of third-year cians, and faculty: A multicenter study. al. Clinical evaluation versus Doppler medical students. Med Educ Online Arch Intern Med 2006;166:610-616. echocardiography in the quantitative as- 2004;9:4364. 4. Mangione S, Nieman LZ. Cardiac auscul- sessment of valvular heart disease. Circu- 27. Lam MZ, Lee TJ, Boey PY, et al. Factors tatory skills of internal medicine and fam- lation 1988;78:267-275. influencing cardiac auscultation proficien- ily practice trainees. A comparison of 15. Mehta M, Jacobson T, Peters D, et al. cy in physician trainees. Singapore Med J diagnostic proficiency. JAMA 1997;278: Handheld ultrasound versus physical ex- 2005;46:11-14. 717-722. amination in patients referred for transtho- 28. American College of Cardiology. Heart 5. Mangione S, Nieman LZ, Gracely E, Kaye racic echocardiography for a suspected songs for institutions: Heart sounds. Ac- D. The teaching and practice of cardiac cardiac condition. JACC Cardiovasc Imag- cessed 21 July 2018. http://edu.acc.org/ auscultation during internal medicine and ing 2014;7:983-990. diweb/catalog/launch/package/sid/ cardiology training. A nationwide survey. 16. Solomon SD, Saldana F. Point-of-care ul- 40047974. Ann Intern Med 1993;119:47-54. trasound in medical education—stop lis- 29. Teaching Heart Auscultation to Health 6. Mangione S. Cardiac auscultatory skills of tening and look. N Engl J Med 2014; Professionals. Learning Programs. Ac- physicians-in-training: A comparison of 370:1083-1085. cessed 31 December 2018. http://teach three English-speaking countries. Am J 17. Fuster V. The stethoscope’s prognosis: ingheartauscultation.com/learning Med 2001;110:210-216. Very much alive and very necessary. J Am -programs. 7. Barrett MJ, Martinez MW, Pieretti J. The Coll Cardiol 2016;67:1118-1119. 30. Blaufuss Medical Multimedia Laborato- power of repetition in mastering cardiac 18. Barrett MJ, Mackie AS, Finley JP. Cardiac ries. Heart sounds and cardiac arrhyth- auscultation. In: Finley J, ed. Teaching auscultation in the modern era: Premature mias. Tutorials. Accessed 1 October 2018. heart auscultation to health professionals: requiem or phoenix rising? Cardiol Rev www.blaufuss.org.

130 bc medical journal vol. 61 no. 3, april 2019 bcmj.org worksafebc

Indoor air quality

ndoor air quality in an office en- the number of people in the space. Acceptable indoor vironment is meant to be safe Elevated levels of CO2 commonly I and comfortable. The office en- correlate with complaints of poor air air quality levels vironment is very different from the quality and a multitude of nonspecific Temperature: 20 to 27 oC industrial setting. Toxic emissions in health symptoms. This can be cor- Relative humidity: 30% to 60% an office setting are not expected but rected simply by increasing the fresh may occur on rare occasions due to air intake. CO originates from incom- CO2: < 1000 ppm above the out- something unusual in the office envi- plete combustion of organic matter, door concentration ronment or the entrainment of pollu- and common sources include fires, in- CO: ≤ 25 ppm (should be 0 ppm) tion from outside. Air pollutants may ternal combustion engines, furnaces, originate from a neighboring industry, and cigarette smoke. The occupation­ somehow bypassing the building’s al exposure limit for CO level is 25 and gradually diminishes over time. ventilation system, or they may enter ppm or less. However, in an office Other emissions may originate from the building due to poor design, such building, there should not be any CO occupants, in the form of body odor or as a ventilation air intake located in a scented personal care products. While parking lot, resulting in entrainment these products are not harmful, they of car exhaust into the office space. A well-maintained, can produce many complaints, and a Many modern office buildings are well-balanced, properly general office policy regarding their sealed to the outside with windows running heating, ventilation, use is usually sufficient to eliminate that do not open. These buildings rely and air conditioning (HVAC) the problem. completely on the ventilation system Office renovations are also often system should provide a for healthy indoor air quality. A well- the source of air-quality complaints maintained, well-balanced, properly cleaner and more from office workers, as the renovations running heating, ventilation, and air comfortable environment may involve the release of unwanted conditioning (HVAC) system should than the outdoors. aerosols in the form of particulates, provide a cleaner and more comfort- volatile chemicals, and paint vapors, able environment than the outdoors. as well as noise. Many of these con- This system filters out most outdoor in the air. Any level of CO in the am- taminants will eventually be removed dust and particulates. It also maintains bient air of an office building should by the HVAC system, but controlling the temperature and relative humidity be investigated and mitigated. the release of pollutants at the source within the recommended range for There are other contaminants that is of primary importance to maintain- occupant comfort. It provides an ad- can be found in office buildings, such ing good air quality. One way to do equate mix of recycled and fresh air as emissions from printers, photo- this is to isolate the source of emis- to minimize heating or cooling costs, copiers, and fax machines. These ma- sions by containing the area of work. while avoiding staleness of the air. chines can release ozone and volatile For example, office renovations can be Typically, four parameters are organic compounds (VOC), as well done during non-business hours. The measured when evaluating indoor air as fine dust. To mitigate the effects of renovation area should be enclosed, quality: temperature, relative humid- these emissions, fax and photocopy and localized ventilation can be used

ity, carbon dioxide (CO2) levels, and machines can be placed in a sepa- to prevent the migration of pollutants. carbon monoxide (CO) levels (see rate, enclosed room with higher local For more information, visit www Box ). CO2 is emitted by people work- ventilation to prevent entrainment of .worksafebc.com and search for ing in the office building. An exces- the emissions into the general office “indoor air quality,” or contact a

sive accumulation of CO2 indicates environment. medical advisor in WorkSafeBC’s an inadequate amount of fresh air for Office furnishings, carpeting, and Occupational Disease Services at 604 wall coatings such as paint can also 231-8842. This article is the opinion of WorkSafeBC emit VOC through off-gassing. This is —Sami Youakim, MD, MSc, FRCP and has not been peer reviewed by the typically worse when the furnishings, WorkSafeBC Occupational BCMJ Editorial Board. carpets, and paints are relatively new Disease Services

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 131 news

Changes to the The winter 2019 issue features appropriate and timely care to chil- Editorial Board news on: dren and youth close to home. It is not without • Proactive panel management. When you call for a consultation, a little sadness • Improving care for at-risk moms. you will have access to a multidisci- that the BCMJ • Change to some GPSC fees. plinary team who can offer: says goodbye • New committee members. • Telephone advice and support. to Dr Tim- • Top 10 GPSC stories for 2018. • Identification and help with connec- othy Rowe. Dr To subscribe to the GPSC newslet- tion to local and online resources. Rowe has been ter, log in to your account on the Doc- • Telehealth consultation to you and an Editorial tors of BC website and adjust your your patient, when needed. Board member subscription preferences accordingly. • Tailored training and education. since the dawn The multidisciplinary team in- Timothy Rowe, MD of civilization GPSC article update cludes child and youth psychiatrists, (1993), and The GPSC outlined details about mental health and substance use clini- his vast experience will be missed. eligibility for the GPSC Panel De- cians (social workers, nurses, psychol- Dr Rowe applies his high intellect in velopment Incentive in its November ogists, etc.) and a care coordinator. the pursuit of both correctness (par- BCMJ article, “New GPSC incentive The Compass team can help with ticularly grammar) and wisdom. The supports family doctors to implement diagnostic clarification, medication Editorial Board would like to thank panel management” [2018;60:432- recommendations, treatment planning, Dr Rowe on behalf of all members 433]. Since publication of that article, consultation on cognitive behavioral and wish him the best in his next details about claiming the Panel De- therapy, dialectical behavior therapy, endeavors. velopment Incentive have changed. substance counseling, behavioral is- According to revised GPSC policy, sues, family issues, trauma treatment, Dr Rowe’s sessional payments claimed for PSP- and general support when things aren’t place at the supported panel work occurring on going well. You will receive a written BCMJ table or before 11 September 2018 are no record of all consultation recommen- has been filled longer deducted from the Panel De- dations for your patient’s chart. by Dr Amanda velopment Incentive. Sessional pay- Compass aims to have a member Ribeiro. Dr Ri- ments claimed for PSP-supported of our multidisciplinary team answer beiro is an OB/ panel work occurring after 11 Sep- most phone calls and respond to your GYN resident tember 2018 will continue to be de- questions in real time. For more spe- and a former ducted from the Panel Development cialized questions, we aim to get back co-editor of Incentive. Visit www.bcmj.org/gpsc/ to you within the same or next day. Amanda Ribeiro, MD the UBC Med- new-gpsc-incentive-supports-family Telehealth consultations are orga- ical Journal. -doctors-implement-panel-manage nized on an as-needed basis following She is as well rounded as they come ment to read the article. the initial phone consultation. and brings a welcome, passionate, What you need to know to use the younger voice to our Board. Dr Ri- Compass program service: beiro’s contributions will ensure on- Compass is a province-wide service • Compass is a consultative service going excellence at the BCMJ in the to support evidence-based care for and community providers retain full years to come. all BC children and youth living with clinical responsibility of their pa- –DRR mental health and substance use con- tients. Recommendations provided cerns. Community care providers by Compass should not supersede Read the quarterly GPSC such as primary care providers, spe- the best clinical judgment of an in- newsletter online cialist physicians, child and youth person care provider. Emailed directly to BC family phys- mental health team clinicians, Foun- • If patients and family consent, icians, the GPSC’s quarterly news- dry clinicians, and concurrent disor- Compass will collect identifying letter, GP Update, is also available ders/substance use clinicians have patient information to facilitate any online at www.gpscbc.ca/news/ access to information, advice, and re- needed follow-up with you (or with publications. sources they need in order to deliver the families directly). If patients or

132 bc medical journal vol. 61 no. 3, april 2019 bcmj.org news

families don’t want their informa- While online health care is ex- Tool to help with early tion stored, Compass can provide pected to be more convenient for us- detection of melanoma recommendations on an anony- ers, there are concerns that it won’t Work is being done on a simple com- mous basis. deliver the same opportunities to pact laser probe that can distinguish • Compass is not a crisis intervention educate patients about their health between harmless moles and cancer- service, but will support providers and well-being, and preventive mea- ous ones in a matter of seconds. Dan- with advice on safety planning, risk sures. One of the studies compared iel Louie, a PhD student, constructed assessments, etc. Please contact clients’ knowledge of HIV testing the device as part of his studies in bio- your local crisis services for any and prevention among clinic visitors medical engineering at the University emergencies. and GetCheckedOnline users. The of British Columbia. The probe works • Compass will collect and store your researchers found that GetChecked on the principle that light waves demographic and practice-related Online users had equal knowledge of change as they pass through objects. information. HIV as people who had gone to clin- Researchers aimed a laser into 69 • Compass will periodically reach out ics for testing, even 3 months after to providers to better understand testing. their experience with the service and Along with online services, pro- communicate any upcoming work- cesses that connect clients with doc- shops or educational opportunities. tors when needed are still required. For more information, call 1 855 Some users also noted face-to-face 702-7272, Monday to Friday, 9:00 visits provide opportunities to discuss a.m. to 5:00 p.m. Register at www.bc other health matters and can lead to childrens.ca/compass. referrals for further care. Previous re- search from the BCCDC shows there Online sexually transmitted is a growing interest in integrating infection testing offers mental and sexual health services. many benefits The three studies were recently Researchers with the BC Centre published in Sexually Transmitted Skin cancer probe for Disease Control (BCCDC) and Infections: the University of British Columbia • “Qualitative analysis of the experi- lesions from 47 volunteer patients at (UBC) published three studies evalu- ences of gay, bisexual and other men the Vancouver General Hospital Skin ating users’ experiences of the free who have sex with men who use Get Care Centre and studied the changes and confidential online testing pro- CheckedOnline.com: A comprehen- that occurred to this light beam. Be- gram, GetCheckedOnline (http://get sive internet-based diagnostic service cause cancer cells are denser, larger, checkedonline.com), during the first for HIV and other STIs” (https://sti and more irregularly shaped than few years of its operation. Users re- .bmj.com/content/early/2019/01/12/ normal cells, they caused distinctive ported that online sexually transmitted sextrans-2018-053645) scattering in the light waves as they infection (STI) testing removes some • “Differences in experiences of bar- passed through. Researchers were of the barriers that prevent people from riers to STI testing between clients able to invent a novel way to interpret getting tested while providing key in- of the internet-based diagnostic test- the patterns instantaneously. This op- formation about health and wellness. ing service GetCheckedOnline.com tical probe can extract measurements GetCheckedOnline tests for STIs and an STI clinic in Vancouver, without needing expensive lenses or and blood-borne infections such as Canada” (https://sti.bmj.com/content/ cameras, and it can provide a more HIV and hepatitis C. It is the first on- early/2018/02/15/sextrans-2017 easily interpreted numerical result line sexual health service in BC and -053325) like those of a thermometer. Although is available to people living in Metro • “Post-test comparison of HIV test the components of the probe cost only Vancouver and, in partnership with knowledge and changes in sexual a few hundred dollars, it is not en- Island Health and Interior Health risk behaviour between clients ac- visioned to be a consumer product. Authorities, some parts of Vancou- cessing HIV testing online versus in- Tim Lee, an associate professor of ver Island and the Interior. More than clinic” (https://sti.bmj.com/content/ skin science and dermatology at UBC 12 000 tests have been completed early/2019/01/12/sextrans-2018 and a senior scientist at both BC Can- since it launched in 2014, and 43% of -053652.long) cer and the Vancouver Coastal Health people have used it for testing more For more information, vist http:// Research Institute, supervised the than once. getcheckedonline.com. Continued on page 134

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 133 news

Continued from page 133 lating the progression of sepsis. Re- work. He believes the device would Pre- and postnatal nutrition searchers discovered that ABCF1 acts be a good future addition to standard program in Victoria as a “switch” at the molecular level cancer screening methods, but not a Victoria Best Babies is a pre- and that can stop the uncontrolled chain- replacement. postnatal nutrition program that pro- reaction of inflammation in the body This is a joint project between vides support to improve the health and dampen the potential damage. UBC, BC Cancer, and the Vancouver and well-being of pregnant women, With no specific course of treatment, Coastal Health Research Institute. Re- new mothers, and babies facing management of sepsis for the 30 mil- searchers hope to eventually achieve challenging life circumstances. The lion people who develop it each year Health Canada certification and ap- program aims to improve maternal– relies on infection control and organ- proval before being able to offer this infant health, increase the rates of function support. testing through health professionals. healthy birth weights, and promote Though sepsis is hard to diagnose, This will require further refinement of and support breastfeeding. The pro- scientists do know that it occurs in the technology and additional clinical gram also aims to promote the cre- two phases. The first phase, system- testing in more patients. ation of partnerships in communities ic inflammatory response syndrome Study authors are Daniel C. Lou- and strengthen community capacity (SIRS), results in a “cytokine storm,” ie, Jamie Phillips, Lioudmila Tchvia- to increase support for vulnerable a dramatic increase in immune cells leva, Sunil Kalia, Harvey Lui, Wei pregnant women and new mothers. such as macrophages, a type of white Wang, and Tim K. Lee. The article What is included: blood cell. This results in inflammation describing the study, “Degree of opti- • Educational sessions. and a decrease in anti-inflammatory cal polarization as a tool for detect- • One-on-one support. cells, leading to chemical imbalances ing melanoma: Proof of principle,” is • Monthly food vouchers and Good in blood and damage to tissues and in the Journal of Biomedical Optics. Food Box produce. organs. Recovery starts to take place It is available online at https://doi • Prenatal vitamins and vitamin D when the body enters a second phase .org/10.1117/1.JBO.23.12.125004. drops. (endotoxtin tolerance, or ET), where • Baby food demos. the opposite occurs. Dragon® Medical • Healthy snacks and lunches. Building on previous knowledge • Hospital tours and hospital prereg- of ABCF1 as part of a family of pro- Practice Edition 4 istration. teins that plays a key role in the im- (it’s the version you have been • On-site access to a public health mune system, researchers examined waiting for) nurse, a dietitian, and a dental hy- its role in white blood cells during in- gienist. flammation in a mouse model of sep- For more information, or to re- sis. They discovered that ABCF1 had fer a patient to the program, contact the ability to act as a “switch” in sep- Shonna at 250 381-1552 (ext.116) or sis to transition from the initial SIRS [email protected]. phase into the ET phase and regulate This program is sponsored by the “cytokine storm.” Furthermore, Fernwood NRG with funding from without the ABCF1 switch, immune the Public Health Agency of Canada. responses are stalled in the SIRS phase, causing severe tissue damage Protein “switch” could and death. be key to controlling The discovery opens up potential blood poisoning for new treatments for chronic and Dragon Software Scientists at the University of Brit- acute inflammatory diseases, as well Installation & Support ish Columbia have discovered a new as autoimmune diseases. EMR Integration & Training protein “switch” that could stop the The research was conducted in progression of sepsis and increase the collaboration with the Vancouver CONTACT US TODAY! chances of surviving the life-threat- Prostate Centre, a Vancouver Coast- speakeasysolutions.com ening disease. Sepsis causes an esti- al Health Research Institute research 1-888-964-9109 mated 14 million deaths every year. centre, and was funded by the Canadi- speech technology specialists In a study published recently in Im- an Institutes of Health Research. The for 18 years munity, researchers examined the role article is available online at https://doi of a protein called ABCF1 in regu- .org/10.1016/j.immuni.2019.01.014.

134 bc medical journal vol. 61 no. 3, april 2019 bcmj.org council on health promotion

Canadian physicians support mandatory alcohol screening

n May 2010, the Canadian Medical necessary because the impaired driv- crease in total serious and fatal night- Association passed the following ing laws were working well. In fact, time crashes and saved society more I resolution: “The Canadian Medical­ Canada has long had a very poor im- than $1 billion in 1997. Ireland’s MAS Association supports the use of ran- paired driving record relative to com- legislation came into force in July dom breath tests (i.e., MAS) in exist- parable countries. The US Centers for 2006. By the end of 2015, total traffic ing police spot-check programs, as Disease Control reported that in 2013 deaths had fallen 54.5%, and serious part of a comprehensive plan to re- Canada had the highest percentage of injuries had decreased 59.8%. Rather duce drunk-driving related mortality alcohol involvement in crash deaths than overburdening criminal justice and morbidity in Canada. Any such resources, MAS greatly reduced im- programs should be consistent with paired driving charges, which fell to the protections in the Canadian Char- approximately 6525 from 18 650. ter of Rights and Freedoms.” Conviction data show that, Critics of MAS also allege that In June 2018, Parliament enacted MAS could be used to target vis- on average, a Canadian Bill C-46, which among other things ible minorities. According to leading authorized police to demand a road- could drive impaired once Australian researchers, exactly the side breath test from any driver who a week for over 3 years opposite occurred when MAS was they have lawfully stopped. Mandato- without being charged, and implemented. Rather than drivers be- ry alcohol screening (MAS) changes for over 6 years without ing stopped and assessed based on an only one aspect of Canada’s impaired being convicted of an individual officer’s subjective assess- driving law—the basis for demanding ment, all drivers approaching a MAS impaired driving offence. a roadside breath test. Police already checkpoint are stopped (unless there had authority to stop drivers to inspect is a backlog), and all stopped drivers their documents and question them are tested. about their driving and sobriety. Pre- While MAS, like many criminal viously, a roadside breath test could (33.6%) among 20 high-income coun- amendments, will face Charter chal- only be demanded from a driver who tries. While Canadians drink consid- lenges, it must be put in the context of was reasonably suspected to have al- erably less than residents of many of other accepted screening procedures. cohol in his or her body. these countries, they are much more Millions of Canadians are routinely Research indicates that police de- likely to die in alcohol-related crash- subject to mandatory screening at tect only a small fraction of drinking es. Not surprisingly, almost all of Canadian airports, borders, and gov- drivers when they are required to rely these countries have MAS programs. ernment facilities. MAS operates the solely on their own unaided senses, as Despite recent progress, impairment- same way and serves the same protec- was the case in Canada. Survey, ar- related crashes were killing approxi- tive purposes as these other screening rest, and conviction data show that, on mately 1000 Canadians a year and programs. average, a Canadian could drive im- injuring another 60 000, a dispropor- The Canadian courts have never paired once a week for over 3 years tionate number of whom were teenag- held that these mandatory searches, without being charged, and for over ers or young adults. or those imposed on courtroom en- 6 years without being convicted of an Forty-five years of research in trants, violated the Charter. Indeed, impaired driving offence. numerous countries have established the Ontario Court of Appeal stated Some critics claim that MAS is un­ that comprehensive MAS programs that searching all courtroom entrants dramatically reduce impaired driving makes for a safer environment, is not This article is the opinion of the Emer- and crash deaths. For example, when intrusive or stigmatizing, and does gency and Public Safety Committee, a Switzerland enacted MAS in 2005, the not violate the Charter. Given that the subcommittee of Doctors of BC’s Council percentage of alcohol-positive driv- courts have upheld the constitution- on Health Promotion and is not necessarily ers fell to 7.6% from about 25%, and ality of these procedures, there is no the opinion of Doctors of BC. This article alcohol-related crash deaths dropped principled basis for reaching the op- has not been peer reviewed by the BCMJ approximately 25%. New Zealand’s posite conclusion regarding MAS. Editorial Board. MAS program resulted in a 54.1% de- Continued on page 142

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 135 bc centre for disease control

British Columbia’s Tuberculosis Strategic Plan: Refreshed and focused on TB elimination

espite being both preventable Priority areas Key deliverables and curable, tuberculosis (TB) Contact evaluation Develop, implement, and evaluate a cascade of care that approximates remains one of the top 10 D measurable indicators from screening of contacts to LTBI treatment causes of death worldwide and is the completion and outcome. leading cause of death from a single in- LTBI screening and Streamline TB screening recommendations for those entering fectious agent.1 In 2017, an estimated treatment congregate living settings and implement a variety of LTBI treatment 10 million people developed TB dis- options. ease globally, resulting in an estimated Active TB treatment Remove barriers to care and support clients through treatment including 1.6 million deaths, with 300 000 of identifying social support resources and trialing virtual health methods for reaching clients and providers. those deaths occurring in people living with HIV.1 Labs Create efficiencies within laboratory services and assemble a formal working group to move key lab work forward. TB is not just an international public health issue. Cases are diag- Service provision Develop service maps and/or relationship algorithms between BCCDC’s TB Services and each health authority, which helps to depict roles, nosed every day in Canada. In BC, identify points of intersection, and reduce duplication, as well as there were 241 cases of active TB in incorporate patient-centred care into the method of care delivery. 2016. In 2015, 745 clients were start- TB literacy Conduct a TB needs assessment to identify learning and literacy gaps for ed on latent tuberculosis infection both clients and providers and consider findings for future resource (LTBI) therapy to prevent dormant development. TB from progressing to the active, Table. British Columbia’s TB Strategic Plan, summary of priority areas and corresponding infectious state.2 Although active TB deliverables. incidence has generally declined over the last 10 years, BC’s active TB inci- dence remains slightly higher than the collaborative effort supported by the meeting helped to identify successes national rate (5.1/100 000 population BC TB Strategic Committee (TBSC) and challenges to date, highlight key compared to 4.8/100 000).2 TB also with broad representation from all areas of focus, identify gaps in the disproportionately affects persons regional health authorities, the First plan, and clarify responsibility and with comorbid medical conditions Nations Health Authority, PHSA, and ownership for the refreshed priorities. (e.g., chronic kidney disease, trans- the ministry. Refreshed provincial TB priorities plant) and other marginalized groups. and key deliverables are summarized In an effort to reduce the inci- in the Table. dence, morbidity, and mortality of The refreshed TB Strategic The refreshed TB Strategic Plan TB in BC, the BC Strategic Plan for Plan guides the provincial guides the provincial response to Tuberculosis Prevention, Treatment response to TB and signifies TB and signifies a solid commit- and Control3 was released in 2012. a solid commitment from ment from involved stakeholders to The 10-year plan was developed in involved stakeholders to ensure British Columbians are pro- partnership with a broad range of tected from TB and receive quality ensure British Columbians stakeholders including the BC Minis- care should infection or disease oc- try of Health, health authorities, and are protected from TB and cur. This plan also helps solidify the community organizations. The plan receive quality care should importance of TB prevention and contains five strategic goals, each infection or disease occur. treatment as a provincial health prior- supported by corresponding objec- ity. On an international level, the re- tives and actions. Implementation of freshed plan is aligned with the World the Strategic Plan continues to be a In late 2017, midway through the Health Organization’s goal of elimi- current plan, members of the TBSC nating TB in low-incidence countries This article is the opinion of the BC Centre came together over 2 days to repriori- like Canada.4 The British Columbia for Disease Control and has not been peer tize and streamline the objectives not- Tuberculosis Strategic Plan 5-Year reviewed by the BCMJ Editorial Board. ed in the 2012 plan. This face-to-face Continued on page 137

136 bc medical journal vol. 61 no. 3, april 2019 bcmj.org college library

DynaMed Plus: Updated point-of-care tool now available

he College Library now sub- DynaMed Plus provides improved advantage of CME credits, readers scribes to DynaMed Plus, the search functionality, medical graphs must first create a user account with T updated version of DynaMed. and images, links to Micromedx drug DynaMed Plus. Like its predecessor, DynaMed Plus content, and a new mobile app. Rel- Registrants may access DynaMed is a point-of-care resource providing evant medical images and drug con- Plus from the College Library’s Point current disease guidance and recom- tent specific to the topic are located of Care and Drug Tools webpage mendations for treating and managing (www.cpsbc.ca/library/search-mater patients. It contains more than 3200 Topic summaries are ials/point-of-care-drug-tools, login topic summaries created by physi- required). Instructions for updating updated daily based on a cians and evaluated by an editorial to the DynaMed Plus app (iOS or An- team for clinical relevance and sci- review of the scientific droid) are available on the Apps and entific validity. Topic summaries are literature. Audiovisual page (www.cpsbc.ca/ updated daily based on a review of the library/search-materials/audiovisual). scientific literature. with the summaries. The mobile app For further information about features access to content offline, the DynaMed Plus or any of our other This article is the opinion of the Library of option to bookmark favorite topics, e-resources, please contact the li- the College of Physicians and Surgeons of and the ability to email topics. CME brary at [email protected] or call 604 BC and has not been peer reviewed by the credits are available for reading topic 733-6671. BCMJ Editorial Board. summaries in DynaMed Plus. To take —Robert Melrose Librarian bccdc BC Medical Journal @BCMedicalJournal Continued from page 136 Refresh (2017–2021) can be found at ments/Statistics%20and%20Research/ High biotin concentrations in blood combined-files-april.docwww.bccdc Statistics%20and%20Reports/TB/TB samples for immunoassays can interfere with investigations for cardiac disease, _Annual_Report_2016.pdf. .ca/resource-gallery/Documents/Sta endocrine disorders, malignancies, tistics%20and%20Research/Publica 3. BC Communicable Disease Policy Advi- anemias, and infectious diseases and tions/TB/BC%20TB%20Strat%20 sory Committee. BC strategic plan for tu- lead to falsely low or falsely high results. Plan%20Refresh%202017.pdf. berculosis prevention, treatment and con- Read the article: bcmj.org/articles/when- —Shaila Jiwa, RN, MScPPH trol. Accessed 26 February 2019. www vitamin-supplementation-leads-harm- .bccdc.ca/resource-gallery/Documents/ growing-popularity-biotin-and-its-impact- Senior Practice Leader, Clinical laboratory Prevention Services, BCCDC Statistics%20and%20Research/Publica —Victoria Cook, MD, FRCPC tions/TB/BC_Strategic_Plan_Tuberculo Medical Head, Provincial TB sis.pdf. Services, BCCDC 4. World Health Organization. Towards TB elimination: An action framework for low- References incidence countries, 2014. Accessed 19 1. World Health Organization. Global tuber- February 2019. https://apps.who.int/iris/ culosis report, 2018. Accessed 13 Feb­ bitstream/handle/10665/132231/ ruary 2019. https://apps.who.int/iris/ 9789241507707_eng.pdf;jsessionid=15 bitstream/handle/10665/274453/ 75EF1019F0C5EE82EAC6AD26D86C0 BCMJ.ORG 9789241565646-eng.pdf?ua=1. C?sequence=1. 4 1 Comment 3 Shares 2. BC Centre for Disease Control. Annual TB Like Comment Share report, 2016. Accessed 13 February 2019. www.bccdc.ca/resource-gallery/Docu Like @BCMedicalJournal and join in the conversation.

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 137 cme calendar

CME listings OBESITY SUMMIT der to facilitate improved communi- rates and details Vancouver, 6 Apr (Sat) cation with patients about health To be held at the Morris J. Wosk promotion, disease prevention, and Rates: $75 for up to 1000 char- Centre for Dialogue, UBC CPD’s preferences for treatment. This group acters (maximum),­ plus GST per 7th annual Obesity Summit aims to learning program has been certified month; there is no partial rate. If connects health care practitioners by the College of Family Physicians the course or event is over be- with specific interests in caring for of Canada for up to 5.75 Mainpro+ fore an issue of the BCMJ patients who are obese. Expert and credits. At the conclusion of this ac- comes out, there is no discount. guest speakers from the obesity disci- tivity, participants will be able to cri- pline will discuss a broad range of tique current evidence for nutritional Visa and Master­Card accepted. topics on obesity and bariatrics. Tar- support in several conditions com- get audience: family physicians, sur- monly encountered in primary care Deadlines: geons, registered dietitians, nurses, including the prevention of dementia Online: Every Thursday (list­ings physiotherapists, occupational ther- and support of cardiovascular health; are posted every Friday). apists, residents, and others interested evaluate claims for potential health Print: The first of the month 1 in caring for patients who are obese. benefits or adverse effects resulting month prior to the issue in Topics covered: medical and dietary from popular weight loss diets; ex- which you want your notice to management of obesity, challenging plain nutritional biochemistry re- appear, e.g., 1 February for the medico-surgical case rounds, pre- lated to specific metabolic pathways March issue. The BCMJ is dis- operative and postoperative patient and physiological processes influen- tributed by second-class mail in care, and obesity management with cing stress and adrenal health; and the second week of each month additional medical issues. Course for- communicate knowledgeably with except Jan­uary and August. mat consists of collaborative didactic patients about their preferences for lectures and interactive small group treatment, including the use of specif- Place your ad at www.bcmj workshops and panel discussions. ic diets and nutritional supplements. .org/cme-advertising. You will Time has been set aside for network- Download the program brochure for ing. Join us at the end of the day for additional information. Scholarships be invoiced upon publication. a reception to meet with friends and are available to undergraduate and Payment is accepted by Visa or colleagues. Program details and on- graduate medical students. Online MasterCard on our secure on- line registration: https://ubccpd.ca/ registration: https://isom.ca/event/ line payment site. course/BCOS2019. BC Obesity Soci- npc-bc. Email [email protected]. ety website http://bcobesity.net/. Tel Planning your CME listing: 604 675-3777, email cpd.info@ubc MINDFULNESS IN MEDICINE Planning to advertise your CME .ca; ubccpd.ca. WORKSHOPS AND RETREATS event several months in ad- Tofino, 26–29 Apr (Fri–Mon) vance can help improve atten- NUTRITION IN PRIMARY CARE Cortes Island, 14–19 Jun dance. Members need several Vancouver, 6 Apr (Sat) (Fri–Wed) weeks to plan to attend; we Nutrition in Primary Care: Update Join Dr Mark Sherman for an explor- suggest that your ad be posted and Controversies 2019 will be held ation of mindfulness and meditation 2 to 4 months prior to the event. at SFU Harbour Centre. This program and how these practices support the is designed to enhance primary care work you do, the life you live, and the providers’ knowledge of applied nu- person you are. Tofino: Foundations tritional biochemistry and the asso- of Theory and Practice Workshop for ciated research literature pertaining Physicians and Partners. Cortes Is- to several conditions commonly en- land (Hollyhock): A Physician Medi- countered in clinical practice. Various tation Retreat. For more information levels of evidence will be presented or to register please go to www.living for evaluation and discussion in or- thismoment.ca/events.

138 bc medical journal vol. 61 no. 3, april 2019 bcmj.org calendar

PEDIATRIC EMERGENCY Target audience: pediatricians, emer- TROPICAL & GEOGRAPHIC MEDICINE UPDATE gency physicians, family physicians, MED INTENSIVE SHORT Vancouver, 2–4 May (Thu–Sat) allied health professionals, and resi- COURSE The 16th annual Pediatric Emergency dents. Accreditation: Up to 12.5 Vancouver, 6–10 May (Mon–Fri) Medicine Update will be held at UBC MOC Section 1/Mainpro+ credits. The University of British Columbia Robson Square. Course theme: Care Course content: ubccpd.ca/course/ Faculty of Medicine is pleased to offer of the complex child in the emergency PedER2019#agenda. Pre-conference this 6th annual CME course for health department (ubccpd.ca/course/PedER course, Thu, 2 May: APLS: Advanced care providers who seek to learn an 2019). Course highlights: Newsies: Pediatric Life Support Course (https:// approach to preventing, diagnosing, 2018–2019 Practice altering articles ubccpd.ca/course/PedER2019#pre evaluating, treating, and managing (Dr Ran Goldman); It’s complicated: _post). Requirement: successful pre- tropical diseases. It is especially use- Abdominal pain in the adolescent vious completion of PALS or APLS ful for those who intend to practise girl (Dr Karen Black); Bend It Like course suggested. Only for physicians in areas endemic for these diseases. Beckham: Common sports medi- who are routinely involved in the care Three broad areas are emphasized: cine emergencies (Dr Paul Enarson); of critically ill or injured children. clinical tropical medicine, parasitol- Nick of time: Common mistakes in Accreditation: Up to 16.0 MOC Sec- ogy, and public health. Material to pediatric resuscitations (Dr Melissa tion 3 credits or 16.0 Mainpro+ cred- be covered includes clinical descrip- Chan); Sinister: Pediatric oncologic its (2cr/hr). Maximum participants: tions and approaches to evaluation emergencies (Dr David Dix); The 24. Register: https://events.eply.com/ and treatment of tropical diseases and hurt locker: Headaches in children PedER2019. strategies for infection control within (Dr Badri Narayan); Eyes wide shut: communities that make a critical dif- Common eye emergencies (Dr Ben- ference to survival. Participants will etta Chin); Lost: Children with com- gain practical experience through plex medical needs in the ER—A laboratory and problem-solving case-based approach (Dr Esther Lee). Continued on page 140

What’s Changing? We’re making changes to increase care for your patients injured in a crash. This means: • double the money for care and recovery • more money per treatment • more types of treatments covered • reduced user fees.

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bc medical journal vol. 61 no. 3, april 2019 bcmj.org 139

EDIT: Nov. 2018 calendar

Continued from page 139 Course fee: $420 (includes GST). tion syndrome: Management pearls. exercises. Register early as space is Participants in this intensive course To register and for more information, limited. More information at www will learn new approaches, primar- visit ubccpd.ca, call 604 675-3777, or .spph.ubc.ca/continuing-education/ ily through interview simulations in email [email protected]. tgm2019/. Contact: [email protected], small groups, supported by sympa- tel 604 822-9599. thetic, experienced, clinical teachers. PsychedUP CME At the conclusion of this course, par- Vancouver, 31 May (Fri) DIABETES DIRECTORS ticipants will be able to identify com- To be held at UBC Robson Square, SEMINAR mon clinical pitfalls in the prescribing 800 Robson St. This accredited CME Vancouver, 10 May (Fri) of drugs of potential abuse to patients; event (9 a.m. to 2 p.m.) has been at- The Endocrine Research Society develop a tool kit and strategies to tended by 800 health care profession- is pleased to present the 31st Dia- assist in the management of chronic als so far. Some of the testimonials betes Directors Seminar, an annual noncancer pain with opioid medica- we received can be viewed at www UBC-accredited gathering of lead- tions; identify and begin to apply clin- .psychedupcme.com/testimonials. Dr ing diabetes experts and caregivers ical interviewing strategies that assist Diane McIntosh says, “I developed from across British Columbia. Join in managing difficult problems in the PsychedUp CME to make psychiatry us at the Sandman Hotel Vancouver office setting; develop and begin to continuing medical education clinic- City Centre for a full-day presenta- apply strategies to detect and manage ally relevant, practical, engaging, and tion series covering the latest and misuse and abuse of drugs of poten- interactive. Our patients are counting most pertinent aspects of diabetes, tial abuse in their practice; implement on us to be at the leading edge when therapeutics, and clinical care. Tar- changes to their practice as a result we diagnose a mental illness, and pre- get audience: specialists and family of attending this course and reflect- scribe or switch psychotropic medica- physicians with an interest in dia- ing on the implications of its content. tions. You’ll be there with PsychedUp betes care, nurses, dieticians, phar- This group learning program meets CME.” Target audience: psychiatrists, macists, and other diabetes educators the certification criteria of the Col- family physicians, nurse practition- responsible for diabetes management lege of Family Physicians of Canada ers, registered nurses, and pharma- in their own groups and commun- and has been certified by UBC CPD cists. Accreditation: 4.5 Mainpro+ ities. Register now; space is limited. for up to 7.25 Mainpro+ credits. Each and Section 1 credits. Topics: Anx- Register online at www.endocrine physician should claim only those iety disorders and adult ADHD. Bi- researchsociety.com/events/31st-ann credits they actually spent in the ac- polar disorder will be covered time ual-diabetes-directors-seminar. For tivity. Registration: drugprograms@ permitting. You’ll leave PsychedUp further information contact Tristan cpsbc.ca, or 604 733-7758 ext. 2629. CME with a plan for conducting Jeffery, Endocrine Research Society: highly effective, time-efficient diag- email endocrine.research.society@ CME ON THE RUN nostic interviews; a review of the gmail.com, phone 604 689-1055. VGH and various videoconference most up-to-date, evidence-based, locations, 10 May (Fri) clinically relevant psychiatric treat- PRESCRIBERS COURSE CME on the Run sessions are held at ments; a patient-focused, individual- Vancouver, 10 May (Fri) the Paetzold Lecture Theatre, Van- ized, prescribing plan that will save Family physicians consistently rate couver General Hospital and there you time, lessen your clinical burden, prescribing for chronic pain amongst are opportunities to participate via and relieve your patients’ suffering; the most difficult areas of their pro- videoconference from various hospi- renewed confidence when managing fessional lives. In a discipline where tal sites. Each program runs on Friday mental illnesses in your busy practice. communication is the core skill set, afternoons from 1 p.m. to 5 p.m. and For more information, write to us at talking to patients in realistic terms includes great speakers and learning [email protected]. Register about the risks and benefits that at- materials. Date and topics: 10 May on psychedupcme.com. tend the use of opioids, benzodiazep- (internal medicine). Topics include: ines, and other potentially habituating Management of obesity; Manage- ORTHOMOLECULAR medications challenges even the most ment of migraine; COPD: Current MEDICINE TODAY seasoned practitioners. This 1-day treatments; Common cardiac ar- Vancouver, 31 May–2 Jun (Fri-Sun) course (8 a.m. to 5 p.m. with regis- rhythmias: When to worry and refer; To be held at the Fairmont Hotel, the tration starting at 7:30 a.m.) will be Atrial fib initial management; Lyme 48th annual International Orthom- held at the College of Physicians and disease update; Gut microbiome: olecular Medicine Today conference Surgeons of BC, 300 – 669 Howe St. The second brain; Central sensitiza- is a continuing education event for

140 bc medical journal vol. 61 no. 3, april 2019 bcmj.org calendar medical doctors, naturopathic doc- EMERGENCY AND CRITICAL icians, locums, IMGs, physicians new tors, nurse practitioners, pharmacists, CARE CONFERENCE to BC, family practice and specialty and other health care profession- Parksville, 1–2 Jun (Sat–Sun) residents, and physicians working in als. The conference is presented by Join us in Parksville on Vancouver episodic care settings. Course for- the International Society for Ortho- Island for this year’s Vancouver Is- mat comprises collaborative didactic molecular Medicine, which brings land “Top 5 in 10” Emergency and lectures and interactive small-group together orthomolecular associations Critical Care conference. This course workshops; plenty of networking op- established in more than 20 countries will be held at the Parksville Com- portunities, and practice-based ex- around the world. Orthomolecular munity Centre and is geared to emer- hibits. Join us in the afternoon for a Medicine Today provides a forum gency physicians, family physicians, job fair and networking reception to for leading clinicians and researchers registered nurses, residents, and stu- meet with colleagues and make career to present current advances in ortho- dents. This event has been expanded connections. Program details and on- molecular oncology, immunology, to 2 days and will maintain the same line registration at https://ubccpd.ca/ and general medicine. Learn about great format of 10-minute lectures, course/practice-survival-skills-2019. the safe and effective use of natur- fun intermissions, contests, entertain- Tel 604 675-3777, email cpd.info@ ally occurring molecules for improv- ment, and videos. Come laugh and ubc.ca. ing patient outcomes. Additional learn. Saturday night mixer with spe- information and online registration cial guest Dr Brian Goldman. Course GP IN ONCOLOGY TRAINING at https://isom.ca/event/omt2019/. features at the new venue will now Vancouver, 9–20 Sep and 3-14 Feb Email: [email protected]. include the critical care compon- 2020 (Mon–Fri) ent. Great speakers: Drs Grant Innes, The BC Cancer’s Family Practice SKIN SPECTRUM SUMMIT Peter Rosen, David Williscroft, and Oncology Network offers an 8-week Vancouver, 1 Jun (Sat) more. There may also be an APLS General Practitioner in Oncology Skin Spectrum Summit, Canada’s pre-conference course—stay tuned. training program beginning with a Conference on Ethnodermatology, Accommodation: The Beach Club 2-week introductory session every is a landmark 1-day event designed Resort: http://bit.ly/viec2019rooms. spring and fall at the Vancouver Cen- to enhance patient care provided by Group code: UBC CPD-Vancouver tre. This program provides an oppor- GPs, FPs, NPs, dermatologists, and Island Emergency Conference. Book- tunity for rural family physicians, residents, when treating patients with ing deadline: 30 Apr. Program details with the support of their community, skin of color, notably Fitzpatrick and registration: https://ubccpd.ca/ to strengthen their oncology skills so Scale Skin Types III–VI. Location course/viec2019. Tel 604 675-3777, that they may provide enhanced care and time: Coast Coal Harbour Hotel, email [email protected]. for local cancer patients and their 7:30 a.m. to 3 p.m. Curriculum chair: families. Following the introductory Dr Jason Rivers, University of British PRACTICE SURVIVAL SKILLS session, participants complete a fur- Columbia. Learning objectives: Learn Vancouver, 15 Jun (Sat) ther 30 days of customized clinic ex- about the different skin conditions in The 12th annual Practice Survival perience at the cancer centre where Canada’s ethnic population includ- Skills—What I Wish I Knew In My their patients are referred. These can ing the manifestations of common First Years of Practice conference be scheduled flexibly over 6 months. dermatological problems for persons will be held at the UBC AMS Nest Participants who complete the pro- with skin of color. Improve diagnostic and emphasize practical, nonclinical gram are eligible for credits from the practices of different skin conditions knowledge crucial for your career. College of Family Physicians of Can- in the growing ethnic population. Topics include billing and billing ada. Those who are REAP-eligible Learn strategies and tools to better forms, rural incentives, MSP audits, receive a stipend and expense cover- manage patients with skin of color medicolegal advice and report writ- age through UBC’s Enhanced Skills including potential unique challen- ing, job finding and locums, financial Program. For more information or to ges they may face in their treatment. and insurance planning, practice man- apply, visit www.fpon.ca, or contact Registration at www.skinspectrum agement and incorporation, licensing Jennifer Wolfe at 604 219-9579. .ca. When registering enter this ex- and credentialing, and digital com- clusive discount code BCMedJou20 munication advice. Target audience: to receive 20% off your registration. family physicians, specialty phys-

bc medical journal vol. 61 no. 3, april 2019 bcmj.org 141 cohp guidelines for authors

Continued from page 135 —Robert Solomon, LLB, LLM BC Medical Journal (short form) As well, the Court’s arguments Distinguished University Professor, @BCMedicalJrnl apply with far greater force in regard Faculty of Law, to MAS. Driving is a privilege, not a The lived experience of people with Western University #dementia. Books about dementia The British Columbia Medical Journal wel­ individual patient is described, written consent adapted from other sources. Permissions should comes letters, articles, and essays. Manuscripts from the patient (or his or her legal guardian or right, and the risks posed by impaired National Director of Legal Policy, initially focused on the disease, the accompany the article when submitted. drivers are several hundred times should not have been submitted to any other pub­ substitute decision maker) is required. MADD Canada caregiver’s journey, and perspectives lication. Articles are subject to copyediting and Papers will not be reviewed without this docu­ Tables and figures greater than those posed by violent —Erika Chamberlain, PhD about the patient’s journey. Only editorial revisions, but authors remain respon­ ment, which is available at www.bcmj.org. Tables and figures should supplement the text, courtroom entrants. Put bluntly, far recently have memoirs been written by sible for statements in the work, including edi­ not duplicate it. Keep length and number of tables Dean and Professor, Faculty of References to published material people with dementia. torial changes; for accuracy of references; and and figures to a minimum. Include a descriptive more Canadians are killed in alco- Law, Western University Try to keep references to fewer than 30. Authors Read the article: bcmj.org/cohp/lived- for obtaining permissions. Send submissions title and units of measure for each table and hol-related crashes every year than Member of the Board of Directors, to: The Editor, BC Medical Journal, journal@ are responsible for reference accuracy. Refer­ experience-people-dementia figure. Obtain permission and acknowledge by terrorists on airplanes, travelers at doctorsofbc.ca. ences must be numbered consecutively in the MADD Canada order in which they appear in the text. Avoid the source fully if you use data or figures from our borders, or courtroom entrants. FOR ALL SUBMISSIONS using auto­numbering as this can cause prob­ another published or unpublished source. Screening drivers is minimally in- Suggested reading • Avoid unnecessary formatting. lems during production. Tables. Please adhere to the following guidelines: trusive, entails no stigma, and takes Solomon R, Chamberlain E. The road to • Double-space all parts of all submissions. Include all relevant details regarding publica­ tion, including correct abbreviation of journal • Submit tables electronically so that they may about 2 minutes while drivers remain traffic safety: Mandatory breath screen- • Include your name, relevant degrees, e-mail address, and phone number. titles, as in Index Medicus; year, volume num­ be formatted for style. seated in their vehicles. ing and Bill C-46. Can Criminal Law Rev • Number all pages consecutively. ber, and inclusive page numbers; full names and • Number tables consecutively in the order of Canadian physicians applaud the 2018;23:1-42. locations of book publishers; inclusive page their first citation in the text and supply a brief CLINICAL ARTICLES/CASE numbers of relevant source material; full web federal government for introducing title for each. REpORTS address of the document, not just to host page, • Place explanatory matter in footnotes, not in MAS. The lives of many Canadian Manuscripts of scientific/clinical articles and case and date the page was accessed. Examples: the heading. citizens will be saved. reports should be 2000 to 4000 words in length, 1. Gilsanz V, Gibbons DT, Roe TF, et al. Vertebral • Explain all nonstandard abbreviations in foot­ including tables and references. Email to journal bone density in children: Effect of puberty. notes. —Roy Purssell, MD 2 Retweets 2 Likes Radiology 2007;166:847-850. @doctorsofbc.ca. The first page of the manu­ • Ensure each table is cited in the text. Professor, Department of script should carry the following: (NB: For more than three authors, list first three, 22 • Title, and subtitle, if any. followed by “et al.”) Emergency Medicine, UBC Figures (illustrations). Please adhere to the fol­ • Preferred given name or initials and last name 2. Mollison PL. Blood Transfusion in Clinical Emergency Physician, Vancouver lowing guidelines: 1-800-663-6729 • www.physicianhealth.com for each author, with relevant academic de­ Medicine. Oxford, UK: Blackwell Scientific General Hospital Follow @BCMedicalJrnl grees. Publications; 2004:178-180. • Send scans of 300 dpi or higher. and join in the conversation. • All authors’ professional/institutional affili­ 3. O’Reilly RA. Vitamin K antagonists. In: • Number figures consecutively in the order of ations, sufficient to provide the basis for an Colman RW, Hirsh J, Marder VJ, et al. (eds). their first citation in the text and supply a brief author note such as: “Dr Smith is an associate Hemostasis and Thrombosis. Philadelphia, title for each. professor in the Department of Obstetrics and PA: JB Lippincott Co; 2005:1367-1372. • Place titles and explanations in legends, not Gynecology at the University of British Col­ 4. Health Canada. Canadian STD Guidelines, on the illustrations themselves. 2007. www.hc-sc.gc.ca/hpb/lcdc/publicat/ umbia and a staff gynecologist at Vancouver std98/index.html (accessed 15 July 2018). • Provide internal scale markers for photo- Hospital.” micrographs. (NB: The access date is the date the author con­ Doctors • A structured or unstructured abstract of no • Ensure each figure is cited in the text. sulted the source.) more than 150 words. If structured, the pre­ • Color is not normally available, but if it is ferred headings are “Background,” “Methods,” References to unpublished material necessary, an exception may be considered. Helping “Results,” and “Conclusions.” These may include articles that have been read • Three key words or short phrases to assist in Units at a meeting or symposium but have not been Doctors indexing. published, or material accepted for publication Report measurements of length, height, weight, • Name, address, telephone number, and e-mail but not yet published (in press). Examples: and volume in metric units. Give temperatures address of corresponding author. 1. Maurice WL, Sheps SB, Schechter MT. in degrees Celsius and blood pressures in mil­ The Physician Health Authorship, copyright, disclosure, Sexual activity with patients: A survey limetres of mercury. Report hematologic and and consent form of BC physicians. Presented at the 52nd clinical chemistry measurements in the metric Program of British Annual Meeting of the Canadian Psychiatric When submitting a clinical/scientific/review system according to the International System of Columbia offers help Association, Winnipeg, MB, 5 October 2008. Units (SI). paper, all authors must complete the BCMJ’s 2. Kim-Sing C, Kutynec C, Harris S, et al. four­part “Authorship, copyright, disclosure, 24/7 to B.C. doctors and their Breast cancer and risk reduction: Diet, Abbreviations and consent form.” families for a wide range of personal physical activity, and chemoprevention. Except for units of measure, we discourage 1. Authorship. All authors must certify in writ­ CMAJ. In press. abbreviations. However, if a small number are and professional problems: physical, ing that they qualify as an author of the paper. Personal communications are not included in necessary, use standard abbreviations only, pre­ Order of authorship is decided by the co-authors. the reference list, but may be cited in the text, psychological and social. ceded by the full name at first mention, e.g., in 2. Copyright. All authors must sign and return with type of communication (oral or written) If something is on your mind, give us a call at an “Assignment of copyright” prior to publica­ communicant’s full name, affiliation, and date vitro fertilization (IVF). Avoid abbreviations in tion. Published manuscripts become the prop­ (e.g., oral communication with H.E. Marmon, the title and abstract. 1-800-663-6729. Or for more information about erty of the BC Medical Association and may not director, BC Centre for Disease Control, 12 Drug names our services, visit www.physicianhealth.com. be published elsewhere without permission. November 2017). 3. Disclosure. All authors must sign a “Dis­ Material submitted for publication but not Use generic drug names. Use lowercase for closure of financial interests” statement and accepted should not be included. generic names, uppercase for brand names, e.g., provide it to the BCMJ. This helps reviewers venlafaxine hydrochloride (Effexor). determine whether the paper will be accepted Permissions for publication, and may be used for a note to It is the author’s responsibility to obtain written Full guidelines accompany the text. permission from both author and publisher for Please see www.bcmj.org/submit-article for the 4. Consent. If the article is a case report or if an material, including figures and tables, taken or full Guidelines for Authors.

142 bc medical journal vol. 61 no. 3, april 2019 bcmj.org guidelines for authorsguidelines for authors (short form) (short form)

The British Columbia Medical Journal wel­ individual patient is described, written consent adapted from other sources. Permissions should comes letters, articles, and essays. Manuscripts from the patient (or his or her legal guardian or accompany the article when submitted. should not have been submitted to any other pub­ substitute decision maker) is required. lication. Articles are subject to copyediting and Papers will not be reviewed without this docu­ Tables and figures editorial revisions, but authors remain respon­ ment, which is available at www.bcmj.org. Tables and figures should supplement the text, sible for statements in the work, including edi­ not duplicate it. Keep length and number of tables References to published material torial changes; for accuracy of references; and and figures to a minimum. Include a descriptive for obtaining permissions. Send submissions Try to keep references to fewer than 30. Authors title and units of measure for each table and are responsible for reference accuracy. Refer­ to: The Editor, BC Medical Journal, journal@ figure. Obtain permission and acknowledge doctorsofbc.ca. ences must be numbered consecutively in the order in which they appear in the text. Avoid the source fully if you use data or figures from FOR ALL SUBMISSIONS using auto­numbering as this can cause prob­ another published or unpublished source. • Avoid unnecessary formatting. lems during production. • Double-space all parts of all submissions. Include all relevant details regarding publica­ Tables. Please adhere to the following guidelines: • Include your name, relevant degrees, e-mail tion, including correct abbreviation of journal • Submit tables electronically so that they may address, and phone number. titles, as in Index Medicus; year, volume num­ be formatted for style. • Number all pages consecutively. ber, and inclusive page numbers; full names and • Number tables consecutively in the order of locations of book publishers; inclusive page their first citation in the text and supply a brief CLINICAL ARTICLES/CASE numbers of relevant source material; full web title for each. REpORTS address of the document, not just to host page, • Place explanatory matter in footnotes, not in Manuscripts of scientific/clinical articles and case and date the page was accessed. Examples: the heading. reports should be 2000 to 4000 words in length, 1. Gilsanz V, Gibbons DT, Roe TF, et al. Vertebral • Explain all nonstandard abbreviations in foot­ including tables and references. Email to journal bone density in children: Effect of puberty. notes. Radiology 2007;166:847-850. @doctorsofbc.ca. The first page of the manu­ • Ensure each table is cited in the text. script should carry the following: (NB: For more than three authors, list first three, • Title, and subtitle, if any. followed by “et al.”) Figures (illustrations). Please adhere to the fol­ • Preferred given name or initials and last name 2. Mollison PL. Blood Transfusion in Clinical lowing guidelines: for each author, with relevant academic de­ Medicine. Oxford, UK: Blackwell Scientific grees. Publications; 2004:178-180. • Send scans of 300 dpi or higher. • All authors’ professional/institutional affili­ 3. O’Reilly RA. Vitamin K antagonists. In: • Number figures consecutively in the order of ations, sufficient to provide the basis for an Colman RW, Hirsh J, Marder VJ, et al. (eds). their first citation in the text and supply a brief author note such as: “Dr Smith is an associate Hemostasis and Thrombosis. Philadelphia, title for each. professor in the Department of Obstetrics and PA: JB Lippincott Co; 2005:1367-1372. • Place titles and explanations in legends, not Gynecology at the University of British Col­ 4. Health Canada. Canadian STD Guidelines, on the illustrations themselves. 2007. www.hc-sc.gc.ca/hpb/lcdc/publicat/ umbia and a staff gynecologist at Vancouver std98/index.html (accessed 15 July 2018). • Provide internal scale markers for photo- Hospital.” micrographs. (NB: The access date is the date the author con­ • A structured or unstructured abstract of no • Ensure each figure is cited in the text. sulted the source.) more than 150 words. 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bc medical journal vol. 61 no. 3, april 2019 bcmj.org 145 back page

Proust questionnaire: Dr Caitlin Dunne

What is your idea of perfect What medical advance do you happiness? most anticipate? Happy children. Gene editing in embryos.

What is your greatest fear? What is your most marked That gender equality will not be characteristic? achieved within my daughter’s Hard work and consistency. lifetime. What do you most value in your What is the trait you most colleagues? deplore in yourself? Integrity. My partners are known for it. That I cannot think of a witty answer to this question. What are your favorite books? I like listening to David Sedaris’s What characteristic do your audiobooks. favorite patients share? What profession might you have Optimism. What is your greatest regret? pursued, if not medicine? Not learning a second language. As a I was in the clinical psychology pro- Which living physician do you result, my kids are learning three. gram at McGill before medical school. most admire? Dr Roberta Bondar. What is the proudest moment of Which talent would you most like your career? to have? What is your favorite activity? Joining the Pacific Centre for Re- The ability to heal 100% of the time. I Running at sunrise while listening to productive Medicine as a co-director think every doctor wants that. the New York Times podcast. right after fellowship.

What do you consider your On what occasion do you lie? What is your motto? greatest achievement? I don’t admit when I am having a bad “If a job’s worth doing, it’s worth do- Writing for the popular media has be- day. I say something positive instead. ing well.” I read that in an Amelia Be- come a passion. It gives me a platform delia book when I was a kid and it has to raise awareness for women’s health Which words or phrases do you stuck with me. and battle the stigma of infertility. most overuse? Congratulations, you’re pregnant. How would you like to die? Who are your heroes? Old, in my sleep, after eating a bunch I have two: my late grandmother and What is your favorite place? of cupcakes with my family. my husband, each for their character Sitting on the dock at the cottage. and their feminism.

Submit a Proust Questionnaire Dr Dunne is a co-director at the Pacific Cen- Online: www.bcmj.org/submit-proust-questionnaire tre for Reproductive Medicine (PCRM) and a clinical assistant professor at the Univer- Email: [email protected]. Email and we’ll send you a Word document to sity of British Columbia. She specializes in complete and email back to us. reproductive endocrinology and infertility.

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bc medical journal vol. 61 no. 3, april 2019 bcmj.org 147 HELP MAKE DOCTORS OF BC MORE DIVERSE AND INCLUSIVE

BC doctors are a diverse group — comprised of different genders, nation- alities, religiousBC doctors affiliations, are a diverse sexual group identity, – comprised ages, and of differentmore. genders, nationalities, religious affiliations, sexual Yet, the representativeorientations, ages, structures practice at locationsDoctors of and BC more. don’t reflect the full range of our diverse members. This is a challenge because only when we are truly Doctorsinclusive, of can BC weis seeking do a better to find job ofways strategizing to be more and inclusive planning for the futureof of all the these whole groups profession. within our governance structures – the Board, Representative Assembly and committees. We need your help to figure this out. Over the next few months, we will ask for your views Over theon next how few we months can do we this. will Our be goal reaching is to bringout to new you. and As a first step, we’d likefresh to find perspectives out what barriersfrom those you whoencounter are currently if or when under- you are con- sidering represented,applying for aso position that we in can a committee do a better or job on of our planning Board or RA. for the future of the whole profession.

We hope you will engage with us – because we all have our mark to make. Make your mark. Find out how you can get involved at doctorsofbc.ca. For more information, visit: _____ Questions? E-mail us at [email protected].

148 bc medical journal vol. 61 no. 3, april 2019 bcmj.org We all have our mark to make.