Dr Alan Ruddiman Doctors of BC President 2016–17

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Congenital heart disease: September 2016; 58: 7 • History and evolution of treatment Pages 349–432 • Surgical and interventional management • Special considerations • Successful transition from pediatric to adult care Influenza vaccine in pregnancy Billing tips: Long-term care facility visits Proust: Dr Harvey Thommasen

bcmj.org September 2016 Volume 58 • Number 7 contents Pages 349–432

A R T I C L E S THEME ISSUE: CONGENITAL HEART DISEASE 366 Guest Editorial: Complexities and considerations Jasmine Grewal, MD, Marla Kiess, MD Established 1959 368 History and evolution of the treatment of adult congenital heart disease Marla Kiess, MD 373 Surgical and interventional management of adult congenital heart disease Andrew Campbell, MD, Ronald G. Carere, MD 381 Special considerations in the management of adult congenital heart disease Jasmine Grewal, MD, Nathan Brunner, MD, Jennifer Ellis, MD, John Swiston, MD, Jonathon Leipsic, MD, Robert Levy, MD, Amanda Barlow, MD, Santabanu Chakrabarti, MD 389 Ensuring a successful transition and On the cover: Dr Alan transfer from pediatric to adult care in Ruddiman at the Spadefoot Toad Vineyard near Oliver, patients with congenital heart disease BC. Read about Dr Ruddi Karen LeComte, RN, Brian Sinclair, MD, Sarah Cockell, PhD, Emma Iacoe, RN, man’s family and profes Alexia Gillespie, RN, Derek Human, MD sional background, his life experiences, and his ideas for the future of health care O P I N I O N S in BC in the interview be ginning on page 410. 352 Editorials Let’s discuss, David R. Richardson, MD (352) The future is not what it used to be, Brian Day, MB (353) 354 Personal View Medical cannabis: Concern with College standard, Donna Dryer, MD, Caroline Ferris, MD, Gwyllyn S. Goddard, MD, Peter A. Gooch, MB, Philippa Hawley, MD, Cecil Hershler, MD, Gill Lauder, MB, Caroline MacCallum, FRCPC, Ian Mitchell, MD, Michael Negraeff, MD, Conrad Oja, MD, Arnold Shoichet, MD, Christine Singh, MD (354); College replies, Gerrard A. Vaughn, MD, Heidi M. Oetter, MD (357); Re: Ah, the good ol’ days, Scott D. Smith, MD (358); The editor replies, David R. Richardson, MD (358); Re: Addressing existential suffering, Stephen D. Anderson, MD (359); Re: Thoughts on professionalism, J.N. Mahy, MD (359); ECO-AUDIT: President replies, Alan Ruddiman, MBBCh (360); Safe prescribing (1), Stephen Environmental benefits of using recycled paper Using recycled paper made with post- M. Shore, MD (360); College replies (1), Gerrard A. Vaughn, MD, Heidi M. Oetter, consumer waste and bleached without the use MD (361); Safe prescribing (2), Owen D. Williamson, MBBC (361); College replies of chlorine or chlorine compounds results in measurable environmental benefits. We are (2), Gerrard A. Vaughn, MD, Heidi M. Oetter, MD (362); Safe prescribing (3), Steve pleased to report the following savings. Wiseman, MD, Carol-Ann Sari, MD (362); Gerrard A. Vaughn, • 1399 pounds of post-consumer waste used College replies (3), instead of virgin fibre saves: MD, Heidi M. Oetter, MD (363); EHRs and burnout (a.k.a. early retirement), Andre • 8 trees C. Piver, MD (363); Joel Fox, MD • 760 pounds of solid waste Re: The impact of excessive endurance exercise, • 837 gallons of water (364); Authors reply, Andrea K.Y. Lee, MD, Andrew D. Krahn, MD (364) • 1091 kilowatt hours of electricity (equivalent: 1.4 months of electric power required by the President’s Comment average home) 355 • 1382 pounds of greenhouse gases (equivalent: How is Doctors of BC doing in meeting your needs? You told us and we are 1119 miles traveled in the average car) Alan Ruddiman, MBBCh, Dip PEMP, FRRMS • 6 pounds of HAPs, VOCs, and AOX combined listening, • 2 cubic yards of landfill space Environmental impact estimates were made 410 Special Feature using the Environmental Paper Network Paper Calculator Version 3.2. For more information visit Q&A with Dr Alan Ruddiman: Doctors of BC President 2016–17 www.papercalculator.org. Joanne Jablkowski

350 bc medical journal vol. 58 no. 7, september 2016 bcmj.org #115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4 Tel: 604 638-2815 or 604 638-2858 Fax: 604 638-2917 E-mail: [email protected] Web: www.bcmj.org contents

O P I N I O N S ( Continued) 430 Back Page Proust questionnaire: Harvey Thommasen, MD

D E P A R T M E N T S

editor 396 In Memoriam David R. Richardson, MD Dr James Holmes, Jim Tisdale, MD (396); Dr G. Barrie Purves, Sherrill Purves, MD, editorial board Brian Hunt, MD (396); Dr John William Ibbott, William Jory, MD (397) Jeevyn Chahal, MD David B. Chapman, MBChB 397 Advertiser Index Anne I. Clarke, MD Brian Day, MB WorkSafeBC Timothy C. Rowe, MB 399 Cynthia Verchere, MD First-time traumatic anterior shoulder dislocations in young patients, Derek Smith, MD Willem R. Vroom, MD managing editor 401 Billing Tips Jay Draper Long-term care facility visits (fee items 00114 and 00115), Keith J. White, MD senior editorial and production coordinator 402 Pulsimeter Kashmira Suraliwalla Three BC doctors awarded Order of BC (402); Dr Michael Klein appointed to the associate editor Order of Canada (402); Farewell to Dr Susan Haigh (402); Welcome Dr Jeevyn Joanne Jablkowski Chahal (402); Reminder: Apply for 2016–17 benefits under the Parental Leave copy editor Program (403); Canadian Blood Services reduces restrictions for blood donation Barbara Tomlin (403); Doctors of BC 2017 awards: Seeking nominations (403); First clinical proofreader guidelines in Canada for pain following spinal cord injury (404); Doctors of BC Ruth Wilson Annual Report survey, winner (404); Seniors with undiagnosed hearing loss can design and production become isolated (404); Depression screening tools not accurate for children and Scout Creative adolescents (404); Middle-age memory decline a matter of changing focus (406); COVER CONCEPT Half of patients with depression are inadequately treated (406); Scientists develop & ART DIRECTION microneedle system to monitor drugs (407); Correction: Dr Erik Paterson, 1941– Jerry Wong (407); (407) Peaceful Warrior Arts 2016 Canadian technology uses speech to track Alzheimer disease printing 408 BC Centre for Disease Control Mitchell Press Influenza vaccine in pregnancy: Is it safe?Monika Naus, MD advertising Kashmira Suraliwalla 418 Calendar 604 638-2815 [email protected] 423 Council on Health Promotion Let’s help our children as parents and as doctors. Ron Wilson, MD ISSN: 0007-0556 424 Guidelines for Authors 426 Classifieds 431 Club MD

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bc medical journal vol. 58 no. 7, september 2016 bcmj.org 351 editorials

Let’s discuss

ecently our profession has between reducing prescription drug The ever-increasing use of medic- faced a number of contro- abuse/deaths and alleviation of suf- inal marijuana is also quite polar- R versial issues—physician- fering is difficult indeed. However, in izing. I have had a number of dying assisted dying, narcotic prescribing my over 20 years of clinical practice, patients report that marijuana eased for nonmalignant pain, and the use of suffering and made their last days medicinal marijuana to name a few. more comfortable. However, I now I’m not an expert on any of these is- have patients using medicinal mari- sues so naturally I will tell you how It is an honor juana for fatigue, insomnia, depres- things are. to publish the various sion, fibromyalgia, musculoskeletal The process of legalizing doctors opinions of our discomfort, and more. These prescrip- to aid in the deaths of their patients readers and act as a tions didn’t come from my hand, but has brought forth strong emotions on none of my patients had any trouble vehicle of respectful both sides of the issue. Words such as obtaining them. I am troubled by the “killing,” “murder,” “torture,” “inhu- discourse in all large number of people taking a cen- manity,” and more have been used matters. We might not tral nervous system active substance to bolster one position or the other. I always agree, but we with little scientific evidence to sup- believe most patients, if offered good are definitely in this port its use. palliation, would choose not to end together, so please Why bring up these controver- their life. But, on the other hand, how sies? The British Columbia Medical continue to send in do you effectively palliate conditions Journal is the perfect place for BC such as amyotrophic lateral sclerosis? your thoughts and physicians to share their points of To observe your body dying around musings. view on all topics. It is an honor to you is not a death I would wish on publish the various opinions of our anyone. readers and act as a vehicle of respect- The College’s recent standards ful discourse in all matters. We might and guidelines on prescribing nar- I can count on one hand the number not always agree, but we are definite- cotics for chronic nonmalignant pain of patients for whom daily narcotic ly in this together, so please continue have raised the ire of a number of use for chronic nonmalignant pain to send in your thoughts and musings. physician groups. Walking the line improved quality of life. —DRR

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352 bc medical journal vol. 58 no. 7, september 2016 bcmj.org editorials

The future is not what it used to be

ver the years hundreds of Senator Kirby’s Commission made than we imagine.” These examples millions of tax dollars have creative suggestions, such as patient- reflect the arrogance of government- Obeen spent on over 300 gov- focused funding and a care guaran- funded advisors and explain why ernment health care task forces and tee. These would empower patients input from patients and practising commissions; 25 years ago BC’s and limit the monopoly control of physicians has been discounted. Royal Commission on Health Care governments. The report of the BC Reform may come soon as patients and Costs (the Seaton Commission) Select Standing Committee on Health gain their freedom after an objective made its recommendations for health concluded, “Your Committee recom- and impartial evaluation of the facts reform. Ministers of health, deputy mends improved wait-list manage- and evidence by the courts. After an ministers, and health bureaucrats ment not a health care guarantee.” almost 8-year delay, our constitution- across Canada embraced and imple- (Translation: let’s study and manage al trial begins this September. I fore- mented many of the BC proposals, in- wait lists, rather than fix them.) see that within 5 years following the cluding the following: “The commis- Other tax-funded experts en- judgment all patients in Canada will sion recommends that the Ministry of dorsed this approach. They have have rapid access as wait lists are dra- Health and the BCMA give priority to dominated health policy in Canada. matically shortened. Medicare will be the joint development of a program to Jonathan Lomas, former executive expanded to cover prescription drugs, limit the number of physicians.” director of the Canadian Health Ser- physiotherapy, dentistry, prosthetics, Their rationale was that doctors vices Research Foundation, made his etc. (areas now inexplicably excluded and patients were to blame for ris- views clear when stating, “I think we by arbitrarily designating them medi- ing costs and if we stopped treat- have to be very careful about empow- cally unnecessary). Funding will come ing patients costs would fall. This ering the consumer because they will from the economic savings of short- assumption was based on now-dis- make choices that are not in their own ened waits and added revenues as credited theories that failed to recog- health interest.” wealthier Canadians are encouraged to nize that rationing leads to delayed Dr Charles Wright, former VP at contribute more than the less wealthy. care and that waiting costs more. The Vancouver General Hospital, wait- In Canada, lower socioeconomic legacy of their actions was a short- list consultant to the BC Ministry of groups have the least coverage, poor- age of doctors, as Canada dropped in Health, Health Council of Canada est access, and worst outcomes. Both the rankings of doctor supply to 26th member, and recipient of an $850 000 Statistics Canada and independent in the world (when I started practice grant to study wait lists, stated, “Ad- study groups around the world have we were fourth). Commissioner and ministrators maintain waiting lists the verified this. In 2010, Italian health UBC economist Robert Evans had way airlines overbook. As for urgent law expert Giandeomenico Barcello- earlier written, “A central cause of the patients in pain, the public system na, wrote, “I am very fond of Canada, problem was the oversupply of physi- will decide when their pain requires one of the best countries in the world, cians, which tended to generate great- care. These are societal decisions. but this (Canada’s health) system is er utilization of services; there are too The individual is not able to decide tailor made just for very rich people, many doctors; and a supply-induced rationally.” who can get medical care abroad.” demand; a bed built was a (hospital) Yet another expert, Dr Gordon Change is on the way. In the hybrid bed filled.” His philosophies domi- Guyatt, a former NDP candidate, co- system that evolves, the poor and eco- nated the report. founder and leading spokesperson of nomically deprived will benefit as wait When reflecting on the frenzy Medical Reform Group (which later lists disappear. The only advantage the and turmoil that consumed commu- evolved into Canadian Doctors for rich will experience is their ability to nist China in the 1950s during Mao Medicare), wrote: “. . . adverse health access timely care in Canada. Govern- Tse-tung’s Great Leap Forward, vol- consequences among those waiting ments and citizens will enjoy the mas- unteers commented that what seemed for care are few and far between. . . . It sive economic benefits that result from completely normal at the time seemed is likely that there are areas of Canada reduced disability and work loss. like madness after the fact. I believe in which certain patients—possibly Sadly, for some health policy ex- we will look back on our current those with cancer, heart disease—wait perts and economists, they will find health system with similar sentiments. too long. But the complexities of the that the end of wait lists will mean More recent commissions have wait-list issue suggest careful study that their tax-funded grants to study also been failures. The Romanow and planning before we try to solve them will likewise disappear. Commission endorsed the status quo. a problem that may be much smaller —BD

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 353 personal view

Letters of less than 300 words are welcomed provided they do not contain material that has been submitted or published elsewhere; they may be edited for clarity and length. Letters may be e-mailed to [email protected], submitted online at bcmj.org/content/ contribute, or sent through the post and must include your mailing address, telephone number, and e-mail address.

Medicinal cannabis: out the professional requirements of PMC concerns Concern with physicians in BC who plan to support First, we consider that the CPSBC College standard patients in the use of cannabis for standard fails to acknowledge or Medicinal cannabis presents a unique medical purposes. accommodate the unique and com- dilemma for physicians and regula- Practitioners for Medicinal Can- plex nature of cannabis, or how it is tory authorities because it represents nabis (PMC) is a nationwide network used for medical purposes. Cannabis an unapproved treatment with lim- of specialists and general practition- is not a single therapeutic entity. The ited good-quality research to inform ers among whom there is extensive plant contains many different physi- guidelines that clarify specific age- clinical experience in the medicinal ologically active compounds with a related indications, dosage, or risks. use of cannabis. PMC is committed wide variety of potential therapeutic In addition, many myths portray neg- to best possible patient care, includ- uses. Different strains possess a dif- ative effects, which results in a cul- ing the informed use of cannabis and ferent balance of components, spe- ture of ill-informed lack of medical cannabis-derived products. As par- cifically in the balance of THC to support. Despite these barriers phy- ticipants in PMC, we write as a group CBD. In spite of the commonly held sicians have been designated as the of physicians to share with readers of perception that cannabis is smoked, gatekeepers of access to cannabis for the BCMJ our concerns about some of there are other safer, less stigmatized medical purposes. On 5 May 2015 the statements included in the CPSBC ways to prepare cannabis for thera- the College of Physicians and Sur- standard. We also offer access to an peutic applications. Effects of a par- geons of British Columbia (CPSBC) information resource and networking ticular product on one clinical situ- published a standard entitled Mari- with PMC. ation cannot be assumed to apply to juana for Medical Purposes, to set Continued on page 356

For Jack Chang, M.D.

354 bc medical journal vol. 58 no. 7, september 2016 bcmj.org president’s comment

How is Doctors of BC doing in meeting your needs? You told us and we are listening etter together. You will often key areas of priority: negotiations, logue between facilities-based physi- hear me repeat these are two policy development to support mem- cians and health authorities. This will Bwords when I’m communicat- bers on ministry and health authority help provide the opportunity for our ing with our members. Quite simply initiatives that impact you, and mem- physicians to not only have a stron- it means that when we are united as a ber consultation. ger and legitimate voice, but to have profession and working together, we Respondents further identified a voice that is also authoritative. We really can make a meaningful differ- two additional key areas where you now have 77 sites involved at various ence. You have probably also seen the think we can do a better job. You told stages of development, with a target two words associated with our Doc- us that you want us to be more time- of having 50 of those sites approved tors of BC logo (Better. Together.). ly and proactive, and you want us to for full operational funding by Janu- That’s because they form the foun- provide more ways to share and com- ary 2017. Whereas the MSAs will dation of the work we do with and municate your views on issues that strengthen the physician voice and for our members. Though to do this are important to you. The association professional leadership in our prov- work, we need to know your thoughts commits to giving these areas high ince’s facilities, the divisions of fam- on how we’re meeting and addressing priority and attention as we move for- ily practice are already providing a your needs—where we are doing well ward. strong voice for family doctors work- and, even more importantly, how we We also asked members about ing in the community. can improve in the areas that are a pri- how well they are engaging with their The information we gathered ority for you. health authorities. Many of you feel through the Member Engagement To garner this information we your professional voice is not being Survey will help develop our 2017 conducted a comprehensive member heard at that level, nor do you have 3-year strategic plan. The data and re- survey earlier this year to measure the opportunity for credible input sponses will be used by staff as they engagement—how we are engaging into health authority decisions. You adapt and enhance our member pro- and interacting with you and how will find detailed information about grams and services. you are engaging and interacting this in the survey results available in I want to thank the many mem- with your health authorities. We also the Members Area of the Doctors of bers who participated in the survey, asked some overarching questions BC website. Doctors of BC is com- and I encourage all members to speak on your impressions of how we are municating these results to the health up and provide your input, not just doing as an association. We received authorities and to government to help through our surveys, but continually. a response rate of 20%, which is an foster stronger and more positive pro- Doctors of BC is committed to excellent response for this kind of sur- fessional relationships that benefit our providing the best professional value vey and what now provides the basis patients, the health care system, and to you, and your input enables us to for a statistically sound analysis. The the profession. do just that. Your voice is important almost 2500 responses were also I can assure you that work is al- to me and to our association, so please demographically and geographically ready underway to address your don’t hesitate to connect with me at representative of the broader mem- areas of concern, especially with [email protected] and fol- bership. regard to health authority relation- low me, like many of your peers do, In general, most of our physician ships. We have been and continue to on social media via Twitter @awruddi members feel we are doing a good support physicians to better engage man. job, but we can do better. We want to with their health authorities through —Alan Ruddiman, MBBCh, do a great job in serving and address- the creation of the medical staff as- Dip PEMP, FRRMS ing your needs. sociations (MSAs), created by our Doctors of BC President The majority of respondents said most recent Physician Master Agree- they are pleased with the work we do ment. In many respects the MSAs will in representing you, consulting with play a key role in helping to achieve you, and advocating for your issues these objectives by fostering two- with government. You identified three way communication and open dia-

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 355 personal view

Continued from page 354 other drug use, pre-existing mental been attempted to assist the patient in other products or clinical contexts, health issues, age, genetic factors, and the management of his/her medical and each individual patient’s response recreational versus medicinal canna- condition and have not successfully is unique. bis use), cannot be replicated or con- helped the patient.” We are concerned Second, we believe that the CPS- firmed in a meaningful way. It is also that this requirement does not duly BC standard fails to recognize the sig- questionable whether conclusions respect a patient’s personal autonomy nificance and importance of existing drawn about cannabis from studies of and right to make decisions pertaining scientific literature. In particular, this recreational users can be extrapolated to his/her own health care. We recom- includes the enormous and grow- to its use in a medical context. mend that the word “attempted” be ing literature regarding the body’s Third, we question the appropri- replaced by “considered.” endocannabinoid system with which ateness of the College warnings to Fifth, we are concerned that the cannabis interacts. As many readers physicians who consider authorizing CPSBC standard, through its several are aware, large-scale double-blind legal access to cannabis. The Col- requirements and restrictions on phy- controlled trials are not the only lege’s position presents an alarming sician behavior, creates a barrier to resource that informs clinical know- perspective of a physician’s risk in care for patients. In addition, the stan- ledge. There is a considerable body authorizing the use of cannabis; for dard does not put the physician’s role of sound evidence to support the use example, “may be the subject of accu- or the College’s responsibility into of cannabis for medical purposes that sations or suggestions of negligence, an appropriate societal context. Fed- also confirms its relative safety, espe- including liability if the use of mari- eral courts have deemed use of can- cially compared with other agents. juana produces unforeseen or uniden- nabis for approved medical purposes The CPSBC standard also fails to tified negative effects.” This risk is to be a Charter right, protected by the acknowledge appropriately the con- not substantially different from that Constitution. The College’s mandate text of more questionable studies that of prescribing any other substance or of public protection through effective underpin some of the well-established undertaking any medical procedure. regulation of the medical profession but misinformed myths around canna- Fourth, we take issue with the includes protection of those disabled bis. Given the complex nature of can- College’s prerequisite that conven- and seriously ill patients who benefit nabis, it is relevant to note that stud- tional therapies be attempted before from the medical use of cannabis. The ies that report on or make correlations cannabis. The College standard lists College standard presents consider- between cannabis use and specific eight requirements for physicians. able challenges for a physician who outcomes, but which don’t also take The first of these says the physician wishes to provide the professional into account or adequately address shall: “Document that conventional support that a patient needs in order to pertinent variables (THC/CBD con- therapies for the condition for which exercise his or her constitutional right. tent, THC/CBD ratios, confounding the authorization of marijuana for factors such as cigarette smoking or medical purposes was provided have

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356 bc medical journal vol. 58 no. 7, september 2016 bcmj.org personal view

A helpful resource that e-mail address PMC participants College replies The College standard lists a number share resources and questions about The College appreciates the op- of groups of patients for whom “can- clinical cases, and discuss issues portunity to respond to a letter re- nabis is generally not appropriate,” related to the medical use of cannabis. garding its professional standard, but acknowledges that there are cir- The following physicians, in al- Marijuana for Medical Purposes. cumstances where exceptions may phabetical order, endorse the content According to the Health Professions be made. Several members of our of this letter. They are all participants Act (HPA), the role of the College group have co-authored a summary in PMC. is to establish, monitor, and enforce of the relevant literature informing —Donna Dryer, MD, FRCPC standards of practice to reduce in- the use of cannabis in the care of such —Caroline Ferris, MD, CCFP, competent, impaired, or unethical patients. Our intention is to provide FCFP practice. The regulation of medical a clinical perspective and a nuanced —Gwyllyn S. Goddard, BSc, marijuana is an obligation that med- discussion to help physicians bal- CCFP, MD ical regulatory authorities across ance potential risks against potential —Peter A Gooch, MB ChB Canada have been reluctant to take benefits when considering a trial of a —Philippa Hawley, FRCPC on. The revisions to the Medical cannabis-derived product for an indi- —Cecil Hershler, MD, PhD, Marijuana Access Regulations es- vidual patient. FRCP(C) sentially removed Health Canada If any physician is interested in —Gill Lauder, MB BCh, FRCA, from any oversight of the use of this obtaining an online copy of that sum- FRCPC, CPE substance. mary, please contact the Practitioners —Caroline MacCallum, FRCPC, When the College’s Ethics Com- for Medicinal Cannabis by e-mail at BSc mittee drafted the standard regarding [email protected] and include —Ian Mitchell, MD, FRCP medical use of marijuana, it reviewed “BC standard” in the subject. Any —Michael Negraeff, MD, FRCPC the considerable experience of the health care practitioner is welcome —Conrad Oja, MD, PhD, FRCPC state medical boards that have been to participate in PMC, or to submit —Arnold Shoichet, BSc, MD regulating this aspect of practice for a a question to the network. Through —Christine Singh, MD, CCFP while. Published and personal reports Continued on page 358

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Continued from page 357 juana is a treatment decision based grams) in BC. It also included a num- emphasized the importance of docu- on a professional interaction with the ber of misleading statements. menting a professional interaction patient, weighing the unique risks For example, the author claims with the patient, which includes tak- and benefits for each patient, and in that “patients who were cared for by ing a history, conducting an exami- the context of a longitudinal rela- their own GP had shorter hospital nation, considering a differential or tionship—is to ensure good medical stays” than those cared for by hos- provisional diagnosis, formulating practice. pitalists. No references are provided a treatment plan, and following the Readers may wish to review the to support this claim. In fact, numer- patient. It may seem unnecessary to Federation of State Medical Boards’ ous studies in the United States, and remind physicians to act professional- Model Guidelines for the Recommen- some limited evidence from Canada, ly in this regard, but multiple instanc- dation of Marijuana in Patient Care, have shown the opposite—hospital- es of documents being signed with no adopted as policy in April 2016. Like ists reduce length of stay compared to or minimal patient interactions had the College standard, the guideline nonhospitalists,1-3 while reducing hos- been identified. The College did not addresses similar important topics: pital costs and possibly also improv- want to have the entire profession dis- the physician-patient relationship, pa- ing quality of care. graced because of a few individuals tient evaluation, informed and shared There are clearly advantages to exchanging their signature for a fee— decision making, treatment agree- the traditional model of inpatient care and not much else. ments, qualifying conditions, ongoing provided by a patient’s own GP. Good Turning to the specifics in the let- monitoring and adapting treatment continuity of care is the most obvious ter, the College standard is not a clini- plans, consultation and referral, medi- example. I have great respect for the cal practice guideline so it does not cal records, and physician conflict of dedication of my GP colleagues who address how marijuana is used for interest. maintain busy community practices as medical purposes. The paucity of sci- The College hopes that continued well as hospital privileges. The medi- entific evidence is acknowledged by research and the development of phar- um-sized community where I work is the authors of the letter, and is noted maceutical cannabis-derived prod- fortunate to have a strong hospitalist on the Health Canada website as well ucts provided through traditional pre- department that has regular contact as the College standard. The College scription/pharmacist dispensing will and an active collegial relationship doesn’t evaluate studies, scientific or soon be reality. When recreational with the community-based family otherwise, in the context of ethical use of marijuana is legalized, taxed physicians, both those with and with- and professional standards. This is the appropriately to increase revenues out active hospital privileges. purview and responsibility of subject for the publically funded health care —Scott D. Smith, MD, CCFP, MSc matter experts who draft clinical prac- system, and sold responsibly through Hospitalist, Kelowna tice guidelines. provincial agencies that have a solid With respect to the cautions in the track record of not selling alcohol to References standard, the College is reminding children, physicians will be able to 1. Rifkin WD, Holmboe E, Scherer H, Sierra physicians that as a natural substance, perform their customary role where H. Comparison of hospitalists and non- marijuana use is not without potential substance use is concerned: counsel- hospitalists in inpatient length of stay ad- harmful effects. Given the high rate of ing patients to moderate their con- justing for patient and physician character- recreational use and the lack of legal sumption. istics. J Gen Intern Med 2004;19:1127- access to marijuana, the lines between —Gerrard A. Vaughan, MD 1132. true medical use and convenience for President, College of Physicians 2. Lindenauer PK, Rothberg MB, Pekow PS, recreational use are blurry. Even in and Surgeons of British Columbia et al. Outcomes of care by hospitalists, jurisdictions that authorize medical —Heidi M. Oetter, MD general internists, and family physicians. use and lawful recreational use, recre- Registrar and CEO, College of N Engl J Med. 2007;357:2589-2600. ational users may still seek out medi- Physicians and Surgeons of British 3. Yousefi V, Wilton D. Re-designing hospital cal authorization because it is cheaper. Columbia care: Learning from the experience of hos- The College is encouraged that pital medicine in Canada. J Global Health the federal government is moving to Re: Ah, the good ol’ days Care Systems 2011;1:2-10. legalize recreational use of marijua- The editorial “Ah, the good ol’ days. na. This will no doubt alleviate pres- Nary an orphan in sight.” (BCMJ The editor replies sure on the existing medical access 2016;58:244) provided a simplistic Thank you for your response letter pathways. The foundation of the Col- description of the growth of hospi- to my editorial. I have great respect lege’s standard—that medical mari- tal medicine (a.k.a., hospitalist pro- for my hardworking hospitalist col-

358 bc medical journal vol. 58 no. 7, september 2016 bcmj.org personal view leagues and meant no disrespect. My especially those who have chronic ill- I would like to add comments per- piece reflects the statistics and experi- ness and suffering. It could be used as taining to his third tenet of our pro- ences at my hospital and was meant a brief screening tool, similar to the fession’s longstanding tradition—the to be a tribute to the valuable con- CAGE questionnaire, which is com- value and merit of the social contract. tribution made by family physicians monly used to screen for alcohol/ This longstanding tradition of a through the years. substance abuse. Over the years I historically great and independent —Ed have seen no negative effects from profession predates this country’s asking patients about spiritual issues. tiny historical anomaly of forced and Re: Addressing Instead, it usually improves rapport unconstitutional social contracts—a existential suffering and contributes to a positive doctor- contract that is with the state rather I enjoyed reading Dr Bates’s excel- patient relationship. Patients can be than with the patient, contrary to our lent article on addressing existential referred to appropriate spiritual care Hippocratic Oath. Forced because we suffering in patients with terminal resources as needed, but physicians have a single payer that has legislat- illnesses (BCMJ 2016;58:268-273). should not neglect identifying impor- ed a monopoly, and because doctors Spiritual/religious issues are important spiritual/religious issues that may must travel abroad to change their tant for many of our patients, not be affecting a patient’s well-being. employers. Unconstitutional because just those facing end-of-life issues. A —Stephen D. Anderson, MD, it is a rationing monopoly, at least study of 2000 physicians published FRCP(C) hurting patients in need. in 20071 indicated that most psychia- Clinical Associate Professor, The issue has become far more trists and nonpsychiatric physicians UBC Faculty of Medicine, concerning recently for patients and believe that religion/spirituality helps Dept. of Psychiatry physicians alike because the topic patients cope with and endure illness of physician-assisted death now also and suffering by offering a positive, Reference raises the uncomfortable question hopeful state of mind and/or a com- 1. Curlin FA, Lawrence RE, Odell S, et al. of whether physicians have finally munity that offers emotional or prac- Religion, spirituality, and medicine: become de facto agents of the state in tical support. Over the years I have Psychiatrists’ and other physicians’ this country. recommended that medical students, differing observations, interpreta- Since professionalism is rather psychiatry residents, and residents in tions, and clinical approaches. Am J defined by skills, good judgment, and other disciplines routinely ask patients Psychiatry 2007;164:1825-1831. polite behavior that is expected from about their spiritual beliefs and how a person who is trained to do a job they would like them to be addressed. Re: Thoughts on well, we should ask ourselves: where Dr Bates included a copy of the FICA professionalism has our collective independence of spiritual history tool in his article. I In response to our president’s thought and actions necessary to sup- would highly recommend1/3 that horizontalthe “Thoughts on professionalism” 6.625 in port 2.75good judgment gone lately? And FICA be used routinely with patients, the June issue (BCMJ 2016;58:247), Continued on page 360

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bc medical journal vol. 58 no. 7, september 2016 bcmj.org 359 personal view

Continued from page 359 as each of us sets out every day to to adverse events) for other modes of will our patients be better off for its deliver the highest quality of care to treatment. apparent absence? all patients across British Columbia. We are to advise our patients that Advocacy for our patients should While I agree that physicians would long-term opioid therapy is not indi- be the real cornerstone of our profes- gladly embrace greater independence cated for certain medical conditions, sion, and it requires independence. within our health care system, it is including headaches, headache disor- Fighting internal and external factors not necessarily the cornerstone with ders, and axial low back pain, but if that degrade our ability to advocate which to effectively advocate on we are at the point of prescribing opi- and care for patients and reverting the behalf of our patients. Every day, indi- oids to a patient in chronic pain then erosion of our profession is the ulti- vidually and collectively, we as a pro- usually everything else has failed. mate healing goal for the profession fession effectively advocate on behalf I have patients with chronic head- itself. of our patients, both for their needs aches where neurologists have pre- This social contract that imposed and those of our health care system. scribed narcotics because nothing itself slowly across several genera- Doctors of BC is now enhancing this else works. I have patients who have tions, by misrepresenting the original advocacy on behalf of the profession had benzodiazepines added to their aim of Tommy Douglas, can only be with the development of medical staff narcotic regimen by neurologists and seen as a clumsy ideological vestige associations all across our province pain clinics so that they can get some of the past. It interferes with our pri- to support and grow physician lead- sleep. Patients who are nonsurgical mary commitment: our patients. ership, our influence, indeed our very candidates for chronic back pain often Dr Ruddiman, what we are fortu- independence. suffer until opioids are prescribed. nate to have is not that social contract —Alan Ruddiman, MBBCh, Dip When did it become gospel that but a direct contract with our patients, PEMP, FRRMS patients with a history of addictions and having had an opportunity to ac- President, Doctors of BC or those with psychiatric illness or quire an amazing education (rapidly young people, whoever that applies paid back with income tax), lifesav- Safe prescribing (1) to, can’t suffer severe pain? I attended ing skills in a very rewarding profes- I and every doctor in British Colum- a medical conference years ago when sion—an old one indeed—all these bia received the new College of Phy- a well-respected clinical pharmacolo- transcending ideology, generations, sicians and Surgeons of BC profes- gist asked, “Would you rather have postal codes, and bureaucrats. That sional standards on safe prescribing a patient in chronic pain suffer, be should be the foundation of our inde- last week to address the public health bedridden, and/or housebound, and pendence. emergency related to opioid overdos- not be on narcotics, or be adequately Our problem is then that we, as a es. This is a new professional standard treated and be a productive member profession, no longer believe that we to assist physicians with the challeng- of society working, enjoying his/her belong to a great independent profes- ing task of prescribing opioids, ben- quality of life, and paying taxes, albeit sion; rather, we subject ourselves to zodiazepines, and other medications. needing narcotics to do so?” I thought whatever master of the day is willing This was adopted to “direct appropri- about what he said and changed my to pay us. Mercenaries, agents of the ate prescribing of potentially harmful whole attitude on treating chronic state, whatever you may want to call drugs,” and “these professional stan- noncancer pain and have never regret- us, we are no longer the healers of the dards are not discretionary and must ted it. Hippocratic Oath. The legacy will be adhered to.” We are all directed Yes, patients become dependent not be excellent 21st-century medi- to document discussions with our on narcotics, but there is a difference cal care and we will be remembered patients about the benefit of pharma- between dependence and addiction. as enablers who replaced the Hippo- cologic and non-opioid therapies for We have patients who are dependent cratic Oath with an oath (little “o”) to the treatment of chronic pain. on antihypertensive medications, on the state. And isn’t that what we do The College accepts aggressive thyroid medications, on diabetic med- not want to become! pharmacotherapy in the context of ications, and the list goes on. We also —J.N. Mahy, MD, FRCSC, FACS active cancer, palliative, and end-of- have patients dependent on narcotics Burnaby life care. But it frowns on continuing and if that’s what it takes for them to to prescribe opioids to patients with have some quality of life and function President replies chronic noncancer pain who, usu- normally, or as close to normally as Thank you, Dr Mahy, for sharing your ally, after everything else has been possible, then I am all in favor of pre- thoughts on the milieu of medical pro- tried and failed, need narcotics as an scribing narcotics. fessionalism. This is to be considered add-on or replacement (usually due I have no problems with the Col-

360 bc medical journal vol. 58 no. 7, september 2016 bcmj.org personal view lege’s new standards, but what do cal conditions or symptomatology for to reduce the additional harm that is they recommend I treat my chronic which an effective treatment cannot caused by unsafe pharmacotherapy. pain patients with? Many cannot tol- be found, or for which the patient is —Gerrard A. Vaughan, MD erate nonsteroidal antiinflammato- unable to pay. President, College of Physicians ry drugs (NSAIDs). (It is said more Safe Prescribing of Drugs with and Surgeons of British Columbia people die from NSAIDS in Canada Potential for Misuse/Diversion was —Heidi M. Oetter, MD than all of the traffic accidents com- developed over the past year because Registrar and CEO, College of bined.) NSAIDS are contraindicated the previous document, entitled Pre- Physicians and Surgeons of British in so many situations—chronic kid- scribing Principles, failed to prevent Columbia ney disease, heart problems, gastro- an increasing toll of prescription intestinal bleeds, etc. Tylenol is min- drug misuse and overdose deaths in Safe prescribing (2) imally effective, if at all, in patients this province. Additionally, clinical In an unprecedented move, the Col- with anything more than mild pain, guidelines developed by NOUGG in lege of Physicians and Surgeons of especially in the geriatric population. 2010, an initiative sponsored by this BC (CPSBC) introduced the profes- We send our difficult patients to and other Canadian medical regula- sional standards and guidelines Safe pain clinics, and after a prolonged tory authorities, have also apparently Prescribing of Drugs with Potential wait for usually minimal benefit, rare- not been effective in preventing the for Misuse/Diversion as a legally ly, if ever, do they suggest to taper or increasing reliance of prescribers on enforceable policy on 1 June 2016. stop opioids. long-term opioid treatment for chron- The standard extends the US Studies have shown it to be safe to ic noncancer pain. Centers for Disease Control and Pre- drive, etc., in those with steady-state There is an excellent summary vention’s (CDC) Guideline for Pre- narcotic administration. I will gladly of the current medical evidence and scribing Opioids for Chronic Pain to stop prescribing opioids for chronic expert opinion in the US Centers for include stimulants and sedatives. pain, but tell me what should I pre- Disease Control and Prevention’s The CPSBC gave no reasons for scribe? Guidelines for Prescribing Opioids rejecting the evidence-based Cana- My prescribing habits can easily for Chronic Pain. The conclusion of dian Guideline for Safe and Effec- be monitored through PharmaNet and the experts is that opioid treatment for tive Use of Opioids for Chronic Non- the duplicate prescription program. chronic pain provides small to mod- Cancer Pain or adopting the CDC Those who are prescribing out of erate short-term benefits, uncertain guideline as a standard. range can be audited and disciplined long-term benefits, and potential for The CPSBC did not consult the if they can’t justify their prescribing, serious harm. Pain Medicine Physicians of BC but leave the rest of us alone to care While there is limited evidence of Society (PMPoBC) or Pain BC, the as best we can for our patients in pain. the long-term benefits of non-opioid key organizations representing physi- Not all patients are con artists or therapies, the risk of harm is clearly cians with focused pain practices and junkies. Not all doctors are inappro- far less and thus they should be con- the one in five British Columbians liv- priate prescribers. We care about our sidered preferred treatments. Non- ing with persistent pain. patients and hate to see them suffer pharmacologic therapies can include The PMPoBC wants to minimize but our options are limited. exercise and physical therapies as harm from drugs we prescribe. How- I have yet to have a specialist in well as psychological therapy such ever, we are very concerned that en- pain, surgery, physiatry, internal med- as cognitive behavioral therapy. Not forcing the standard will diminish icine, etc., suggest I stop narcotic pre- all of these approaches have to be quality of life in the majority of pa- scribing for appropriate indications, in the context of multidisciplinary tients who do not misuse, divert, or and I have been practising for a long programs, which many patients are become addicted to opioids, sedative, time. unable to afford. or stimulants. The CPSBC appears to Give me readily accessible, work- The College’s statutory mandate is accept this consequence. able alternatives to narcotics when all public protection, and the purpose of The PMPoBC is very concerned else fails or leave me alone! this professional standard is to reduce that, given the lack of access to —Stephen M. Shore, MD, CCFP inappropriate prescribing of certain interdisciplinary pain clinics and Langley classes of medications. The College community-based physical and psy- cannot address all of the societal chological therapies, some patients College replies (1) problems that make the treatment of will seek illicit drugs to relieve their The College fully appreciates the dif- patients with chronic noncancer pain conditions which will further escalate ficulty in treating patients with medi- so challenging; however, it can try Continued on page 362

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 361 personal view

Continued from page 361 benefit from long-term opioid thera- Safe prescribing (3) the current public health emergency. py, only that the benefit is very mod- The Section of Psychiatry is both dis- We also hope that physicians do not est, the risks significant, and the evi- appointed with and concerned about withdraw from managing persistent dence tentative, despite over 20 years the new professional standards and pain because of mandated restrictions of escalating prescribing. guidelines for Safe Prescribing of to their practices. While the College participates Drugs with Potential for Misuse/ The PMPoBC has written to the in a consultative process during the Diversion put into effect by the Col- CPSBC seeking clarification of many development of professional stan- lege of Physicians and Surgeons of statements in the standard, including dards, it cannot and must not abrogate BC on 1 June 2016. We believe that those mandating maximum daily doses its legal obligation to regulate medi- the release of this document reflects a of opioid and prohibiting trials of opi- cal practice, including prescribing. striking failure of due diligence, and oids in certain conditions, including Regulation is foundational, and the a major misstep in the College’s fidu- many psychiatric disorders. We have advice in the standard is deliberately ciary duty to guard public safety. offered to help the CPSBC revise their formulated in general terms, allowing By codifying so many complex standard. We await their response. flexibility for bedside clinical judg- clinical decisions as standards instead —Owen D Williamson, MBBC, ment. Nothing in the standard prohib- of guidelines, the College has intrud- FRSCS, FFPMANZCA its or even materially interferes with ed into the doctor-patient relationship President, Pain Medicine the ability of pain specialists or other in an unprecedented fashion. Limit- Physicians of BC Society physicians to safely and effectively ing opioid dosing to an absolute, no- care for their patients. exceptions maximum of 90 mg of mor- College replies (2) The College shares concerns that phine equivalent per day is one such The development of this or any other services for patients who suffer from example. In clinical practice, patients’ professional standard is not “unprec- chronic pain are often difficult to requirements, physiologies, condi- edented.” The College has a statutory access or navigate. Solutions to that tions, and options/alternatives are obligation to set standards for medical are beyond the mandate of the regula- often highly divergent. Protection for practice, and most elements contained tor. What is within the College’s man- patients on stable, responsible, endur- in the standard on safe prescribing date is the ability to investigate any ing, and successful opioid treatment have appeared in successive versions report of physicians misapplying the regimens that happen to be in excess developed by the College’s Prescrip- standard to the detriment of patients. of this arbitrary figure—and there are tion Review Program entitled Pre- —Gerrard A. Vaughan, MD many—is lacking in this document. scribing Principles. The College has President, College of Physicians That the College does not explic- been using the prescribing principles and Surgeons of British Columbia itly make an exception for active can- in its work with registrants for more —Heidi M. Oetter, MD cer, palliative, and end-of-life patients than 3 years. Hundreds of BC physi- Registrar and CEO, is an unconscionable oversight that cians have successfully operational- College of Physicians and requires formal revision immediately. ized them in their practices—by that Surgeons of British Columbia Our biggest concern is the Col- measure, they are extensively field lege’s failure to account for the welfare tested in real-life clinical settings. References of the many British Columbians suf- With respect to strong opioids 1. Furlan AD, Sandoval JA, Mailis-Gagnon fering from chronic mental illness. The for chronic noncancer pain, succes- A, Tunks E. Opioids for chronic noncan- idea that someone who needs a benzo- sive, authoritative systematic reviews cer pain: A meta-analysis of effective- diazepine for treatment of a complex by Furlan,1 Ballantyne,2 Chou,3 and ness and side effects. CMAJ 2006; sleep disorder, or a psychostimulant colleagues suggest that, on average, 174:1589-1594. for severe ADHD, now does not have there is weak evidence of modest 2. Ballantyne JC, Shin NS. Efficacy of opi- the option of receiving basic ongo- relief of pain for a period of weeks oids for chronic pain: A review of the ing opioid pain control medication if or a few months, with minimal func- evidence. Clin J Pain 2008;24:469-478. needed—unlike every other patient in tional improvement, not superior to 3. Chou R, Turner JA, Devine EB, et al. The the province—is frankly discrimina- naproxen or nortriptyline. Dr Chou’s effectiveness and risks of long-term opi- tory. By failing to clearly define “seda- recent paper in the Annals of Internal oid therapy for chronic pain: A systematic tives,” “stimulants,” and “psychoac- Medicine documents accumulating review for a National Institutes of Health tive medications,” and by painting epidemiological evidence of harms, Pathways to Prevention Workshop. Ann such treatments with the same brush including addiction and death. This is Intern Med 2015;162:276-286. used for Schedule I drugs, the College not to say that some patients do not further stigmatizes the mentally ill.

362 bc medical journal vol. 58 no. 7, september 2016 bcmj.org personal view

The Section of Psychiatry is ex- before the College—that it is often existing records/history. EHRs have tremely supportive of well-consid- patients with concurrent diagnoses of been a boon for the regional health ered and effective strategies and ini- mental illness or addiction who are authorities in British Columbia— tiatives that aim to reduce the risk of the victims of the adverse and some- gathering of big data to allow further harm to the public. This document, times fatal side effects of inappropri- simplification of complex realities clearly produced without meaningful ate long-term opioid treatment. and ultimately leading to more hom- input from psychiatrists, will leave —Gerrard A. Vaughan, MD ogenization and standardization of physicians in certain cases facing the President, College of Physicians our (ideally) complex relationships dilemma of either disregarding stan- and Surgeons of British Columbia with real people (patients) on the dards published by their regulatory —Heidi M. Oetter, MD ground. Bonus incentives for man- body, or compromising patient care. Registrar and CEO, agement that are modelled on the cor- We object. College of Physicians and Surgeons porate sphere make the mining of big —Steve Wiseman, MD of British Columbia data without a thorough understand- Chair, Economics Committee, ing of the front-line complexities BC Psychiatric Association EHRs and burnout (a.k.a. dangerous. With an agenda to make —Carol-Ann Saari, MD early retirement) it easier to have the appearance of President, BC Psychiatric A recent article in the Globe and Mail, accountability and standardization of Association included in a Doctors of BC news- care, the data are often used to justify flash, led me to write about electron- reduced real services on the ground College replies (3) ic health records (www.theglobeand and increased micromanagement. Safe Prescribing of Drugs with Poten- mail.com/life/health-and-fitness/ I would hypothesize that in family tial for Misuse/Diversion was devel- health/doctors-using-electronic medicine, burnout leads to a decreased oped over the past year as an evolu- -records-at-higher-risk-for-burnout ability to be our patients’ advocates in tion to a previous document entitled -study/article30652673/). navigating the idiosyncrasies of non- Prescribing Principles, which failed EHR adoption has not included transparently rationed care, less face to prevent an increasing toll of pre- provisions for transcription of pre- Continued on page 364 scription drug misuse and overdose deaths in this province. The decision to reframe what is essentially the same advice as a standard rather than a guideline was based on what the College saw as a need to provide more authoritative direction to the profession in the context of Dr Perry Kendall’s recent description of BC’s health care emergency of opioid misuse and overdose. The authors write that the professional standard does not explicitly make an exception for active cancer, palliative, and end-of-life patients. In fact it does, but perhaps greater clarity or emphasis on this point would be helpful when the standard is next reviewed. The College does not accept that the professional standard in any way fails to account for the welfare of patients with mental illness or contributes to the stigmatization of these patients. A large part of the impetus to provide more authoritative direction for safe prescribing was evidence

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 363 personal view

Continued from page 363 this length and showed a marked The other related articles in the April time with patients, and more errors, U-curve. and May issues of the BCMJ may thus justifying a need for more qual- I didn’t see any obvious differ- provide more insight into the specific ity assurance and more idiot-proofing ences in other subject characteristics, benefits of exercise, since it is clear built into the EHRs, followed by a though I may have missed something. that moderate exercise is beneficial. need for constant improvements (i.e., Are there any other studies sug- The specific studies mentioned are not intuitive patches that are usually gesting differences in exercise bene- all observational studies with inher- inconsistent with the original operat- fits among different races or exercise ent limitations. There are other simi- ing platform), and resulting in EHRs modalities? lar studies not included in the scope that are even more rigid and frustrat- Thanks again for a stimulating of the review that demonstrate similar ing. It’s a positive feedback loop and article! U-shaped curves or reverse J-shaped more business for the IT industry. —Joel Fox, MD (PGY-1 curves, but there appears to be a con- The apparent smartness of drop-down Psychiatry) sistent signal that further benefit and menus and rigid algorithms have Vancouver potential harm may lie at the extreme reduced flexibility and fit, as well as end of exercise. To our knowledge, satisfaction and connection, which References there are no randomized studies are essential in family medicine. 1. Schnohr P, Marott JL, Lange P, et al. Lon- that directly compare differences in Many of us may retire earlier than we gevity in male and female joggers: The exercise modality on cardiovascular otherwise would have, not because Copenhagen City Heart Study. Am J Epi- morbidity or mortality. Overall, our we don’t get it and are too rigid to demiol 2013;177:683-689. take-home message is that we know learn, but rather because we do. 2. Schnohr P, O’Keefe JH, Marott JL, et al. moderate and even high levels of —Andre C. Piver, MD Dose of jogging and long-term mortality: exercise appear to show benefit, but Nelson The Copenhagen City Heart Study. J Am the upper limit at which adverse car- Coll Cardiol 2015;65:411-419. diac effects occur is not known. Re: The impact of excessive 3. Lee DC, Pate RR, Lavie CJ, et al. Leisure- —Andrea K.Y. Lee, MD endurance exercise time running reduces all-cause and cardio- —Andrew D. Krahn, MD First, thank you for a very impor- vascular mortality risk. J Am Coll Cardiol tant and well-written article [BCMJ 2014;64:472-481. Reference 2016;58:203-209]. 4. Wen CP, Wai JP, Tsai MK, et al. Minimum 1. Wen CP, Wai JP, Tsai MK, et al. Minimum I took a look at the four recent amount of physical activity for reduced amount of physical activity for reduced studies that were discussed in the mortality and extended life expectancy: A mortality and extended life expectancy: A “How much exercise is enough?” sec- prospective cohort study. Lancet prospective cohort study. Lancet tion and wonder if you can shed light 2011;378(9798):1244-1253. 2011;378(9798):1244-1253. on something. The clearest U-curve is found in the study on Copenhagen Authors reply joggers.1,2 The study on runners in We would like to thank Dr Fox for his Did You Know?

3 *All ads to use Did You Know? as the title and to include he PSP logo, please. The “fact” and the graph are to be the key feature of Texas also showed a U curve though comments. The studies mentioned are the ad. A Fact (s) Boilerplate copy – BCMJ ad Boilerplate copy – PSP site d 1. 3,400+ GP s participated in To learn more about how the Practice To participate in a PSP service, contact your it was less striking. The study on all population cohort studies looking at a at least one PSP service in Support Program can help doctors build local RST. 2015/16 capacity in their practices, visit www.pspbc.ca. 4 2. 170+ small group learning To learn more about how the Practice To participate in a small group learning sessions were held across Support Program can help doctors build session, contact your local RST or division. forms of exercise in Taiwan, how- wide range of individuals with vary- BC in 2015/16 capacity in their practices, visit www.pspbc.ca. 3. Nearly 1,300 doctors To learn more about how the Practice To participate in a learning module, contact participated in 80+ modules Support Program can help doctors build your local RST. in 2015/16 capacity in their practices, visit ever, showed a continued benefit with ing activity and fitness levels. The www.pspbc.ca. 4. 7 EMR vendors now host To learn more about how the Practice To learn more about how you can optimize screening and diagnostic Support Program can help doctors build your EMR, contact your local RST. 1 tools for 5 key care capacity in their practices, visit longer and more vigorous exercise. Taiwan study attempted to define the conditions www.pspbc.ca.

Graphs to use for each ad:

The main differences in these minimal amount of exercise required Ad 1: studies that I found were: and looked at all comers in a standard 1. Difference in race: East Asian ver- medical screening program. They

Modules sus two white populations. did demonstrate that higher levels of SGLS Peer support 2. Difference in exercise modality: moderate or vigorous activity con- In-pracWce coaching running versus all forms. ferred no additional health benefits

3. Difference in follow-up period: and, thus, more of a reverse J-shaped The study in Taiwan was only 8 curve than a U-shaped curve. Giv- years of follow-up, which is less en the scope of this review, which than in Copenhagen or Texas, focused on excessive endurance exer- though the subgroup analysis in cise, we have focused on those at the Copenhagen2 was also around extreme end of these mortality curves.

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BCDO-219737-07 BCMedicalJournalAds-Print_apprvd_V3.indd 1 8/16/16 8:54 AM Guest editorial

Congenital heart disease: Complexities and considerations

uring normal fetal circulation Since the introduction of cardiac the fetus receives oxygen surgery and the first successful liga- Ddirect ly from the mother tion of a patent ductus arteriosus in through the placenta. Blood enters the 1930s, the care of patients with the fetus’s right atrium, and about CHD has been characterized by dra- two-thirds of it then flows through the matic progress and widespread opti- foramen ovale into the left atrium, by- mism. Historically, most patients with passing the lungs. Blood from the left CHD died in infancy or childhood. In atrium passes into the left ventricle the past 4 decades, however, advanc- and on to the aorta. The remainder es in medical care, surgery, and inter- of blood from the right atrium flows ventional cardiology have changed through the pulmonary artery and is this poor prognosis, and today over Dr Jasmine Grewal shunted away from the lungs to the 90% of patients with CHD reach aorta through the ductus arteriosus. adulthood. Blood from the aorta then enters the Analysis of administrative data umbilical arteries and flows into the from Quebec indicates that in the placenta and is oxygenated. The oxy- year 2000 there was a prevalence genated blood flows back through the rate of 4.09 cases per 1000 adults umbilical cord to the liver, is bypassed for all CHD and 0.38 cases per 1000 through the ductus venosus into the adults for severe lesions,2 and that an inferior vena cava, and arrives in the equal number of adults and children right atrium of the heart. At birth the were affected by CHD. Since 2000 umbilical cord is clamped and the the number of adults with CHD has baby no longer receives oxygen from grown to exceed the number of chil- the mother. With the first breaths the dren with CHD. The prevalence of se- lungs begin to expand and the ductus vere CHD in adults increased by 85% Dr Marla Kiess arteriosus and the foramen ovale both from 1985 to 2000 and by 55% from close. 2000 to 2010, consistent with the con- The heart is completely formed by cept that the greatest survival benefit 8 weeks of gestation, but if problems has occurred in those with more se- occur during the crucial steps of cardi- vere forms of CHD.2 In 2010, adults ac development congenital heart dis- represented 66% of the entire CHD ease (CHD) can result. The incidence population. of CHD Canada-wide is estimated to One result of the successful treat- be 12 to 14 cases per 1000 live births1 ment of children with CHD is an and includes a spectrum of abnormali- increasing number of medically com- ties, from minor narrowing of a blood plex adult CHD patients who live with vessel to malformation of one or more uncertainty regarding complications This article has been peer reviewed. cardiac valves and chambers. and prognosis. Few of these patients

366 bc medical journal vol. 58 no. 7, september 2016 bcmj.org Guest editorial

have been cured and most have been left with residual defects or abnormalities that will lead to problems later in At some time in their medical careers, life (e.g., valvular dysfunction, steno- most physicians in BC will encounter sis in previously implanted conduits, ventricular dysfunction, arrhythmias, patients who have CHD. heart failure, pulmonary hypertension, thromboembolism, complications associated with pregnancy). Issues unique to adults with CHD include long-term and multisystemic effects of single-ventricle physiology, cyanosis, systemically positioned right ventricles, complex intracardiac baffles, and complex arrhyth- by such a team decreases morbidity The goal of these articles is not mias. Acquired heart diseases such and mortality in this complex patient to outline specific management prin- as hypertension and coronary artery population.3 ciples, but rather to highlight some disease may have a significant nega- At some time in their medical complexities and considerations tive impact on patients with delicate- careers, most physicians in BC will faced by these patients so that physi- ly balanced circulation. Even simple encounter patients who have CHD. cians can make appropriate referrals procedures may pose additional risk Physicians are often at a loss when and provide better care for adults with in some patients (e.g., insertion of a dealing with these medically complex congenital heart disease. jugular line in a patient with intracar- patients and can benefit from know- —Jasmine Grewal, MD, FRCPC diac baffles can result in puncture of ing more about common issues and Director, Cardiac Obstetrics the baffle and death). The majority available resources. Program, Cardiologist, of these patients will require lifelong In this theme issue we attempt to Pacific Adult Congenital Heart cardiac-focused medical care and bridge some knowledge gaps with (PACH) clinic, repeat cardiac surgery or interven- four articles by adult congenital heart Division of Cardiology, tional procedures. As well, a number disease experts from the Pacific Adult St. Paul’s Hospital of these patients will be developmen- Congenital Heart Disease program —Marla Kiess, MD, FRCPC tally delayed, have learning difficul- based at St. Paul’s Hospital in Van- Director, Pacific Adult Congenital ties, and/or psychological, social, and couver. The first article, by Dr Marla Heart Clinic, Division of financial difficulties that present bar- Kiess, provides some historical con- Cardiology, St. Paul’s Hospital riers to proactive health management. text and reviews the current state of Many of these patients will require care for adults with CHD in BC. The References genetic counseling, reproductive second article, by Drs Andrew Camp- 1. Health Canada. Congenital anomalies in counseling, advice about insurability, bell and Ronald Carere, describes cur- Canada – a perinatal health report, 2002. and guidance regarding appropriate rent surgical and noninvasive inter- Ottawa: Minister of Public Works and leisure activities, employment restric- ventions for managing adult patients Government Services Canada, 2002. tions, and career choices. with CHD. 2. Marelli AJ, Mackie AS, Ionescu-Ittu R, et The majority of adult CHD pa- In the third article, Dr Jasmine al. Congenital heart disease in the general tients should be seen at least once by Grewal and colleagues consider spe- population: Changing prevalence and age an adult CHD specialist to determine cific medical issues in adult CHD distribution. Circulation 2007;115:163- the most appropriate care, and cer- patients related to pregnancy, pul- 172. tainly patients with moderate to se- monary hypertension, and arrhyth- 3. Mylotte D, Pilote L, Ionescu-Ittu R, et al. vere disease merit ongoing follow-up mias. Finally, in the fourth article, Ms Specialized adult congenital heart disease by an expert multidisciplinary team Karen LeComte and colleagues dis- care: The impact of policy on mortality. dedicated to the care of adults with cuss the need to ensure a successful Circulation 2014;129:1804-1812. CHD. There is strong evidence to transition and transfer when a patient show that referral to and management moves from pediatric to adult care.

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 367 Marla Kiess, MD, FRCPC

History and evolution of the treatment of adult congenital heart disease

Surgical developments and other advances mean that more congenital heart disease patients are reaching adulthood and requiring the support of a team that includes cardiologists, nurses, psychologists, and social workers with knowledge of adult CHD.

ABSTRACT: Cardiology experts tostomy was developed in 1966 to of the many advances made since around the world, including many promote mixing at the atrial level and the 1930s, children born with CHD Canadians, have contributed to dramatically improved the outcome today are much more likely to grow dramatic surgical, interventional, for newborns with complete trans to adulthood, but they are also like and diagnostic advances since the position of the great arteries. Be ly to require multiple operations for 1930s. These developments began ginning with innovative use of X-ray scarring and narrowing of arteries or when Dr Helen Taussig established imaging, diagnostic techniques sup veins and insertion or replacement the pediatric cardiology clinic at ported both surgical and nonsurgical of conduits and valves. Patients Johns Hopkins Hospital in Balti interventions. Right heart catheter with moderate to severe disease are more in 1930 and Dr Maude Abbott ization became available in the late rarely cured and face a lifetime of re of Montreal published the Atlas of 1940s and left heart catheterization peat surgical and interventional pro Congenital Heart Disease in 1936. was developed in the 1950s. The cedures. Each year, BC Children’s The first surgical procedure was advent of two-dimensional echocar Hospital registers approximately ligation of a patent ductus arterio diography in the 1970s permitted a 500 newly diagnosed CHD patients sus performed by Dr Robert Gross major step forward in the treatment and moves 300 previously diagnosed at the Children’s Hospital in Boston of congenital heart disease (CHD), as patients from pediatric to adult care. in 1938. Intracardiac repair first be did the establishment of standard Approximately 150 patients per year came possible with the development ized nomenclature. Canadian doctor will require follow-up in an adult CHD of cardiopulmonary bypass technol Wilfred Bigelow determined how to clinic. A review of advances in the ogy in the 1950s, followed in the use total body hypothermia for open treatment of CHD reveals dramatic 1970s by the development of deep heart surgery in 1953, and the first progress beginning in the 1930s and hypothermia with circulatory arrest, open heart procedure in Canada was continuing to the present. Cardiology which made lengthier surgeries performed by Dr John Callaghan in experts around the world, including possible. Interventional techniques Edmonton in 1954. In British Colum many Canadians, have contributed went hand in hand with surgical ad bia, Dr Ross Robertson performed a to a variety of surgical, intervention vances. Balloon dilatation of the pul Blalock-Taussig shunt, closed a pat al, and diagnostic developments. monary valve was first described in ent ductus arteriosus, and repaired a the 1950s and became widely used coarctation of the aorta at Vancouver Dr Kiess is director of the Pacific Adult after static balloon dilatation was in General Hospital in 1947. In the late Congenital Heart (PACH) clinic, Division of troduced in 1982. Balloon atrial sep 1950s Dr Harold Rice built the first Cardiology, St. Paul’s Hospital. She is also cardiopulmonary bypass machine a clinical professor in the Division of Cardi- This article has been peer reviewed. used at St. Paul’s Hospital. Because ology at the University of British Columbia.

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Surgical developments Lillehei and his colleagues to develop riosus, and atrial septal defects. A The organized study of congenital a pump oxygenator.9 However, even major advance was the development heart disease (CDH) began with the with this innovation the preservation of prosthetic pulmonary valves by establishment of Dr Helen Taussig’s of blood flow to the brain was not Dr Bonhoeffer13 and prosthetic aortic pediatric cardiology clinic at Johns always optimal and surgeons had to valves by Drs Cribier14 and Webb15 in Hopkins Hospital in Baltimore in work quickly until the development the 2000s. 19301 and the publication of Dr of deep hypothermia with circulatory Diagnostic techniques, begin- Maude Abbott’s incredible atlas de- arrest in the early 1970s made length- ning with Dr Taussig’s innovative scribing 1000 CHD cases in 1936.2 ier surgeries possible. use of X-ray imaging, supported both The first surgical procedure was ligation of a patent ductus arteriosus (PDA) performed by Dr Robert Gross at the Children’s Hospital in Boston in 1938.3 Dr Taussig had observed that some children became progressively more cyanotic with spontaneous clos- Canadians have been at the ure of the ductus arteriosus and pro- posed using an arterial to pulmonary forefront of improvements for patients artery shunt. She convinced Dr Alfred with congenital heart disease. Blalock of the merit of this idea and eventually Blalock collaborated with his technician, Vivien Thomas, to construct a shunt from the right subclavian artery to the right pulmonary artery in a cyanotic child. A report on the procedure was published in 1945.4 Interventional and surgical and nonsurgical interven- Also in 1945, Drs Crafoord and Nylin diagnostic techniques tions. Right heart catheterization of Stockholm performed surgery on a Interventional techniques went hand became available in the late 1940s and patient with coarctation of the aorta.5 in hand with surgical advances. left heart catheterization was devel- In 1948, Sir Russell Brock, working in Although balloon dilatation of the oped in the 1950s. M-mode echocar- Guy’s Hospital in London, England, pulmonary valve was described in diograms, first available in the 1960s, published a report describing three 1953 by Rubio-Alvarez and col- were helpful, but it was the advent of cases of pulmonary stenosis that were leagues,10 the procedure did not two-dimensional echocardiography repaired with pulmonary valvotomy.6 become widely used until Kan and in the 1970s that permitted a major In 1950, Drs Blalock and Hanlon per- colleagues11 introduced static bal- step forward. Important advances in formed atrial septectomy using a sur- loon dilatation in 1982. Balloon atrial pathology included the establishment gical clamp devised by Vivien Thom- septostomy, developed in 1966 by of standardized nomenclature by as.7 With the development of cardio- Drs Rashkind and Miller,12 promoted Richard and Stella Van Praagh work- pulmonary bypass technology, intra- mixing at the atrial level and dramati- ing in Toronto, Chicago, and then cardiac repair became possible. The cally improved the outcome for new- Boston, and by Robert Anderson, first procedure done with the use of borns with complete transposition working in London, England. a heart-lung machine was for closure of the great arteries. There was an of an atrial septal defect and was per- explosion of catheter-based therapies Canadian contributions formed by Dr Gibbon in Philadelphia in the 1980s, including balloon dila- Canadians have been at the forefront in 1953.8 Later that year, Dr Lillehei, tation for repair of coarctation of the of improvements for patients with working in Minneapolis, performed aorta and stenotic valves, shunts, and congenital heart disease, beginning open heart surgery using cross- conduits. The development of stents with Dr Maude Abbott of Montreal, circulation between the child and a vastly improved long-term results. who wrote the Atlas of Congenital parent. This procedure was found to Various devices became available to Heart Disease already mentioned. have a high mortality rate, which led address fistulae, patent ductus arte- Dr Wilfred Bigelow16 of the Toronto

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General Hospital determined how to wife, Dorothy, was born with an atri- formed on older children. Congenital use total body hypothermia for open al septal defect, and in 1953 she was heart lesions frequently resulted in heart surgery in 1953. The first open the fourth patient in the world and too much or too little blood flow to the heart procedures in Canada were for the first patient at the Mayo Clinic to lungs. Infants and young children with closure of an atrial septal defect and have open heart surgery under hypo- reduced blood flow to the lungs were a ventricular septal defect and were thermic cardiac arrest. An anomalous palliated with arterial shunts, either performed by Dr John Callaghan in pulmonary vein discovered at surgery Blalock-Taussig (subclavian artery Edmonton in 1954. Dr William Mus- could not be repaired until the advent to pulmonary artery), Potts (descend- tard at the Hospital for Sick Children of cardiopulmonary bypass, and she ing aorta to pulmonary artery), or Waterston (ascending aorta to pulmonary artery), and those with excess blood flow to the lungs were palliated with pulmonary artery banding. The flow through these arterial shunts was difficult to control and pulmo- In the early days of cardiac nary hypertension was a significant surgery, intracardiac repairs risk. Dr Glenn felt that venous shunts would be superior, anastomosing the could only be performed superior vena cava to the pulmonary on older children. artery in 1959.20 Many patients had repeat operations with ligation of arterial shunts and replacement with right and/or left Glenn shunts. When the child patient reached an adequate size, usually around age 4, intracardiac repair was performed, the shunts in Toronto significantly advanced the had a second procedure in 1958 at the were ligated, or the pulmonary band care of patients with complete trans- Mayo Clinic when she was in her late was removed. Dr Fontan developed position of the great arteries with his forties. Drs Bob Gourlay, Ted Mus- total right heart bypass for patients atrial switch operation (Mustard pro- grove, and Gerry Coursley closed with single-ventricle physiology in cedure) in 1963.17 an atrial septal defect in a 12-year- 197121 and subsequent modifica- In British Columbia, Dr Ross old girl using Dr Rice’s machine at tions to improve hemodynamics were Robertson performed a Blalock- St. Paul’s Hospital in 1960. Cardiac developed by him and Dr de Leval.22 Taussig shunt, closed a patent ductus catheterization was first performed In the early 1980s, Dr Aldo Castenada arteriosus, and repaired a coarctation at Vancouver General Hospital by perfected neonatal repairs at the Bos- of the aorta at Vancouver General Drs Morris Young and Dennis Vince, ton Children’s Hospital.23 Hospital in 1947. Dr Jack Stenstrom starting in the mid-1950s. Dr Doris started performing PDA ligations and Kavanagh performed the first cardiac Adult congenital heart Blalock-Taussig shunts in Victoria in catheterization at St. Paul’s Hospital disease care in BC 1949. In 1957, Dr Peter Allen, with in 1959. The need for this procedure As in the past, many children born the assistance of Drs Phil Ashmore, was great. After her first successful with congenital heart disease today Bill Trapp, and Ross Robertson, per- study, Dr Kavanagh was asked by Dr will require multiple operations as formed the first open heart procedure Young if she could catheterize some they grow to adulthood for various at Vancouver General Hospital, clos- of his patients and he sent her a list of reasons, including scarring and nar- ing an atrial septal defect in a 9-year- 400 patients who had been waiting for rowing of arteries or veins and inser- old boy.18 In the late 1950s, Dr Harold as long as 4 years. tion or replacement of conduits and Rice built the first cardiopulmonary valves. Patients with moderate to bypass machine used at St. Paul’s Further developments severe disease are rarely cured and Hospital.19 He had a very person- In the early days of cardiac surgery, face a lifetime of repeat surgical and al reason for wanting to do this: his intracardiac repairs could only be per- interventional procedures.

370 bc medical journal vol. 58 no. 7, september 2016 bcmj.org History and evolution of the treatment of adult congenital heart disease

Based on a Canada-wide incidence cine, and the support and expertise of have supported the development of rate of 12 to 14 cases per 1000 live a multidisciplinary team (nurses, psy- both surgical and nonsurgical inter- births,24 500 to 600 infants with CHD chologists, social workers) who have ventions. The many advances made are born per year in British Colum- knowledge of CHD. since the 1930s mean that children bia. Data suggest that as of 2010 over A recent study from Quebec has born with CHD today are much more 24 000 individuals with CHD born in shown that these complex patients likely to grow to adulthood. However, BC had survived to adulthood. Some have higher rates of hospitalization, they are also likely to require multiple of these adults have simple defects more visits to emergency rooms, operations for scarring and narrowing and have little need for medical care. greater use of outpatient cardiolo- of arteries or veins and insertion or However, over 12 000 adults have moderate to severe defects and will require lifelong care by an array of health professionals with expertise in the field of CHD. BC Children’s Hospital currently BC Children’s Hospital currently registers approximately 500 newly diagnosed patients with CHD every registers approximately 500 newly year and moves 300 patients from diagnosed patients with CHD every pediatric to adult care each year. Ap- proximately 50% of these patients, or year and moves 300 patients from 150 per year, will have moderate to pediatric to adult care each year. severe CHD and require follow-up in an adult CHD clinic. These patients need ongoing evaluation to determine whether they require further intervention or medical management. About 110 of these patients (60%) can be gist care, and more days in critical replacement of conduits and valves, expected to require specialized con- care.25 The Canadian Cardiovascular and to require the support and exper- tinuing care for optimal quality of Society,26 American College of Car- tise of a multidisciplinary team with life. A smaller but significant number diology,27 and European Society of knowledge of CHD. of individuals present later in child- Cardiology28 have all recognized the hood or early adulthood with congen- urgent need for trained medical staff, Competing interests ital defects that have gone undetected allied health personnel, and special- None declared. due to the sometimes insidious nature ized clinics to deliver appropriate care of CHD progression, and like patients to this rapidly growing population of References with known CHD, these newly diag- adults with CHD. 1. Taussig HB. Congenital malformations of nosed patients may need advice re- the heart. Vol 1 and 2. Cambridge, MA: garding pregnancy risks and cardiac Summary Harvard University Press; 1960. surgery options. Many advances have followed the 2. Abbott ME. Atlas of congenital cardiac dis- The range of abnormalities, the first successful ligation of a patent ease. New York, NY: American Heart As- complexities of postoperative anato- ductus arteriosus in 1938. Intracar- sociation; 1939:62. my, and the challenges of multisys- diac repair became possible with the 3. Gross RE, Hubbard JP. Surgical ligation of tem involvement mean a full under- development of cardiopulmonary a patent ductus arteriosus: Report of first standing of CHD is now well beyond bypass technology in the 1950s, while successful case. Am Med Assoc J 1939; the education and experience of the lengthier surgeries became possible 112:729-731. typical cardiologist caring for adult after the development of deep hypo- 4. Blalock A, Taussig HB. The surgical treat- patients. To care for these patients, thermia with circulatory arrest in ment of malformations of the heart in practitioners require knowledge and the 1970s. Interventional techniques which there is pulmonary stenosis or pul- training in congenital heart disease, have accompanied surgical advances, monary atresia. J Am Med Assoc 1945; adult cardiology, and general medi- and a variety of imaging innovations 128:189-192.

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5. Crafoord C, Nylin G. Congenital coarcta- 16. Trusler G, McBirnie J, Pearson F, et al. A disease: Executive summary. Can J Car- tion of the aorta and its surgical treatment. study of hibernation in relation to the tech- diol 2010;26:143-150. J Thorac Surg 1945;14:347-361. nique of hypothermia for intracardiac sur- 27. Warnes CA, Williams RG, Bashore TM, et 6. Brock RC. Pulmonary valvotomy for the gery. Surg Forum 1953;4:72-77. al. ACC/AHA 2008 Guidelines for the man- relief of congenital pulmonary stenosis: 17. Mustard WT. Successful two-stage cor- agement of adults with congenital heart Report of three cases. BMJ 1948;1:1121- rection of transposition of the great ves- disease. A report of the American College 1126. sels. Surgery 1964;55:469-472. of Cardiology/American Heart Association 7. Blalock A, Hanlon CR. The surgical treat- 18. Burr L. Some early history of cardiac sur- Task Force on Practice Guidelines (Writing ment of complete transposition of the gery in British Columbia. The Surgical Committee to Develop Guidelines on the aorta and the pulmonary artery. Surg Gy- Times. Newsletter of the UBC Depart- Management of Adults with Congenital necol Obstet 1950;90:1-15. ment of Surgery, 2007. Heart Disease). Circulation 2008;118:e 8. Gibbon JH Jr. Application of a mechanical 19. Lemon K. Spirit of discovery: The history 714-833. heart and lung apparatus to cardiac sur- of cardiopulmonary pioneers at St. Paul’s 28. Baumgartner H, Bonhoeffer P, De Groot gery. Minn Med 1954;37:171-180. Hospital. Ottawa, ON: Catholic Health Al- NMS, et al. Task Force on the Manage- 9. Lillehei CW, Cohen M, Warden HE, Varco liance of Canada; 2000. Accessed 13 June ment of Grown-up Congenital Heart Dis- RL. The direct-vision intracardiac correc- 2016. www.chac.ca/about/history/books/ ease, European Society of Cardiology tion of congenital anomalies by controlled bc/Vancouver_St.%20Pauls’Hospital_ (ESC). ESC Guidelines for the manage- cross circulation: Results in thirty-two pa- Cardiopulmonary%20Pioneers_2000. ment of grown-up congenital heart dis- tients with ventricular septal defect, tetral- pdf. ease (new version 2010). Eur Heart J ogy of Fallot, and atrioventricularis com- 20. Glenn WWL. Circulatory bypass of the 2010:31;2915-2957. munis defects. Surgery 1955;38:11-29. right side of the heart. IV. Shunt between 10. Rubio-Alvarez V, Limon-Larson R, Soni J. superior vena cava and distal right pulmo- [Intracardiac valvulotomy by means of a nary artery; report of clinical application. N catheter]. Arch Inst Cardiol Mexico 1953; Engl J Med 1958;259:117-120. 23:183-192. 21. Fontan F, Baudet E. Surgical repair of tri- 11. Kan SJ, White RI Jr, Mitchell SE, Gardner cuspid atresia. Thorax 1971;26:240-248. TJ. Percutaneous balloon valvuloplasty: A 22. de Leval MR, Kilner P, Gewillig M, Bull C. new method for treating congenital pul- Total cavopulmonary connection: A logical monary valve stenosis. N Engl J Med alternative to atriopulmonary connection 1982;307:540-542. for complex Fontan operations. Experi- 12. Rashkind WJ, Miller WW. Creation of an mental studies and early clinical experi- atrial septal defect without thoracotomy: ence. J Thorac Cardiovasc Surg 1988;96: A palliative approach to complete transpo- 682-695. sition of the great arteries. JAMA 1966; 23. Castaneda AR, Jonas RA, Mayer JE Jr, 196:991-992. Hanley FL. Cardiac surgery of the neonate 13. Bonhoeffer P, Boudjemline Y, Saliba Z, et and infant. Philadelphia, PA: WB Saun- al. Percutaneous replacement of pulmo- ders; 1994:409-438. nary valve in a right-ventricle to pulmonary- 24. Health Canada. Congenital anomalies in artery prosthetic conduit with valve dys- Canada – a perinatal health report, 2002. function. Lancet 2000;356(9239):1403- Ottawa: Minister of Public Works and 1405. Government Services Canada, 2002. 14. Cribier A, Eltchaninoff H, Bash A, et al. 25. Marelli AJ, Therrien J, Mackie AS, et al. Percutaneous transcatheter implantation Planning the specialized care of adult con- of an aortic valve prosthesis for calcific genital heart disease patients: From num- aortic stenosis: First human case descrip- bers to guidelines; an epidemiologic ap- tion. Circulation 2002;106:3006-3008. proach. Am Heart J 2009;157:1-8. 15. Chandavimol M, McClure S, Carere R, et 26. Silversides CK, Marelli AJ, Beauchesne L, al. Percutaneous aortic valve implantation: et al. Canadian Cardiovascular Society A case report. Can J Cardiol 2006;22:1159- 2009 Consensus Conference on the man- 1161. agement of adults with congenital heart

372 bc medical journal vol. 58 no. 7, september 2016 bcmj.org Andrew Campbell, MD, FRCPC, Ronald G. Carere, MD, FRCPC

Surgical and interventional management of adult congenital heart disease

A growing population of patients with adult CHD is being helped today by rapidly developing surgical techniques and catheter- based technologies.

ABSTRACT: Survival of pediatric pa ver the past 2 decades the great vessels were amenable to surgi- tients after surgery for congenital survival of pediatric patients cal repair. heart disease has consistently im Oafter surgery for congenital As Dr Gross stated in his case proved over the past 2 decades. As heart disease (CHD) has consistently report, at that time 50% of the children a consequence, more young adults improved, with in-hospital mortality affected by PDA could be expected are presenting with both historical rates now routinely below 3%. With to die in infancy and the remainder and contemporary repairs, and with this advance more children are now would suffer the consequences of both anticipated and completely un surviving and presenting as young heart failure and, potentially, Eisen- anticipated complications. Surgery adults with both historical and more menger syndrome, which would lead for adult congenital heart disease contemporary repairs and therefore to an early death in the third or fourth continues to evolve in Canada, and with both anticipated and completely decade of life. PDA ligation is now even the recent rapid progress in unanticipated complications. This performed at the bedside in the neo- percutaneous and hybrid approach means we must look at the different natal intensive care unit in 30 minutes es to congenital heart disease has levels of complexity of adult CHD or less. had no impact on the volume or the and the array of surgical and interven- Since this beginning, cardiac sur- complexity of surgical cases. Tech tional options, and determine which gery for congenital defects has made nological advances now permit the cases will truly benefit from novel great strides, but at every step there treatment of both relatively simple therapies and which will require only has been tension between the possible and very complex anatomical and what has always been done. benefits of innovation and the risk of pathophysiological problems using causing more harm than existing ther- percutaneous techniques. Manag Surgical management apies or the natural history of the dis- ing adult congenital heart disease Modern surgical management of con- ease. This tension was very apparent patients now means choosing from genital heart disease began on 26 in the 1980s when therapy for transpo- the surgical and interventional op August 1938 with the first document- tions available and determining ed successful ligation of a patent duc- Dr Campbell is a congenital heart disease which cases will truly benefit from tus arteriosus (PDA) in a 7-year-old surgeon in the Pacific Adult Congenital novel therapies and which will re patient by Dr Robert Gross in Bos- Heart (PACH) clinic, Division of Cardiology, quire only what has always been ton.1 The operation was scheduled St. Paul’s Hospital. He is also a director in done. We will continue to need well- while surgeon-in-chief Dr William the Cardiac Surgery Residency Program integrated congenital heart disease Ladd was on vacation for fear that and assistant professor at the University programs that permit collaboration Ladd would not allow the ground- of British Columbia. Dr Carere is an inter- between adult and pediatric medical breaking surgery to go ahead. Later ventional cardiologist in the PACH clinic. He and surgical subspecialists. this led to an irreparable rift between is also a clinical professor in the Division the two surgeons, despite confirming of Cardiology at the University of British This article has been peer reviewed. that native defects of the heart and Columbia.

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sition of the great arteries underwent genital heart disease requiring man- therefore referred for more complex a revolution as atrial-level repair was agement ( Table ) can be grouped as surgical repair with venous baffling replaced by an arterial-level operation follows: of the anomalous veins. So despite developed principally by Dr Jatene of • Category 1. Previously undiagnosed the large number of ASD cases being the University of Sao Paulo. For the pediatric disease that presents in managed in the catheterization labo- first time, the coronary arteries of adulthood. ratory, the identification of underdiag- children were dissected and trans- • Category 2. Anticipated residual di nosed patients means the number of posed from the pulmonary root to the sease following a pediatric surgical surgical cases has actually increased. neoaorta, a procedure that would have procedure or palliated pathology. Asymptomatic ventricular septal been considered impossible in 1975. • Category 3. Unanticipated deterio- defects are surprisingly common as After repeated efforts, Jatene and ration following a pediatric surgical an incidental echocardiographic find- his team developed a programmatic procedure or palliated pathology. ing but few are found to have a sig- approach to the management of these Understandably, most new lesions nificant shunt. Clefts and parachute- children; even so, Jatene’s review of will initially present as category 3 dis- morphology mitral valves may pres- his first 116 patients revealed an early ease. Once several patients with simi- ent in adulthood with a gradual pro- mortality rate of almost 21%, with lar anatomy are identified, what was gression of regurgitation or stenosis only 33% of surviving patients hav- initially thought of as unanticipated and can be occasionally misinterpret- ing normal function and a good ana- becomes anticipated and a new algo- ed as a more routine anatomy ame- tomic repair.2 Over this same period, rithm for care is developed. nable to conventional repair. This can centres experienced with atrial-level lead to the rare intraoperative consul- repairs achieved early mortality rates Category 1 disease tation for the congenital heart disease of 2% to 3%. However, 25 years later The most common category 1 con- surgeon in a colleague’s operating it appears that the long-term benefits dition leading to surgical referral 15 room, and heightens the importance of a systemic left ventricle clearly years ago was ostium secundum atri- of having a well-integrated CHD outweigh the risks of a more complex al septal defect (ASD). Now with the program with collaboration between neonatal operation as these children refinement and expansion of catheter- adult and pediatric medical and surgi- have grown into adults with improved based technologies surgeons see few- cal subspecialists. survival and better exercise toler- er isolated atrial septal defects. Inter- ance.3 Thus the challenge for man- estingly, the increased scrutiny of Category 2 disease agement of congenital heart disease patients with atrial septal defects for The most common category 2 con- remains: How do you decide which possible catheter-based closure has dition leading to surgical referral procedure is safest when one of the identified a large number of patients remains pulmonary insufficiency procedures is novel and the disease with associated anomalous pulmo- associated with tetralogy of Fallot process is unknown? nary venous return who cannot under- (TOF). Up until the 1980s, the vast The different forms of adult congo catheter-based closure and are majority of surgical repairs for TOF

Table. Forms of adult congenital heart disease requiring management.

Complexity Examples Outcome

Category 1 disease Low Atrial septal defect, ventricular septal defect, double aortic arch, cleft mitral Good Previously undiagnosed pediatric valve disease presenting in adulthood

Category 2 disease Moderate Pulmonary insufficiency following repair for tetralolgy of Fallot, mitral Varies Anticipated complications from regurgitation following repair for atrioventricular septal defect, failure of pediatric repair or palliated pathology Fontan repair, systemic right ventricle failure following atrial switch procedure

Category 3 disease High Neoaortic valve failure following arterial switch, systemic ventricular Unknown Unanticipated complications from dysfunction following repair for ALCAPA (anomalous left coronary artery from pediatric repair or palliated pathology pulmonary artery)

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involved a vertical incision crossing with a subaortic right ventricle be- very complex anatomical and patho- the pulmonary valve and rendering it gin to develop ventricular dysfunc- physiological problems using per- incompetent. Over time the volume tion, their generally young age and cutaneous techniques. Interventions load on the right ventricle creates tolerance of cyanosis can mean they for adult CHD have for some time dilatation and eventually a decrease tolerate pulmonary edema and di- employed devices and techniques in ventricular function that can lead minished cardiac output much bet- that are referred to as “structural heart to symptoms. A great deal of research ter than older ischemic cardiac pa- disease interventions.”6 These inter- has been performed to determine tients. As single-ventricle anatomy ventions require the operator to have the right ventricular volumes above and multiple sternotomies make the expertise in congenital heart disease which an adverse surgical outcome prospect of implanting a ventricular and the unique surgeries and connec- can be expected and whether earlier assist device daunting, CHD patients tions that many of these patients have restoration of pulmonary competence with minimal symptoms but severe had in the past. Broadly speaking, will lead to a more rapid return to dysfunction are often overlooked interventions fall into two main cat- normal ventricular dimensions. Oth- for this therapy and therefore have egories: those for closing abnormal er considerations include timing of great difficulty qualifying for car- connections and those for relieving valve implantation, valve type, and diac transplantation.5 Establishment obstructions. the possibility of future percutaneous of a separate congenital heart disease valve implantation. transplant list has been discussed in Closing abnormal connections several countries, but does not yet The primary goal in closing an Category 3 disease exist in North America. abnormal connection is to obtain or The most complex and challenging Surgery for adult congenital heart improve separation of the oxygenated cases for the surgeon involve catego- disease continues to evolve in Cana- arterial circulation from the deoxy- ry 3 disease, as patients in this cate- da. Even the recent rapid progress in genated venous circulation. Consid- gory generally have survived the most percutaneous and hybrid approaches erations include the effect on symp- severe forms of pediatric CHD. They to complex heart disease has had no tom status, the vasculature, cardiac often have diminished systemic ven- impact on the volume or the com- chambers, and/or physiology. Closure tricular function, either due to a right plexity of surgical cases seen in our of connections can also be performed ventricle in the subaortic position or centre. Instead, with an ever-growing to prevent paradoxical embolization, as a consequence of multiple episodes population of pediatric CHD patients depending on the clinical scenario of cardiopulmonary bypass. There is who will require reintervention in fu- and the lesion in question. Small presently little evidence to guide tim- ture, we expect to be providing more connections that have no significant ing or determine the type of repair options for patient management and hemodynamic effect or present little that is best for these patients. working to minimize the complexity risk for paradoxical embolization are For patients who have received of procedures that will be needed over often followed clinically. a classic right atrial to pulmonary time. As the pediatric CHD popula- Although there are several devic- anastomosis as the final stage of their tion continues to age, more late post- es available to close abnormal vascu- single-ventricle palliation, their atri- operative complications will be rec- lar connections, the most commonly um eventually dilates and becomes ognized and the number of patients used devices worldwide are occlud- an inefficient capacitance chamber with category 3 disease will increase. ers manufactured by St. Jude Medical for systemic venous drainage, which And as we saw with the work of Dr in St. Paul, Minnesota. These devices leads to decreased forward flow into Gross and Dr Jatene, surgeons will are made from a deformable nickel the pulmonary circulation and ab- continue to weigh possible benefits and titanium alloy that allows pas- dominal congestion. These patients against the risk of a new intervention, sage through a catheter and rely on a are considered to have a failed or and in time new surgical treatments screw-release mechanism that allows failing Fontan circulation,4 and as will evolve. the device to be controlled until it is a result are candidates for the more deliberately released ( Figure 1 ). Dif- contemporary Fontan repairs that Interventional ferent series are designed specifically have been developed. Much remains management for closure of atrial septal defects, poorly understood about this patient Technological advances now allow patent foramen ovale, patent ductus population. Similarly, when patients us to treat both relatively simple and arteriosus, and vascular connections.

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Atrial septal defects. There are vari- 1 2 3 ous atrial septal defects that can be repaired with closure devices, with the most common being the ostium secundum atrial septal defect. The direction and magnitude of the shunt in an ASD patient is determined by the size of the defect and the rela- 4 5 6 tive compliance of the right and left ventricle. The shunt occurs predomi- nantly from the left atrium to the right atrium and can lead to right atrial and right ventricular dilation, arrhythmias, and right-sided heart failure. Although it is rare to develop pulmo- Figure 1. Steps in the deployment of the Amplatzer septal occluder. nary hypertension, if this does occur closure should be undertaken only Step 1: Delivery sheath is withdrawn to expose left atrial retention disc. Step 2: Left atrial disc is fully deployed to prepare for pulling entire mechanism back to atrial septum. Step 3: Waist of device after careful consideration. (sized to fit defect) is deployed. Step 4: Delivery sheath is pulled back to right atrium to begin The commonly used Amplatzer deployment of right atrial retention disc. Step 5: Device is fully deployed, with left and right retention atrial septal defect occluders come in discs positioned on either side of atrial septum, and placement and security of device are checked. Step 6: Delivery cable is unscrewed and removed. sizes ranging from 4 to 40 mm, with retention discs that are 8 to16 mm larger than the waist. All patients are A B C prescreened with a transesophageal echocardiogram (TEE) to confirm there is an adequate rim of atrial septal tissue to safely anchor the closure device and ensure there are no other associated congenital heart defects that would preclude percutaneous closure. After the size of the defect is established using transesophageal or intracardiac echocardiography, the device is positioned and released once the position and stability are con- firmed. Although large defects and D E multiple defects are more challenging

Figure 2. A: Image from a transesophageal echocardiogram (TEE) combined with color doppler ultrasound reveals the size of an atrial septal defect and shows blood flow through the defect from the left atrium (top) to the right atrium. B: Sizing balloon is inflated in a defect so that the balloon waist can be measured and the appropriate device size selected. C: A 14-mm septal occluder in position with the left atrial disc deployed. D: A 34-mm septal occluder in position. E: Two devices positioned but not yet released—a septal occluder (higher to left) and a cribriform patent foramen ovale occluder with Figure 2. Atrial septal defects a narrow waist to close multiple defects.

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to correct than small single defects, they can often be closed successfully A B ( Figure 2 ).7

Patent ductus arteriosus. In the developing fetus, the ductus arteriosus between the pulmonary artery and the descending aorta is the connection that enables passage of oxygenated blood from the mother’s placenta directly to the systemic circulation. When this fails to close shortly after birth, blood shunts from the aorta to the pulmonary artery. Indications for closure include a significant shunt that C D affects the left heart chambers or pulmonary pressures. More controver- sially, closure may also be considered as a way to reduce the long-term risk of endarteritis in the event of systemic bacteremia. Patent ductus arteriosus comes in a variety of configurations. When small, such defects may be closed with coils, while larger defects may be closed with one of many Amplatzer devices ( Figure 3 ). Figure 3. Patent ductus arteriosus Figure 3. A: Patent ductus shown from contrast injection from the aorta. The small defect results in Fistulas. Fistulas are connections minimal evident blood flow into the pulmonary artery in this image.B: The defect shown in image A has been closed using Cook “Flipper” coils (Cook Medical, Bloomington, IN). C: A larger patent between vascular structures and can ductus is shown with flow evident from the aorta into the pulmonary artery. D: Defect shown in be arteriovenous or venovenous. Fis- image C successfully closed with an Amplatzer duct occluder (St. Jude Medical, St. Paul, MN). tulas can also occur between a cardiac chamber and vein or artery. Indications for fistula repair include the establish- A B C ment of hemodynamic significance, deoxygenation, and endocarditis. Clo- sure of a fistula commonly involves a catheter in RCA vascular plug ( Figure 4 ). catheter in fistula Figure 4. A: Large fistula (centre) from the right fistula coronary artery to the right atrium in a 45-year- old man who had previously experienced an Amplatzer episode of bacterial endocarditis and right vascular plug atrial vegetation that was successfully treated RCA with antibiotics. B: Delivery cable for 12-mm Amplatzer vascular plug can be seen traversing the right atrium from the lower right corner of the image toward the upper left and entering the fistula, where the cable will be used to position and deploy the plug. C: Successful occlusion of fistula after deployment of the plug. Figure 4. Atrial septal defects

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Relieving obstructions to reduce the risk of vascular rupture Relieving obstructions in native vas- ( Figure 5 ). cular or postsurgical connections involves basic interventional cardiac Venous obstructions. There are no and vascular procedures. Typically, clear indications for treating obstruc- the structure to be treated is crossed tions involving the venous circula- with a guide wire and then prepared tion. However, even a small pressure with a balloon. Although the balloon gradient can be important in inhib- may be a definitive treatment, con- iting venous return. Also, since the temporary procedures usually employ pressure is typically assessed and Figure 5. Stents commonly used for stents to improve the immediate and measured at rest, a low pressure gra- treating congenital heart disease. long-term result. A variety of wires dient can be expected to worsen on From left: expanded and unexpanded are available along with balloon and exercise when greater venous return Cheatham-Platinum (CP) stents. From right: expanded and unexpanded, covered versions stent products that range from sever- is required to increase cardiac output. of CP stents (NuMed, Hopkinton, NY). al millimetres to 30 mm in diameter. An example of a repair for an extreme Stents are typically made from stain- case of obstructed venous return is years before undergoing heart trans- less steel and alloys of platinum and shown in Figure 6 . The patient origi- plantation. Given the significantly iridium or cobalt and chromium, and nally had complex congenital heart abnormal anatomy, the transplant may be used as bare metal scaffolds disease and was palliated with a num- surgeon needed to construct unique or with a covering of polyethylene ber of surgical procedures over many connections to provide venous return from the patient to the donor heart. In the postoperative period, one of these A B connections from the head and neck did not remain patent and the connection from the inferior vena cava was restrictive because it was necessary to use a portion of a pre-existing conduit. These anomalies were successfully treated by percutaneous stent placement in a two-stage procedure. Treatment also included working directly with a device manufacturer to create a custom-made covered stent, a requirement in cases where the anatomy is very complex and there is no product readily available.8,9 C D

Figure 6. A: Obstructed connection from the superior vena cava to the right atrium in a heart transplant patient. B: Obstruction seen in image A treated with three percutaneous stainless steel Genesis stents (Cordis Corp, Fremont, CA). C: Heart of same transplant patient showing stenosis at the inferior vena cava connection to the right atrium as a result of a remnant of synthetic conduit left from a previous surgical procedure. D: Stenosis seen in image C treated with placement of a custom-made 16-by-22-mm Cheatham-Platinum stent (NuMed, Hopkinton, Figure 6. Venous obstructions NY).

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Aortic and valvular obstructions. Indications are usually clearer for A B treating aortic and valvular obstructions; these issues can often be resolved with interventional procedures as shown in Figure 7 . Aortic coarctation is an example of an obstruction that can be successfully managed without complex surgery using a contemporary approach that employs covered stents. In general, a peak-to-peak systolic pressure gradient of less than 20 mm Hg is an indication for intervention, although other factors, such as the presence of C D systemic hypertension, left ventricular hypertrophy, or extensive collater- als, will also influence the management decision. Although the more common example of percutaneous aortic valve implantation has been well described,10 percutaneous implantation was originally used for valves in the pulmonary position for patients with significant right ventricular outflow tract obstruction or severe pul- monic regurgitation.11 The first valve Figure 7. Aortic and valvular obstructions. available was approved in Canada in Figure 7. A: Focal coarctation of the aorta. B: Stenosis seen in image A and problem of associated 2007. The Melody valve (Medtron- pressure gradient are resolved with placement of covered stent (NuMed Inc, Hopkington, NY). ic, Minneapolis, MN) is constructed C: Stenosis in conduit from right ventricle to pulmonary artery. D: Stenosis seen in image C is resolved with placement of a large stent (Johnson and Johnson, New Brunswick, NJ), which also from bovine jugular vein and is indi- helps address significant pressure gradient and pulmonary valve incompetence by providing an cated for relief of obstruction and/ anchoring site for a SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA). or regurgitation in right ventricular to pulmonary artery conduits ranging from 14 to 22 mm. The number of adult patients who can benefit from implantation of this valve has been limited despite improved tech- Aortic coarctation is an niques, largely because of the small valve size. Recently, the SAPIEN XT example of an obstruction that valve from Edwards Lifesciences has can be successfully managed become the valve of choice because of the availability of larger sizes more without complex surgery suitable for use in adults. using a contemporary approach

Summary that employs covered stents. Since the first successful ligation of a patent ductus arteriosus by Dr Robert Gross, cardiac surgery for congenital

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tion. Cardiol Young 2006;16(suppl 1):85- Technological advances allow us to treat 91. 5. Gelow JM, Song HK, Weiss JB, et al. Or- both relatively simple and very complex gan allocation in adults with congenital problems using percutaneous techniques. heart disease listed for heart transplant: Impact of ventricular assist devices. J Heart Lung Transplant 2013;32:1059- 1064. 6. Meadows J, Landzberg MJ. Advances in transcatheter interventions in adults with congenital heart disease. Prog Cardiovasc Dis 2011;53:265-273. defects has made great strides. Today and surgical subspecialists. We will 7. Fischer G, Kramer HH, Stieh J, et al. management for adult CHD addresses also need to consider which is the Transcatheter closure of secundum atrial problems in patients with previously most appropriate surgical or interven- septal defects with the new self-centering undiagnosed pediatric disease that tional option for each patient. Amplatzer Septal Occluder. Eur Heart J presents in adulthood, anticipated 1999;20:541-549. residual disease following a pedi- Competing interests 8. Nietlispach F, Leipsic J, Wijesinghe N, et atric surgical procedure, and unan- None declared. al. First-in-man use of a tapered endovas- ticipated deterioration following a cular stent graft for treatment of aneu- pediatric surgical procedure. Techno- References rysm after coarctation repair. Catheter logical advances also now allow us to 1. Gross RE, Hubbard JP. Surgical ligation of Cardiovasc Interv 2010;76:1035-1040. treat both relatively simple and very a patent ductus arteriosus: Report of first 9. Binder R, Nietlispach F, Carere RG. Cus- complex problems using percutane- succesful case. Am Med Assoc J tomized covered stent graft for percutaneous techniques. Broadly speaking, 1939;112:729-731. ous closure of Fontan baffle leak. J Inva- interventions fall into two main cat- 2. Jatene FB, Bosisio IB, Jatene MB, et al. sive Cardiol 2013;25:2-6. egories: those for closing abnormal Late results (50 to 182 months) of the Ja- 10. Wijesinghe N, Ye J, Rodés-Cabau J, et al. connections and those for relieving tene operation. Eur J Cardiothorac Surg Transcatheter aortic valve implantation in obstructions. 1992;6:575-577. patients with bicuspid aortic valve steno- With a growing population of 3. Ruys TP, van der Bosch AE, Cuypers JA, sis. JACCl Cardiovasc Interv 2010;3:1122- patients with adult congenital heart et al. Long-term outcome and quality of 1125. disease and the developing technol- life after arterial switch operation: A pro- 11. Lurz P, Coats L, Khambadkone S, et al. ogies available to us, we will con- spective study with a historical compari- Percutaneous pulmonary valve implanta- tinue to need well-integrated CHD son. Congenit Heart Dis 2013;8:203-210. tion: Impact of evolving technology and programs that permit collaboration 4. Backer CL, Deal BJ, Mavroudis C, et al. learning curve on clinical outcome. Circu- between adult and pediatric medical Conversion of the failed Fontan circula- lation 2008;117:1964-1972.

380 bc medical journal vol. 58 no. 7, september 2016 bcmj.org Jasmine Grewal, MD, FRCPC, Nathan Brunner, MD, FRCPC, Jennifer Ellis, MD, FRCPC, John Swiston, MD, FRCPC, Jonathon Leipsic, MD, FRCPC, Robert Levy, MD, FRCPC, Amanda Barlow, MD, FRCPC, Santabanu Chakrabarti, MD, FRCPC

Special considerations in the management of adult congenital heart disease

Patients with adult CHD who experience pregnancy-related cardiovascular disease, pulmonary arterial hypertension, or arrhythmias can benefit from the help of a multidisciplinary care team and advances in imaging technology.

ABSTRACT: Special considerations patients with a significant arrhyth omplications in adult con- for the management of adult congen mia, often the first manifestation of genital heart disease (CHD) ital heart disease include pregnancy- deterioration in complex congenital Cinclude pregnancy-related related cardiovascular disease, pul heart disease. Complications that cardiovascular disease (CVD), pulmonary arterial hypertension, and can result from arrhythmias include monary arterial hypertension (PAH), arrhythmias. Improvements in the heart failure, thromboembolism, and arrhythmias. Patients with these treatment of congenital heart dis and sudden cardiac death. A range complications can benefit from a vari- ease mean that more women with of complementary imaging modali ety of treatments and management congenital heart disease are reach ties aid in the management of all approaches. They can also benefit ing childbearing age. In BC the Car these conditions by enabling the as from advances in diagnostic imaging. diac Obstetrics clinic at St. Paul’s sessment of ventricular and valvu Hospital provides coordinated care lar function (echocardiography and Pregnancy-related CVD for pregnant women with cardiac magnetic resonance imaging), quan At present, 0.2% to 4.0% of all conditions. The clinic also offers tification of right ventricular volume pregnancies in Western industrial- preconception counseling so that (multidetector computed tomogra ized countries are complicated by couples can make informed choices phy), and exclusion of coronary ste cardiovascular disease, and the num- about pregnancy. Another service nosis (coronary CT angiography). ber of patients who develop cardiac based at St. Paul’s Hospital, the Pa cific Adult Congenital Heart clinic, helps manage patients with pulmo Dr Grewal is a clinical associate professor of the Pulmonary Hypertension Program. nary arterial hypertension, a pro at the University of British Columbia, and Dr Leipsic is Canada Research Chair in Ad- gressive condition affecting around director of the Cardiac Obstetrics Program vanced Cardiopulmonary Imaging, and a 10% of adult congenital heart dis and cardiologist at the Pacific Adult Con- radiologist at St. Paul’s Hospital. Dr Levy is ease patients. Agents used to treat genital Heart (PACH) clinic. She is also an a professor of medicine in the Respiratory pulmonary arterial hypertension in echocardiographer at St. Paul’s Hospital. Dr Division, UBC, and medical director of the clude endothelin receptor antago Brunner is a clinical assistant professor at Lung Transplant Program. Dr Barlow is di- nists and phosphodiesterase type UBC, and a cardiologist and pulmonary hy- rector of the Heritable Aortopathy Program 5 inhibitors. The Pacific Adult Con pertension specialist at Vancouver General at St. Paul’s Hospital, and a cardiologist in genital Heart clinic also manages Hospital. Dr Ellis is a cardiothoracic radiolo- the PACH clinic. Dr Chakrabarti is a clinical gist at St. Paul’s Hospital. Dr Swiston is an assistant professor at UBC and a cardiolo- This article has been peer reviewed. associate professor at UBC, and director gist in the PACH clinic.

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complications during pregnancy is tries heart disease is now the major en’s Hospital ( Figure 1 ). The Car- increasing.1 This is a unique cir- cause of maternal death during preg- diac Obstetric (COB) clinic, the first cumstance where management for nancy.4 of its kind in Western Canada, was optimal outcome needs to consider Pregnancy induces changes in established 15 years ago to serve the both the mother and the fetus. The the cardiovascular system to meet growing number of women with car- only current guidelines for managing the increased metabolic demands of diac conditions who require special- CVD during pregnancy2 emphasize the mother and fetus. These changes ized cardiac and obstetric care. This the following aspects of care: include increases in blood volume and clinic sees patients once a week and • Counseling and managing women cardiac output, and reductions in sys- is attended by one of two designated of childbearing age with suspected temic vascular resistance and blood cardiologists, the maternity clinical cardiac disease should start before pressure. Along with other physio- nurse specialist, and the COB nurse pregnancy occurs. logical demands of pregnancy, these patient educator. This is also a teach- • Pregnant women with CVD should changes are variably tolerated by ing clinic that is attended by cardiolo- be managed by specialized interdis- women with CVD, and in some cases gy residents, congenital heart disease ciplinary teams. pregnancy should be avoided. There fellows, and maternal-fetal medicine • High-risk patients should be treated are many tools available to determine fellows. in specialized centres. the cardiovascular risk of pregnancy Women referred to the clinic have • Diagnostic procedures and inter- in women with CVD.5,6 Certainly the a range of cardiac conditions that are ventions should be performed by World Health Organization (WHO) either acquired or congenital. Initial specialists with expertise in manag- classification of maternal cardiovas- consultation is provided and the fre- ing pregnant patients. cular risk2 is the most straightforward quency of follow-up is determined by The nature of CVD in pregnancy and helps to stratify pregnancy risk in the severity of the underlying disease differs from one country to anoth- a broad sense.7 A more granular risk and the clinical status of the patient. er. In Western countries, the risk assessment can be made using risk Care provided through the clinic of acquired CVD in pregnancy has scores and lesion-specific research ranges from conservative follow-up increased because of greater age at data. and minimal intervention to more first pregnancy and growing rates of active management, which might diabetes, hypertension, and obesi- Obstetric care include the following: ty. Also, the treatment of congenital A special multidisciplinary team for • Pharmacological treatment for heart disease has improved, resulting the care of pregnant women with complications such as heart failure, in more women with CHD reaching CVD operates at St. Paul’s Hospi- arrhythmias, pulmonary hyperten- childbearing age.3 In Western coun- tal in collaboration with BC Wom- sion, and thromboembolism. • Interventions such as electrical car- dioversion, cardiac catheterization, ablation for arrhythmias, percutane- Nurse Maternal-fetal medicine/ Cardiology ous closure of atrial septal defects, specialists high-risk obstetrics and mitral valvuloplasty. Pulmonary • Cardiac surgery. Advanced hypertension The integral role of obstetrics intensive care specialists in this clinic ensures that both car- Multidisciplinary diac and obstetric care are provided in a planned and coordinated fash- Internal team Cardiac/ medicine fetal imaging ion. Many patients are referred from other parts of BC, and whenever possible support is given so that women Cardiac Neonatology Interventional/ Hematology with low or moderate risk can de- anesthesia surgical care liver in their community. The clinic has worked hard to organize patient- Figure 1. Services and specialists providing care to women at the Cardiac Obstetric (COB) specific care plans regardless of the clinic at St. Paul’s Hospital. patient’s risk level or place of deliv-

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ery. These highlight individual car- through a complex pregnancy. consequent shunting of deoxygenated diac and/or obstetric concerns while Another important aspect of care blood from the right side to the left helping to reassure and guide medical for young women with CVD is relat- side of the heart results in the chronic teams with patient management dur- ed to their risk of bearing a child with hypoxemia and cyanosis associat- ing pregnancy, labor, and delivery. congenital cardiac defects. The risk ed with Eisenmenger syndrome, the There is a monthly conference for parents without CVD is approxi- most advanced form of PAH associ- where the cases of all women fol- mately 1%. The risk can be higher in ated with CHD.18 This form of pul- lowed through the clinic are dis- parents with hereditary conditions, monary hypertension represents a cussed and care plans are reviewed by and in general the risk is higher when subtype of WHO group 1 pulmonary the members of the multidisciplinary the mother rather than the father is arterial hypertension.19,20 Factors COB team. A wide range of com- affected by CVD.8 Depending on the influencing its development include plex cardiac conditions have been type of maternal heart disease, the the complexity, location, and size of successfully managed through the recurrence risk in offspring varies the CHD lesion18,21 The most common clinic. Patients have included those between 3% and 50%. presenting symptom is breathless- with cyanotic heart disease, single- ness.16 Syncope is an ominous prog- ventricle physiology, severe pulmo- Pulmonary arterial nostic symptom that portends a poor nary hypertension, and mechani- hypertension outcome.22 cal heart valve replacement. Many Pulmonary arterial hypertension is moderate-cardiac-risk and all high- common in adult CHD, complicat- Screening for PAH cardiac-risk women are followed ing around 10% of all cases.9,10 PAH The screening test of choice for pul- and deliver their babies at St. Paul’s is a progressive condition resulting monary arterial hypertension is a Hospital. The COB clinic also has a in hypertrophy and proliferation of transthoracic echocardiogram. An well-established registry and research the small pulmonary arteries, which estimated pulmonary systolic pres- is a very important component of the can cause increased resistance to sure greater than 35 mm Hg, especial- program. flow across the pulmonary circula- ly if accompanied by right ventricular tion, right ventricular failure, and, enlargement or dysfunction, should Preconception counseling ultimately, death.11 While the condi- raise concern for PAH.23 The diagno- An additional essential service offered tion is incurable, patients have ben- sis of PAH is based on invasive pres- by the COB team is preconception efited over the past 20 years from the sure measurement at cardiac cath- counseling. It is imperative that cou- development of remarkable therapies eterization. In PAH, catheterization ples understand the risk to maternal that slow the remodeling process and reveals elevated pulmonary artery health posed by a pregnancy. Con- result in prolonged life and improved pressures (mean pulmonary artery siderations include the risk of a car- symptoms.12,13 pressure greater than 25 mm Hg) and diovascular complication in pregnan- In patients with congenital heart low left atrial pressures (wedge pres- cy, labor, or delivery; the long-term disease, PAH is triggered by sys- sure less than 15 mm Hg), along with impact of pregnancy on the progres- temic to pulmonary artery shunting. elevated pulmonary vascular resis- sion of underlying cardiac disease; The increased blood flow through the tance (greater than 3 Wood units).11 and the possible effect of a cardiac pulmonary circulation induces the Given the rarity and complexity of lesion on maternal life expectancy. remodeling of the pulmonary vascula- PAH associated with CHD, it is essen- Understanding these risks allows cou- ture that produces PAH.14,15 Increased tial that evaluation and management ples to make informed choices about flow through the pulmonary arteries proceed in a centre with expertise in pursuing pregnancy. In some cases, results in functional and structural the management of both CHD and women have been told previously changes to the small pulmonary arter- PAH. that they should not become preg- ies.15-17 These changes increase the nant, when in fact this may not have resistance to flow and result in a pro- Therapy for PAH been appropriate advice. In other cas- gressive increase in pulmonary artery Currently, agents for PAH approved es, women with high-risk conditions pressures. Eventually, the pressures in for use in Canada include the pros- such as pulmonary hypertension and the pulmonary circulation may rival tanoid agonists (epoprostenol and cardiomyopathy may not be aware of those in the systemic circulation and treprostinil), endothelin receptor an- all their risks and the care required reverse the direction of the shunt. The tagonists (bosentan, ambrisentan,

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and macitentan), the phosphodiester- Arrhythmias position of the great arteries), inci- ase type 5 inhibitors (sildenafil and Arrhythmias are often the first mani- dence of bradycardia with sinus node tadalafil), and the soluble guanylate festation of deterioration in complex dysfunction is high.32 cyclase stimulator riociguat. These CHD, and can lead to further cardiac Approximately 50% of adults agents were approved primarily on decompensation if not treated on a pri- with CHD develop an atrial tachyar- the basis of trials done in the gen- ority basis. Arrhythmias in adult CHD rhythmia during their lifetime.33 Intra- eral WHO group 1 PAH population. should be identified, investigated, and atrial reentry tachycardia or flutter is However, there are a few notable ex- treated promptly with input from an the most common tachyarrhythmia in ceptions where patients with PAH adult CHD centre. A thorough clini- adult CHD due to scar-related abnor- associated with CHD were studied cal history, physical examination, and malities. Although atrial fibrillation is specifically,24-28 or are being studied hemodynamic assessment are essen- relatively uncommon in the younger specifically.29 Unfortunately, research tial. If any associated symptoms, adult CHD population, the prevalence results so far show that therapy with heart failure, and/or hemodynamic of atrial fibrillation increases with these agents slows but does not halt or abnormalities are identified, prompt age. It is important to note that atrial reverse pulmonary vascular remodel- referral to an adult CHD heart rhythm arrhythmias can often be difficult to ing. Many patients eventually worsen specialist is indicated. detect in this population and the clini- despite optimal pulmonary hyperten- Up to 30% of adult CHD patients cian needs to maintain a high index sion therapy. For these patients, either have significant arrhythmia as an ad- of suspicion as atrial arrhythmias can lung transplant, lung transplant with ditional diagnosis. Arrhythmias are lead to catastrophic events. Ventricu- cardiac surgery to repair the congen- the leading cause of morbidity, im- lar arrhythmias are the leading causes ital defect, or combined heart-lung paired quality of life, emergency room of sudden death in several subtypes transplant are ultimately required. visits, hospitalization, and mortality of CHD. Although the absolute inci- In British Columbia, care for in this patient population.30 The entire dence of cardiac arrest remains rela- patients with CHD-associated PAH spectrum of arrhythmias is encoun- tively low (approximately 0.1% per is centralized at St. Paul’s Hospital in tered in adult CHD, with several types year), the overall risk is up to 100 Vancouver at the Pacific Adult Con- often coexisting in the patient at pre- times higher than in an age-matched genital Heart (PACH) clinic, the first sentation or afterwards. Several fac- control population.34 such clinic in Canada and the model tors make the heart more susceptible for other adult CHD centres. At the to rhythm disorders in adult CHD, in- Investigating arrhythmias clinic, each patient is seen by both cluding congenitally displaced or mal- Accurate delineation of arrhythmias a pulmonary hypertension expert formed sinus nodes or atrioventricular can be accomplished with 12-lead and an adult CHD cardiologist. This conduction systems; primary myocar- electrocardiogram, Holter monitor- has been a highly successful collab- dial disease; scarring from previous ing, cardiac event loop recorders, orative venture that has resulted in ischemic insult or surgery; residual or implantable loop recorders, and inter- markedly improved communication postoperative hemodynamic sequel- rogation of already implanted devic- between health care providers and ae; and intra-atrial or intraventricular es such as pacemakers or defibrilla- much more efficient and effective conduction propagation. tors. An electrophysiological study care for patients. Patients followed Certain adult CHD lesions are (EPS) may be considered when the through this clinic are frequently on associated with a very high risk of conventional diagnostic workup is pulmonary arterial hypertension ther- rhythm problems. For example, in unrevealing in adults with CHD and apy, including endothelin receptor congenitally corrected transposition symptoms suggest sustained arrhyth- antagonists, phosphodiesterase type 5 of the great arteries, approximate- mia. An EPS can also be indicated inhibitors, or a combination of these ly 20% of patients develop com- in cases with unexplained syncope agents. A strong partnership between plete atrioventricular node conduc- and high-risk anatomical substrates the clinic and general cardiologists, tion block by adulthood and require associated with primary ventricular respirologists, internists, and prima- pacemaker implantation.31 In patients arrhythmias or poorly tolerated atri- ry care physicians outside the Lower with prior surgery in the region of the al tachyarrhythmias. High-risk sub- Mainland allows these patients to be sinus node or its arterial supply (e.g., strates include tetralogy of Fallot, followed in their local communities patients who have undergone a Mus- transposition of the great arteries with throughout the province. tard or Senning procedure for trans- atrial switch surgery, and systemic or

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single-ventricle anatomy. However, an inability to induce an arrhythmia A B in the electrophysiology lab does not fully exclude the possibility of a clinical arrhythmia.35 Many complications can occur as a result of arrhythmias, including heart failure, thromboembolism, and sudden cardiac death, and it is important to ensure that worsening hemodynamics are not the cause of the arrhythmia. Adults with CHD who have new-onset or worsening arrhythmias and those who have been resuscitated after sudden cardiac death should undergo hemodynamic Figure 2. Complementary imaging techniques were used to reveal a small pseudoaneurysm (see arrows) at the site of a previous coarctation repair in the thoracic aorta of a 38-year-old male. assessment, including detailed imaging with echocardiography, cardiac A: Multiplanar reformatted IV contrast-enhanced ECG-gated CT image. B: Sagittal oblique view of magnetic resonance imaging, and/ an MRI time-resolved imaging of contrast kinetics (TRICKS) sequence following administration of gadolinium. or cardiac catheterization. New or worsening regurgitant or obstructive lesions, shunts, ischemia, ventricular baffles or conduits, and abnormal adult CHD. Concerns about potential dysfunction, and coronary abnormali- intracardiac connections may have to stochastic effects of ionizing radia- ties can all precipitate arrhythmias. be taken into account. tion have previously limited the use of Arrhythmia management should multidetector computed tomography Managing arrhythmias also include risk assessment for (MDCT). However, the introduction Managing arrhythmias in adult CHD sudden cardiac death, heart failure, of radiation dose-reduction strategies patients can be complex and may and thromboembolic risk—details and recent advancements in CT tech- involve additional considerations: beyond the scope of this article but nology have made MDCT an essen- • Coexisting sinus or atrioventricular readily available from the Heart tial tool for the evaluation of many node dysfunction. Rhythm Society30 and Canadian Car- patients with CHD. Recent advance- • Large scar formation and other ef- diovascular Society.36 ments include submillimetre spatial fects of previous cardiac surgery. resolution in all imaging planes, the • Underlying hemodynamic lesions. Role of imaging ability to synchronize the acquisition • Vascular access issues. in adult CHD to the ECG, and temporal resolution • The patient’s childbearing potential. With advances in imaging technol- as low as 66 msec. Such considerations can make ogy and the longer life expectancy The imaging modalities now com- input from an adult CHD arrhythmia of CHD patients, the role of diagnos- monly used in adult CHD for diagno- specialist vital. For example, if pace- tic imaging in this patient population sis ( Figure 2 ), assessment ( Figure 3 ), maker implantation is recommended has expanded. Echocardiography is and follow-up all have strengths and for a patient with a heart that is dif- the main routine imaging modality weaknesses. ficult to access because of baffles in adults with CHD, enabling assess- MRI is the most common non- and abnormal anatomy, endovascular ment of ventricular function, valvu- invasive imaging modality used to rather than epicardial lead placement lar function, and integrity of surgical support echocardiography. It offers may have to be considered. Vascu- repairs. Magnetic resonance imaging excellent three-dimensional assess- lar access can also be an issue in a (MRI), with its excellent spatial reso- ment and visualization of the often patient requiring electrophysiology lution and ability to assess ventricu- complex postsurgical anatomy and studies and ablation therapy because lar and valvular function without the highly reproducible quantification pharmacological therapy is ineffec- use of ionizing radiation, has played of left and right ventricular volumes tive. Again, impenetrable scar tissue, an essential role in the evaluation of and systolic function. It is also com-

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may heavily degrade image quality, A B or they have an implanted cardiac device. Fortunately, rapid improvements in MDCT have helped fill this imaging gap. Given the good con- cordance between MDCT and MRI findings, multidetector computed tomography is being used increasingly for the quantification of right ventricular volumes and function in those patients unsuitable for MRI assessment. MDCT is able to evaluate the configuration and anatomical dimensions of the right ventricular C D outflow tract, which are major factors when determining whether a patient is suitable for percutaneous pulmonary valve replacement. Coronary CT angiography (CCTA) is now well established as the gold standard for noninvasive detection and exclusion of coronary stenosis. CCTA is also being used increasingly for evaluation of the coronary arteries in patients with coronary anomalies, coronary fistulas, and Kawasaki disease, and after surgical repair for CHD requiring coronary artery ma- Figure 3. Several imaging modalities were used to assess a 27-year-old male for aortic dilatation, aortic regurgitation (AR), and left ventricular function and size in the setting of nipulation. bicuspid aortic valve. When combined with findings from clinical and physiological A: Bicuspid anatomy (arrow) seen with aortic valve plane FIESTA MRI sequence. B: Black forward flow (long arrow) with white regurgitant flow (arrow head) in same direction as white descending assessment, information from these aortic flow (short arrow) seen with functional quantitative assessment of AR on phase contrast complementary imaging modalities imaging. C: Qualitative visualization of AR by flow jet (arrow) across valve plane seen on FIESTA left plays a key role in diagnostic and ventricular outflow tract view.D: Ventricular functional analysis and size evaluation seen on short- axis FIESTA imaging. treatment decision making. Obtain- ing images in more complex adult CHD cases requires a multidisci- monly used for the assessment of assessment of aortic size and repair plinary team with specific expertise valvular function and for myocardial site complication; for the quantifica- and knowledge. Often the images are tissue characterization through the tion of ventricular volumes and func- reviewed with the entire team so that administration of intravenous gado- tion in patients with complex cardiac different perspectives and interpreta- linium contrast medium.37-40 Impor- anatomy; and for evaluation of surgi- tions can be integrated and considered tantly, MRI does not require the use cal repair integrity and aortic dimen- in a clinically meaningful way. of ionizing radiation and is therefore sions. MRI-derived endpoints can a good tool for serial follow-up. Such also be essential to management in Summary serial follow-up is warranted after these circumstances. Pregnancy-related cardiovascular tetralogy of Fallot repair to assess for Many adult CHD patients cannot disease, pulmonary arterial hyper- degree of pulmonary insufficiency as undergo MRI assessment because tension, and arrhythmias are com- well as size and function of the right they suffer from claustrophobia, plications that can affect adult CHD ventricle; after coarctation repair for they have metallic coils in place that patients.

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With improvements in the treatment of congenital heart disease, the number of women with CHD who reach childbearing age is increas- Adult CHD patients with any of ing. In BC a special multidisciplinary the complications discussed here Cardiac Obstetrics clinic at St. Paul’s Hospital provides coordinated care can benefit from recent advances for pregnant women with cardiac con- in imaging technology. ditions. In addition, the clinic offers preconception counseling so that couples can make informed choices about pregnancy. The Pacific Adult Congenital Heart clinic, also based at St. Paul’s, helps manage patients with pulmonary arterial hypertension, a progressive condition affecting around market products used to treat pulmonary arte- 6. Drenthen W, Boersma E, Balci A, et al. 10% of adult CHD patients. Patients rial hypertension: Actelion, Eli Lilly, Pfizer/ Predictors of pregnancy complications in followed through this clinic are fre- Encysive, Bayer, GSK, and Unither. women with congenital heart disease. Eur quently on PAH therapy, includ- Heart J 2010;31:2124-2132. ing endothelin receptor antagonists, References 7. Thorne S, MacGregor A, Nelson-Piercy C. phosphodiesterase type 5 inhibitors, 1. Weiss BM, von Segesser LK, Alon E, et Risks of contraception and pregnancy in or a combination of these agents. al. Outcome of cardiovascular surgery and heart disease. Heart 2006;92:1520-1525. Other adult CHD patients requir- pregnancy: A systematic review of the 8. Burn J, Brennan P, Little J, et al. Recur- ing follow-up are those with a sig- period 1984-1996. Am J Obstet Gynecol rence risks in offspring of adults with ma- nificant arrhythmia, often the first 1998;179:1643-1653. jor heart defects: Results from first cohort manifestation of deterioration in 2. Regitz-Zagrosek V, Lundqvist CB, Borghi of British collaborative study. Lancet complex CHD. Complications that C, et al.; Task Force on the Management 1998;351(9099):311-316. can result from arrhythmias include of Cardiovascular Diseases during Preg- 9. Badesch DB, Raskob GE, Elliott CG, et al. heart failure, thromboembolism, and nancy of the European Society of Cardiol- Pulmonary arterial hypertension: Baseline sudden cardiac death. ogy (ESC). ESC Guidelines on the man- characteristics from the REVEAL registry. Adult CHD patients with any of agement of cardiovascular diseases Chest 2010;137:376-387. the complications discussed here can during pregnancy. Eur Heart J 2011: 10. Engelfriet PM, Duffels MG, Moller T, et al. benefit from recent advances in im- 32;3147-3197. Pulmonary arterial hypertension in adults aging technology. A range of com- 3. Khairy P, Ionescu-Ittu R, Mackie AS, et al. born with a heart septal defect: The Euro plementary modalities now enable Changing mortality in congenital heart dis- Heart Survey on adult congenital heart dis- assessment of ventricular and valvu- ease. J Am Coll Cardiol 2010;56:1149- ease. Heart 2007;93:682-687. lar function (echocardiography and 1157. 11. Farber HW, Loscalzo J. Pulmonary arterial magnetic resonance imaging), quan- 4. Lewis G (ed); Confidential Enquiry into hypertension. N Engl J Med 2004;351: tification of right ventricular volume Maternal and Child Health (CEMACH). 1655-1665. (multidetector computed tomogra- Saving mothers’ lives: Reviewing mater- 12. Agarwal R, Gomberg-Maitland M. Current phy), and exclusion of coronary ste- nal deaths to make motherhood safer— therapeutics and practical management nosis (coronary CT angiography). 2003-2005: The seventh report on confi- strategies for pulmonary arterial hyperten- dential enquiries into maternal deaths in sion. Am Heart J 2011;162:201-213. Competing interests the United Kingdom. London: CEMACH; 13. Humbert M, Sitbon O, Chaouat A, et al. None declared for Drs Grewal, Brunner, Ellis, 2007. Survival in patients with idiopathic, famil- Leipsic, Levy, Barlow, and Chakrabarti. Dr 5. Siu SC, Sermer M, Colman JM, et al. Pro- ial, and anorexigen-associated pulmonary Swiston has received honoraria for speaking spective multicenter study of pregnancy arterial hypertension in the modern man- engagements and advisory board participa- outcomes in women with heart disease. agement era. Circulation 2010;122:156- tion from pharmaceutical companies that Circulation 2001;104:515-521. 163.

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14. D’Alto M, Mahadevan VS. Pulmonary ar- Bosentan therapy in patients with Eisen- tal heart disease. Circulation 2009;120: terial hypertension associated with con- menger syndrome: A multicenter, double- 1679-1686. genital heart disease. Eur Respir Rev blind, randomized, placebo-controlled 34. Silka MJ, Hardy BG, Menashe VD, Morris 2012;21:328-337. study. Circulation 2006;114:48-54. CD. A population-based prospective eval- 15. Krishnan U, Rosenzweig EB. Pulmonary 25. Gatzoulis MA, Beghetti M, Galie N, et al. uation of risk of sudden cardiac death after arterial hypertension associated with con- Longer-term bosentan therapy improves operation for common congenital heart genital heart disease. Clin Chest Med functional capacity in Eisenmenger syn- defects. J Am Coll Cardiol 1998;32:245- 2013;34:707-717. drome: Results of the BREATHE-5 open- 251. 16. Gupta V, Tonelli AR, Krasuski RA. Congen- label extension study. Int J Cardiol 35. Alexander ME, Walsh EP, Saul JP, et al. ital heart disease and pulmonary hyper- 2008;127:27-32. Value of programmed ventricular stimula- tension. Heart Fail Clin 2012;8:427-445. 26. Mukhopadhyay S, Nathani S, Yusuf J, et tion in patients with congenital heart dis- 17. Rabinovitch M. Pulmonary hypertension: al. Clinical efficacy of phosphodiester- ease. J Cardiovasc Electrophysiol 1999; Pathophysiology as a basis for clinical dease-5 inhibitor tadalafil in Eisenmenger 10:1033-1044. cision making. J Heart Lung Transplant syndrome—a randomized, placebo-con- 36. Silversides CK, Marelli A, Beauchesne L, 1999;18:1041-1053. trolled, double-blind crossover study. et al. Canadian Cardiovascular Society 18. Dimopoulos K, Giannakoulas G, Wort SJ, Congenit Heart Dis 2011;6:424-431. 2009 Consensus Conference on the man- Gatzoulis MA. Pulmonary arterial hyper- 27. Zhang ZN, Jiang X, Zhang R, et al. Oral agement of adults with congenital heart tension in adults with congenital heart dis- sildenafil treatment for Eisenmenger syn- disease: Executive summary. Can J Car- ease: Distinct differences from other drome: A prospective, open-label, multi- diol 2010;26:143-150. causes of pulmonary arterial hypertension centre study. Heart 2011;97:1876-1881. 37. Kilner PJ, Geva T, Kaemmerer H, et al. and management implications. Curr Opin 28. Zuckerman WA, Leaderer D, Rowan CA, Recommendations for cardiovascular Cardiol 2008;23:545-554. et al. Ambrisentan for pulmonary arterial magnetic resonance in adults with con- 19. Simonneau G, Gatzoulis MA, Adatia I, et hypertension due to congenital heart dis- genital heart disease from the respective al. Updated clinical classification of pulmo- ease. Am J Cardiol 2011;107:1381-1385. working groups of the European Society nary hypertension. J Am Coll Cardiol 29. National Institutes of Health. Clinical study of Cardiology. Eur Heart J 2010;31:794- 2013;62(25 suppl):D34-41. to evaluate the effects of macitentan on 805. 20. McLaughlin VV, Presberg KW, Doyle RL, exercise capacity in subjects with Eisen- 38. Powell AJ, Maier SE, Chung T, Geva T. et al. Prognosis of pulmonary arterial hy- menger syndrome (MAESTRO). Acces Phase-velocity cine magnetic resonance pertension: ACCP evidence-based clinical sed 1 July 2016. www.clinicaltrials.gov/ imaging measurement of pulsatile blood practice guidelines. Chest 2004;126(1 ct2/show/study/NCT01743001. flow in children and young adults: In vitro suppl):78S-92S. 30. Khairy P, Van Hare GF, Balaji S, et al. PAC- and in vivo validation. Pediatr Cardiol 21. Diller GP, Dimopoulos K, Broberg CS, et ES/HRS Expert Consensus Statement on 2000;21:104-110. al. Presentation, survival prospects, and the Recognition and Management of Ar- 39. Mooij CF, de Wit CJ, Graham DA, et al. predictors of death in Eisenmenger syn- rhythmias in Adult Congenital Heart Dis- Reproducibility of MRI measurements of drome: A combined retrospective and ease: Developed in partnership between right ventricular size and function in pa- case-control study. Eur Heart J 2006;27: the Pediatric and Congenital Electrophys- tients with normal and dilated ventricles. 1737-1742. iology Society (PACES) and the Heart J Magn Reson Imaging 2008;28:67-73. 22. Le RJ, Fenstad ER, Maradit-Kremers H, et Rhythm Society (HRS). Heart Rhythm 40. Prakash A, Powell AJ, Krishnamurthy R, al. Syncope in adults with pulmonary arte- 2014;11:e102-165. Geva T. Magnetic resonance imaging rial hypertension. J Am Coll Cardiol 2011; 31. Oechslin EN, Harrison DA, Connelly MS, evaluation of myocardial perfusion and vi- 58:863-867. et al. Mode of death in adults with con- ability in congenital and acquired pediatric 23. Task Force for Diagnosis and Treatment of genital heart disease. Am J Cardiol 2000; heart disease. Am J Cardiol 2004;93:657- Pulmonary Hypertension of European So- 86:1111-1116. 661. ciety of Cardiology (ESC), European Re- 32. Puley G, Siu S, Connelly M, et al. Arrhyth- spiratory Society (ERS), International So- mia and survival in patients >18 years of ciety of Heart and Lung Transplantation age after the Mustard procedure for com- (ISHLT), et al. Guidelines for the diagnosis plete transposition of the great arteries. and treatment of pulmonary hyperten- Am J Cardiol 1999;83:1080-1084. sion. Eur Respir J 2009;34:1219-1263. 33. Bouchardy J, Therrien J, Pilote L, et al. 24. Galie N, Beghetti M, Gatzoulis MA, et al. Atrial arrhythmias in adults with congeni-

388 bc medical journal vol. 58 no. 7, september 2016 bcmj.org Karen LeComte, MSN, RN, Brian Sinclair, MD, FRCPC, Sarah Cockell, PhD, RPsych, Emma Iacoe, MSN, RN, Alexia Gillespie, BSN, BEd, RN, Derek Human, MD, FRCPC

Ensuring a successful transition and transfer from pediatric to adult care in patients with congenital heart disease

As CHD patients make the shift from a family-centred pediatric model of care to an autonomous adult model, self-management and self-advocacy skills become essential, and resources available through the Transitioning Responsibly to Adult Care initiative (ON TRAC) can be useful.

ABSTRACT: Patients with congenital Pacific Adult Congenital Heart Dis opulation estimates indicate heart disease require lifelong sur ease program at age 18. Resources there are approximately 12 000 veillance for arrhythmias, ventricu that can aid in transition and transfer P adults with moderate and se- lar failure, and complications asso include toolkits developed through vere congenital heart disease (CHD) ciated with childhood surgery. When the Transitioning Responsibly to in British Columbia. The significant pediatric patients with congenital Adult Care initiative and information increase in patient numbers (estimated heart disease become adults they provided by the iHeartChange web growth to be more than 5% per year) can be lost to follow-up or experi site. Primary care considerations for is attributable to the excellent survival ence lapses in care that expose them young adult patients include cardiac outcomes for young patients with to greater risk of adverse health out surveillance and screening, sexual CHD achieved in past decades and the comes. A successful transition and and reproductive health, and psy greater awareness of services for these transfer from pediatric to adult care chosocial health. The population of patients. Services include pediatric supports youth attachment to both congenital heart disease patients is care provided through the Children’s a primary care provider and a spe growing and aging, and continued Heart Centre at BC Children’s Hos- cialized cardiology clinic—ensuring attention will be needed to ensure pital (BCCH) and adult care provided quality and continuity of care. Tran these patients move successfully through the Pacific Adult Congenital sition refers to a process that begins from pediatric to adult care. Heart Disease (PACH) clinic at St. in early adolescence and continues through early adulthood when health care management shifts from the Ms LeComte is a clinical nurse specialist in Cockell is a psychologist in the PACH clinic. family to the patient. Transfer is an the Pacific Adult Congenital Heart (PACH) She is also a psychological associate in the event that occurs when the respon clinic, Division of Cardiology, St. Paul’s Psychology Department at Simon Fraser sibility for patient care moves from Hospital. She is also an adjunct professor University. Ms Iacoe is a patient educator one health care team to another. In in the School of Nursing at the University in the PACH clinic. Ms Gillespie is a patient BC pediatric patients with congenital of British Columbia. Dr Sinclair is a pediat- educator in the PACH clinic. Dr Human is a heart disease are transferred from ric cardiologist in Maternal, Child and Youth pediatric cardiologist in the PACH clinic and the Children’s Heart Centre to the Programs, Vancouver Island Health Author- in the Children’s Heart Centre at BC Chil- ity. He is also a clinical associate professor dren’s Hospital. He is also a clinical profes- This article has been peer reviewed. in the Department of Pediatrics at UBC. Dr sor in the Department of Pediatrics at UBC.

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Paul’s Hospital. Ensuring a successful Pacific Adult Congenital ensures ongoing education for those transition and transfer from pediatric Heart clinic caring for this patient population. to adult care is critical to maintaining The PACH clinic was established at There is a PACH physician on call 24 patient health in adulthood. Shaughnessy Hospital in 1988 to re- hours a day, 7 days a week, to assist There are 15 specialized adult spond to a gap in health services for physicians and other health care pro- CHD centres across the country, all adults with CHD, and moved to St. viders throughout the province. The belonging to the Canadian Adult Con- Paul’s Hospital in 1993. The PACH PACH team provides comprehen- genital Heart network or CACH net- team, a multidisciplinary group of sive, cost-effective care to adults with work (www.cachnet.org). The PACH health professionals with advanced CHD. A team approach to care is integral to optimizing the health of this complex patient population. The PACH patient educators are the initial point of contact for both patients and community health care providers. The patient educators provide case management A team approach to care is integral and liaise on a daily basis with the PACH team to support patient well- to optimizing the health of this ness and assist with the challenges complex patient population. of navigating the health care system. During clinic visits, patient-centred education is based on a chronic disease self-management model. When patients have a better understanding of their individual cardiac condition they are able to recognize concerning symptoms, communicate effectively clinic is one of five that offer a full training in adult CHD, is a unique with their health care providers, and range of services and qualifies as a provincial resource that provides determine when it is appropriate to supraregional centre. CACH network comprehensive health services to seek medical attention. Patient educa- has been instrumental in establishing CHD patients. The core team includes tors are available to provide ongoing templates and guidelines for standard- adult and pediatric cardiologists, car- support in these areas and to facili- ized follow-up of many adult CHD diac surgeons, cardiac radiologists, tate self-management by connecting conditions. Building on this work, the patient educators (registered nurses), patients with resources when nec- Canadian Cardiac Society (CCS) con- a clinical nurse specialist, a psycholo- essary. Telehealth services support vened a panel of international experts gist, a genetic counselor, and a social patients and their health care provid- for an adult CHD consensus confer- worker. Additional specialists are re- ers to manage their CHD and facili- ence in 1996.1 Foremost among the cruited as required. Services provided tate additional patient education out- proposals arising from this forum was include consultation, ongoing medi- side clinic hours. a recommendation that all patients be cal care, cardiac surgery, cardiac in- The PACH clinic currently fol- referred to specialized centres for on- tervention, electrophysiology proce- lows 2700 active patients and has a going care. Mylotte and colleagues dures, diagnostic imaging, obstetrical wait time of 3 to 4 months for patients documented an increase in referrals care, and patient and family education to be seen on a nonurgent basis. The to specialized centres in Quebec after and counseling. volume of patients served has almost publication of the CCS recommenda- Patients are discussed at week- tripled in the last decade and the clin- tions in 1998, and demonstrated that ly case conferences and bimonthly ic has been advocating for expanded referral was independently associated morbidity and mortality rounds. Car- services. To accommodate the grow- with a significant decrease in mortal- diology fellows, residents, medical ing population of adults with CHD ity, supporting the model of special- students, and other health care profes- throughout BC, a closer-to-home ized care for patients with adult CHD.2 sionals in training also attend, which care model, patterned on the success

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of BCCH’s Cardiology Partnership moves from one health care team to CHD. Expert consensus recommends Program, is being explored to bring another. When transition and trans- that structured plans be developed to adult CHD services to communities fer from pediatric to adult health care facilitate the transition process.6 outside the Lower Mainland. Partner- are less than optimal, the repercus- Multiple tools and strategies have ing with communities and local health sions can be serious, and may include been developed and are being evalu- care providers has proven successful hospital admissions, adverse health ated to support the transition and when serving other populations with events, and even death.7 The poten- transfer process for youth with CHD chronic health conditions. Bringing tial for residual disease and compli- as they move from the Children’s the expertise of adult CHD specialists cations following childhood manage- Heart Centre at BCCH to the PACH to communities across the province ment of CHD necessitates lifelong program at St. Paul’s Hospital when would support care providers in local surveillance for arrhythmias, ventric- they reach age 18. communities to deliver quality care to ular failure, and the need for further this group of complex patients. surgery.3 ON TRAC initiative An estimated 30% to 70% of Transitioning Responsibly to Adult Moving from pediatric CHD patients are lost to follow-up or Care (ON TRAC) is a provincial to adult care experience lapses in care,8,9 situations initiative that supports youth with Currently most children born with that expose them to greater risk of chronic health conditions as they pre- CHD are surviving, and can be ex- adverse health outcomes. Gaps in care pare to move from pediatric care and pected to thrive well into their adult are more frequent in males, in those then as they transfer and attach them- years. There are now more adults than with mild and moderate defects, and selves to the adult health care system. children with CHD. With the surgical in patients with a history of follow- Using a framework from the Institute advancements of the past several dec- up outside an adult CHD clinic.4,8,9 for Healthcare Improvement Triple ades, 95% of pediatric congenital Additional challenges to successful Aim framework, ON TRAC consists heart disease patients will now transfer to adult care, the largest growth in this population being youth with complex CHD.3,4 Adults with CHD are pursuing advanced education, building careers, and starting families of their own. Lifelong cardiac follow-up Multiple tools and strategies is required to achieve the best health have been developed and are outcomes for these patients. To support seamless cardiac care across the being evaluated to support lifespan of a congenital heart patient, the transition and transfer a structured transition process followed by a transfer of care is neces- process for youth with CHD. sary.

Transition and transfer A successful transition and transfer from pediatric to adult CHD care supports youth attachment to a primary transition include patient adherence, of four separately funded projects fo- care physician and specialty clinic(s) relocation, and attachment to a spe- cused on policy change, clinical prac- and ensures continuity of care. Tran- cialty clinic.6 As CHD patients move tice, health system performance, and sition refers to a process that begins from a family-centred pediatric model youth engagement. Key stakeholders in early adolescence and continues of care to an autonomous adult model, are involved at every level to inform through early adulthood when health self-management and self-advocacy decisions, develop and test tools, and care management shifts from the skills become essential.10 Transition shape recommendations. ON TRAC family to the patient.5,6 Transfer is and transfer must be seen as essential is supported with funding from the an event that occurs when the patient elements in the care of patients with Vancouver Foundation, BCCH, Child

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Health BC, and the Shared Care Com- • Transition Clinical Pathways (TCP) .ca/transition-to-adult-care/Docu mittee (SCC) and Specialist Services form: Developed through BCCH, ments/MTSCARDIOTemplate Committee (SSC)—joint committees this form is used to guide the prepa- Dec2015.pdf) of Doctors of BC and the BC Ministry ration of youth and document their • Transition Care Management Plan of Health. readiness to manage their care in (TCMP): Developed with the sup- ON TRAC reflects work done the adult care system. The TCP is port of the SSC, the TCMP helps by groups of pediatric and adult care provided to adult specialists and community care providers un- providers, patients, and families to community-based family practi- derstand the care requirements of address gaps that have traditionally tioners at the time of transfer. The patients with CHD. The TCMP consists of background information (purpose, brief description of lesion and management, recommendations for use of the plan) and delineates the role of the primary care physician and adult CHD spe- ON TRAC reflects work done by groups cialist. It outlines the potential risks of pediatric and adult care providers, associated with the specific lesion, health surveillance and clini- patients, and families to address gaps that cal evaluation recommendations, have traditionally been a challenge in the sexual and reproductive health considerations, and noncardiac sur- transition from pediatric to adult care. gery and procedures. The TCMP also outlines patient counseling recommendations for medications, exercise, and lifestyle considerations. TCMPs will be available online beginning November 2016. The TCMP website will contain the been a challenge in the transition from form lists cardiac-specific tests and template and tips on how to devel- pediatric to adult care by: reports and highlights areas where op a plan. These materials will be • Preparing youth and families with additional education and support posted on the ON TRAC website in skills to function in the adult sys- are required to help the young pa- the health care provider toolkit. tem. tient acquire the knowledge and • ON TRAC website: The website • Supporting health care providers skills needed for self-management. provides access to toolkits for youth, through clinical guidelines, train- (www.bcchildrens.ca/transition-to families, and health care providers. ing, tools, and online resources. -adult-care/Documents/TCPCOM The youth toolkit helps patients de- • Defining the role of community- PLEXCARDIOLOGY.pdf) velop the skills and obtain the sup- based family physicians in provid- • Medical Transfer Summary (MTS) port required for an effective tran- ing continuity of care. form: Developed with the support sition into adulthood and the adult • Defining appropriate referral path- of BCCH and the SCC, this form health care system. With the help of ways and care requirements for ensures that the family physician, videos, self-directed activities, and youth with complex health condi- community care providers, and the other resources, youth can develop tions. specialty clinic receive a compre- self-advocacy and self-management The ON TRAC package of transi- hensive summary of the medical skills, obtain peer support, engage in tion and transfer tools for CHD pa- history (including details about educational, vocational, and financial tients, family members, and care pro- investigations, surgeries, medica- planning, and learn more about sexu- viders was developed to ensure that a tions, immunizations), psychoso- al health and healthy lifestyle choic- comprehensive transfer of care occurs cial considerations and anticipato- es. The family toolkit helps family when the transition is complete. The ry guidance and recommendations members provide guidance regard- package includes: for future care. (www.bcchildrens ing additional support for housing, fi-

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nances, personal care, and guardian- ful transition to adult care and to re- Sports and physical activity ship. The health care provider toolkit ceive appropriate health maintenance participation includes templates, guidelines, and advice and ongoing care regarding The vast majority of youth and young resources to assist those supporting the following primary care consider- adults with CHD can participate in youth through the transition process. ations. physical activity and sport with mini- (www.ontracbc.ca) mal restrictions. Exercise recommen- Surveillance, screening, and dations outlined by the congenital iHeartChange counseling cardiologist should be supported by The website iHeartChange (https:// Patients with CHD and acquired val- the primary care provider. iheartchange.org) is a CHD-specific, vular heart disease are at risk for in- empirically studied Internet resource fective endocarditis and may require Psychosocial health developed for youth, families and antibiotic prophylaxis.15 As well as Health care providers may fail to friends, and health care providers. being considered for appropriate anti- detect psychosocial distress if they do The website provides introductions biotic prophylaxis, patients should not ask about it or deliberately screen to adult care teams in many North be screened for acquired cardiac for it as part of routine care. The most American communities, medical and risk factors such as hypertension and straightforward way is to ask patients lifestyle information, and suggestions hypercholesterolemia, and counseled about specific challenges or difficult for becoming independent and cop- regarding nutrition and the use of to- feelings that they may be experiencing with CHD. Users must create an bacco, marijuana, alcohol, and drugs. ing in daily life, and to provide appro- account to access the site, but there is Lifestyle choices such as body pier- priate mental health referrals when no cost or restriction otherwise. Youth cing and tattoos should also be dis- needed. In North America, approxi- can earn a Transition Diploma by vis- cussed. mately 1 in 3 adults with CHD have iting the various sections of the site clinical levels of depression and anxi- and answering questions about living Sexual and reproductive health ety,16-19 even when these patients are with CHD.11 Discussion may be needed about con- assumed to be well adjusted by their cerns regarding body image that can cardiologists.16 Regardless of for- Primary care affect a young patient’s self-esteem mal psychiatric status, many adults considerations and have an impact on sexuality and with CHD face potential psychoso- The primary care physician plays an sexual choices. The risk of having a cial challenges as a result of growing essential role in the transition and child with CHD should be reviewed up with a complex health condition. transfer process. Children and youth with both men and women, and fetal Common challenges include disease who are not well connected to a pri- echocardiography should be offered management, intrapersonal and emo- mary care physician may not devel- to all prospective parents. Specific tional issues, impaired social func- op an effective relationship with the issues regarding contraception and tioning, educational and vocational health care system as young adults.12 pregnancy must be discussed with difficulties, and poor health behav- Given the centralized nature of sub- women. Most women with CHD have iors.20-23 It is unclear whether psy- specialty care, young adult CHD no limits on contraceptive choice, and chosocial functioning is worst among patients may also not learn about the counseling can focus on efficacy and patients with more complex CHD.23 A resources available in their home com- individual needs. The exception is number of factors24,25 may contribute munities.13 In addition, concerns have women with an increased thrombo- to lower psychological functioning: been raised by general internal medi- sis risk in which the use of combined • Female sex. cine specialists regarding inadequate estrogen/progestin oral contracep- • Low capacity for exercise. exposure and knowledge regarding tives should be avoided. This group • Restrictions placed by physician. children with complex pediatric dis- can use progestin (only) agents, such • Body image concerns/perception of orders and the unique health and psy- as oral or implanted agents. scarring. chosocial aspects of these adolescents Preconception counseling to re- • Perceived health status. and young adults.14 view the potential risks and safety of a • Loneliness/social anxiety/fear of Young adults who have a strong pregnancy may be organized with the negative evaluation/poor social relationship with a community physi- Cardiac Obstetrics (COB) clinic at St. support/poor social problem- cian are more likely to have a success- Paul’s Hospital. solving abilities.

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• Poor academic performance. ization and cardiac surgical reports. Pacific Adult Congenital Heart Clinic • Perceived financial strain. Each patient is unique and surgi- Many patients with CHD report cal repairs may have been modified. St. Paul’s Hospital feeling “different,” and the therapeu- Reports from previous consultations Room 5051–1081 Burrard St. tic relationship may improve if both and procedures (pediatric cardiology, Vancouver, BC, V6Z 1Y6 patients and providers view them- cardiac surgery, and adult cardiology) Tel: 604 806-8520 Fax: 604 806-8800 selves as partners of equal status in are helpful, as are imaging reports. the health care process. There are a The clinic orders appropriate inves- E-mail: [email protected] number of excellent review papers tigations prior to the patient’s clinic Website: www.heartcentre.ca/services/ congenital-heart-disease about common psychosocial issues appointment, usually on the same day in CHD for the interested reader.23,25-27 for patients from outside the Lower Mainland, so that a comprehensive care provider and ensures that conti- Referring patients to assessment can be provided at the nuity of care is maintained. Resourc- the PACH clinic time of the consultation. es that aid in transition and transfer Patients age 18 and older with mod- include toolkits developed for the erate and severe congenital heart dis- Summary ON TRAC initiative and the iHeart- ease ( Table ) should be referred to the Approximately 12 000 adults with Change website. PACH clinic (see Box for contact moderate and severe congenital heart Primary care considerations in- information). Patients with simple disease live in British Columbia. clude surveillance and screening, disease may benefit from visiting the Pediatric patients with CHD are fol- sexual and reproductive health, and clinic once to confirm that their diag- lowed through the Children’s Heart psychosocial health. Patients with noses are correct. Patients with sim- Centre at BCCH and are transferred moderate and severe CHD should ple disease may also visit the clinic to the PACH program at St. Paul’s be followed by the multidisciplinary under special circumstances such as Hospital at age 18. To accommodate team at the PACH clinic, while those during pregnancy, or to obtain advice the growing population of adults with with simple disease may benefit from on treating complications such as CHD, a closer-to-home care model visiting the clinic once to confirm that arrhythmias. is being explored as a way to bring their diagnoses are correct. Patients with an urgent referral adult congenital cardiology services The population of adults with can be seen within days. For non- to additional communities throughout CHD is growing and aging. The urgent referrals, the wait time is BC. success of pediatric care providers approximately 3 to 4 months. Before A successful transition and trans- in achieving excellent survival out- an appointment is booked, the clinic fer from pediatric to adult care sup- comes for young patients requires obtains all previous cardiac catheter- ports youth attachment to a primary that we maintain the momentum

Table. Congenital heart defects by severity.

Simple Moderate Severe

• Isolated congenital valve disease • Atrioventricular canal defect • Obstructed conduit • Small, isolated atrial or ventricular • Anomalous pulmonary veins • Cyanotic heart disease septal defect • Coarctation of the aorta • Double outlet right ventricle • Repaired atrial or ventricular • Ebstein anomaly • Eisenmenger syndrome septal defect • Ostium primum atrial septal defect • Fontan procedure complication • Repaired patent ductus arteriosus • Sinus venosus atrial septal defect • Single-ventricle defect • Patent ductus arteriosus not closed • Transposition of the great arteries • Right ventricular outflow tract obstruction • Truncus arteriosus • Moderate to severe pulmonary stenosis or insufficiency • Isomerism • Subvascular or supravalvular aortic stenosis • Heterotaxy syndrome • Tetralogy of Fallot • Ventricular septal defect with associated defects

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and ensure that adult CHD patients tients: HEART-ACHD (The Health, Educa- 2000;75:31-36. receive the quality and continuity of tion, and Access Research Trial). J Am Coll 19. Kovacs AH, Saidi AS, Kuhl EA, et al. De- care they need. Cardiol 2013;61:2180-2184. pression and anxiety in adult congenital 10. Mackie AS, Islam S, Magill-Evans J, et al. heart disease: Predictors and prevalence. Competing interests Healthcare transition for youth with heart Int J Cardiol 2009;137:158-164. None declared. disease: A clinical trial. Heart 2014;100: 20. Bang JS, Jo S, Kim GB, et al. The mental 1113-1118. health and quality of life of adult patients References 11. Kovacs AH, Cullen-Dean G, Harrison JL, with congenital heart disease. Int J Car- 1. Connelly MS, Webb GD, Somerville J, et et al. The iHeartChange website targeting diol 2013;170:49-53. al. Canadian Consensus Conference on transitioning patients with congenital 21. Foster E, Graham Jr TP, Driscoll DJ, et al. Adult Congenital Heart Disease 1996. Can heart disease: Feasibility outcomes. Pre- Task force 2: Special health care needs of J Cardiol 1998;14:395-452. sentation. American Heart Association adults with congenital heart disease. J Am 2. Mylotte D, Pilote L, Ionescu-Ittu R, et al. 2012:A16122. Coll Cardiol 2001;37:1176-1183. Specialized adult congenital heart disease 12. Hopper A, Dokken D, Ahmann E. Transi- 22. Gantt LT. Growing up heartsick: The expe- care: The impact of policy on mortality. tioning from pediatric to adult health care: riences of young women with congenital Circulation 2014;129:1804-1812. The experience of patients and families. heart disease. Health Care Women Int 3. Warnes CA. The adult with congenital Pediatr Nurs 2014;40:249-252. 1992;13:241-248. heart disease: Born to be bad? J Am Coll 13. Sanabria KE, Ruch-Ross HS, Bargeron JL, 23. Kovacs AH, Sears SF, Saidi AS. Biopsy- Cardiol 2005;46:1-8. et al. Transitioning youth to adult health- chosocial experiences of adults with con- 4. Mackie AS, Ionescu-Ittu R, Therrien J, et care: New tools from the Illinois Transition genital heart disease: Review of the litera- al. Children and adults with congenital Care Project. J Pediatr Rehabil Med 2015; ture. Am Heart J 2005;150:193-120. heart disease lost to follow-up: Who and 8:39-51. 24. Kovacs AH, Moons P. Psychosocial func- when? Circulation 2009;120:302-309. 14. McManus M, White P, Barbour A, et al. tioning and quality of life in adults with 5. Canadian Paediatric Society. Transition to Pediatric to adult transition: A quality im- congenital heart disease and heart failure. adult care for youth with special health provement model for primary care. J Ado- Heart Fail Clin 2014;10:35-42. care needs. Paediatr Child Health 2007; lesc Health 2015;56:73-78. 25. Callus E, Quadri E, Ricci C, et al. Update 12:785-788. 15. Wilson W, Taubert KA, Gewitz M, et al. on psychological functioning in adults with 6. Sable C, Foster E, Uzark K, et al. Best prac- Prevention of infective endocarditis: congenital heart disease: A systemic re- tices in managing transition to adulthood Guidelines from the American Heart As- view. Expert Rev Cardiovasc Ther 2013; for adolescents with congenital heart dis- sociation: A guideline from the American 11:785-791. ease: The transition process and medical Heart Association Rheumatic Fever, En- 26. Kovacs AH, Bendell KL, Colman J, et al. and psychosocial issues: A scientific docarditis, and Kawasaki Disease Com- Adults with congenital heart disease: Psy- statement from the American Heart As- mittee, Council on Cardiovascular Dis- chological needs and treatment prefer- sociation. Circulation 2011;123:1454- ease in the Young, and the Council on ences. Congenit Heart Dis 2009;4:139- 1485. Clinical Cardiology, Council on Cardiovas- 146. 7. Reid GJ, Irvine JM, McCrindle BW, et al. cular Surgery and Anesthesia, and the 27. Kovacs AH, Landzberg MJ, Goodlin SJ. Prevalence and correlates of successful Quality of Care and Outcomes Research Advance care planning and end-of-life transfer from pediatric to adult health care Interdisciplinary Working Group. Circula- management of adult patients with con- among a cohort of young adults with com- tion 2007;116:1736-1754. genital heart disease. World J Pediatr Con- plex congenital heart defects. Am Acad 16. Brandhagen DJ, Feldt RH, Williams DE. genit Heart Surg 2013;4:62-69. Pediatr 2004;113:e197-205. Long-term psychologic implications of 8. Goossens E, Stephani I, Hilderson D, et al. congenital heart disease: A 25-year follow Transfer of adolescents with congenital up. Mayo Clin Proc 1991;66:474-479. heart disease from pediatric cardiology to 17. Bromberg JI, Beasley PJ, D’Angelo EJ, et adult health care: An analysis of transfer al. Depression and anxiety in adults with destinations. J Am Coll Cardiol 2011:57; congenital heart disease: A pilot study. 2368-2374. Heart Lung 2003;32:105-110. 9. Gurvitz M, Valente MD, Broberg C, et al. 18. Horner T, Liberthson R, Jellinek MS. Psy- Prevalence and predictors of gaps in care chosocial profile of adults with complex among adult congenital heart disease pa- congenital heart disease. Mayo Clin Proc

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 395 in memoriam

Dr James Holmes Jim and Dixie moved to Kelow- Dr G. Barrie Purves 1934–2016 na in 1965 and he practised internal 1942–2016 It is with great medicine at what was then known sadness that we as the Knox Clinic. My wife, Bitten, announce the and I came to Kelowna 1 year prior passing of Dr to Jim’s arrival and our friendship Jim Holmes on 3 developed quickly. This friendship June 2016. was cemented by nearly 45 years of I am deeply annual bird hunting trips to the Prai- honored to have ries for the four of us. Jim was in his been asked by his element on these trips and many were family to write a our exploits. He was a fan of W.O. few words about Mitchell and his book Who Has Seen my very good friend and colleague. the Wind, and he always delighted in Jim leaves behind his best friend showing us the wind. While ranging and bride of 55 years, Dixie; his across the Prairies, Jim would bring daughters Lisa (Brian), Shelley the vehicle to a screeching stop and (Ron), and Jackie (Mark); his son, we would all hop out and actually Robert (Theresa); and a brood of 10 look at the wind. Not at the grass and grandchildren who all adored him. trees but, when the light was right, Dr Barrie Purves died 11 March First and foremost Jim was a Prai- you could actually see the wind! This 2016 from complications of multiple rie boy, and you could take the boy will stay with me forever. myeloma for which he had been suc- from the Prairies but you could never I would now like to review for you cessfully treated for nearly 14 years. take the Prairies away from the boy. the advances in medicine made at our He is survived by this wife, Sherrill Jim was born 82 years ago in Consort, Kelowna General Hospital thanks to Purves; three daughters; and four Alberta, population 700 souls and Dr Jim Holmes. Jim started the first grandchildren. home to two famous personages: Jim respiratory service in our hospital Dr Purves graduated from the Holmes and singer k.d. lang. Follow- and introduced the I.C.U. and Emer- University of Saskatchewan in 1967 ing his formative years in Consort, gency Department to the Bird respir- and, after interning at Chicago Cook the family moved to Mirror, Alberta. ator, which was cutting edge at the County Hospital, moved to BC to do During his teen years Jim worked as time. This was followed some years his residency in neurosurgery at Van- a fireman on the steam engines of the later by Jim introducing our hospital’s couver General Hospital/UBC Hospi- day. He also became an accomplished first dialysis program using peritoneal tal, which he completed in 1975. Dr baseball player, and it is rumored dialysis. This is now a full hemodialy- Purves was active on the committee that he was scouted by one of the big sis program. Jim then established the that negotiated the first PARI contract American League teams. first cancer clinic in Kelowna and the for UBC residents. He then joined Dr Undergraduate studies were at the Interior. He got the first chemotherapy Brian Hunt at Lions Gate Hospital University of Alberta, and then med- program developed and indeed was and together they built a busy practice ical school followed by postgraduate our very first oncologist in Kelowna. in North Vancouver, which extended studies in internal medicine at the He then worked incredibly hard to get to include Burnaby with active privi- Montreal General Hospital, and an our full-service cancer clinic to where leges at Burnaby General Hospital. exchange in Charlotte, North Caro- it is today. This legacy will be hard to They maintained full coverage of lina, and the famous Hammersmith match indeed! these services with a 1-in-2 call for Hospital in London, England. Jim will be sorely missed by 12 years before they were joined by These studies came to an untimely his friends and colleagues, and our a third neurosurgeon. Dr Purves also halt when Jim’s brother, Jack was tra- thoughts and best wishes are with his found time to serve as head of the gically killed in an air crash and Jim wife, Dixie, and their family. Department of Surgery at Lions Gate and Dixie returned to Canada to com- —Jim Tisdale, MD Hospital, then chief of staff at Lions plete his fellowship at the University Kelowna Gate Hospital in the 1980s, and as the of Alberta Hospital in Edmonton. North Shore representative for Doc-

396 bc medical journal vol. 58 no. 7, september 2016 bcmj.org in memoriam advertiser tors of BC from 1982–84. Dr John William Ibbott index In 1992, frustrated by the lack of 1929–2016 resources to treat the neurosurgery Thanks to the following advertis- patients in BC, Dr Purves left the ers for their support of this issue province to join three neurosurgeons of the BC Medical Journal. in a neurosurgery group in Sioux BC Doctors of Optometry ...... 365 City, Iowa. He worked there at two hospitals (Mercy Medical Center and Cambie Surgery Centre/ St. Luke’s Medical Center) and then Specialist Referral Clinic ..... 352 played an important role in establish- Canadian Medical ing a Speciality Surgical Center in Association ...... 405 North Sioux City, South Dakota. His The death of Dr Bill Ibbott on 26 College of Physicians interpersonal skills were also critical May 2016 marks the end of a remark- and Surgeons of for establishing a multidisciplinary able medico-political career. It is British Columbia ...... 401 group practice called the Center for worth remembering that the weekend Neurosciences and Spine. He retired demanded a great deal of Dr Ibbott’s Grace Fertility Centre ...... 359 from that practice in 2004 after 2 years otherwise private life with so many Johnson Inc ...... 406 of treatment for multiple myeloma. official board meetings held both pro- Mercedes-Benz ...... 357 Fortunately Dr Purves was able vincially and nationally. to enjoy another 12 years of pursuing I served on many executive pro- MNP ...... 427 his hobbies and friendships, which vincial and national boards with Dr Pacific Centre for included a passion for good food Ibbott, and knew him well while he Reproductive Medicine ...... 356 and wine, travelling the world to see was president of the then-BCMA Pollock Clinics ...... 354 the wine-growing regions, teaching from 1975–76 and I from 1976–77 neurosurgery for 1 month for each of (and 1982–83). It was true that we QHR Technologies 3 years in Indonesia with the inter- were often in opposition to each other Accuro Medeo ...... 421 national group FIENS, hunting and but this had some valuable political Record Storage and building, and enjoying his grandchil- advantages. When we met with pro- Retrieval Service ...... 363 dren as they arrived. vincial health ministers we were able Sea Courses Cruises ...... 419 Dr Purves is remembered by to use our most effective arguments patients, friends, and family as a car- and I do not remember Dr Ibbott ever Section of Clinical Faculty ..... 420 ing, competent, and compassionate using our political disagreements at Speakeasy Solutions ...... 422 man who enjoyed life with a twinkle such meetings. Dr Ibbott had a total Summit Counselling in his eye, and who endured the tri- devotion to high-quality health care Group Inc...... 401 als of his medical treatments for many for all Canadians. It will be for this UBC Robson Square years with grace and fortitude. that he will be remembered by so Essential Medical —Sherrill Purves, MD many of us, and we owe him gratitude Legal Toolkit ...... 432 North Vancouver for his lifetime commitment. —Brian Hunt, MD —William Jory, MD WorkSafeBC Physician North Vancouver London, UK Education Conference ...... 400

Recently deceased physicians Now we’re here for you 24 hrs a day, seven days a week. If a BC physician you knew well is recently deceased, consider submitting a piece for our “In Memoriam” section in the BCMJ. Call at 1-800-663-6729 or Include the deceased’s dates of birth and death, full name and the visit www.physicianhealth.com. name the deceased was best known by, key hospital and professional affiliations, relevant biographical data, and a high- resolution photo. Please limit your submission to a maximum of 500 words. Send the content and photo by e-mail to [email protected].

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398 bc medical journal vol. 58 no. 7, september 2016 bcmj.org worksafebc

First-time traumatic anterior shoulder dislocations in young patients raumatic anterior shoulder over time or were persistently unsta- severe arthropathy, but had apprecia- dislocations are a relatively ble. Patients whose shoulders were bly less than shoulders with recurrent T common injury, with an in- surgically stabilized had no difference instability.15 cidence rate near 24 per 100 000 in terms of moderate or severe degen- Historically primary traumatic an- person-years.1 The injury is 2 to 5 erative changes compared to soli- terior shoulder dislocations have been times more common in males, with tary dislocators.15 The second recur- treated conservatively, and surgical almost half occurring before the age rence concern, bony loss, involves stabilization has often been reserved of 30. Between 1990 and 2015, Work- both the glenoid and humeral head. for cases of recurrence. The data sug- SafeBC saw nearly 6000 shoulder Hill-Sach’s lesions—a compression gest that the cohort of young patients dislocations, with 27.8% occurring in fracture of the posterosuperolateral with high-demand activities or occu- patients age 25 or younger. Surgery humeral head—are estimated to occur pations may be better served with pri- has often been reserved for cases of in 40% to 90% of all primary disloca- mary surgical stabilization. As such, recurrence, but the literature suggests tions and near 100% of recurrent dis- patients under age 25 with a first-time that young patients may benefit from locations.16,17 Sufficient glenoid wear traumatic shoulder dislocation should primary surgical stabilization sooner can necessitate a more invasive and be referred to an orthopaedic shoulder rather than later. complex bony procedure (such as a specialist for a discussion regarding The primary concern with shoul- Latarjet), or can lead to failure of a the risks and options. Patients under der dislocations in young patients— soft-tissue procedure (such as a Ban- age 20 are the most likely to benefit after acute management—is recur- kart repair) if not recognized. Glenoid from primary stabilization. rence. Recurrence rates for young insufficiency has been reported in up patients range from 54% to 100%.2-14 to 40% of primary dislocations and For further information The upper limit of what constitutes a up to 90% of patients with recurrent or assistance “young patient” varies slightly from shoulder instability.16,18,19 A quantita- If you have questions or require assis- paper to paper, but it is usually con- tive study on glenoid bone loss found tance with a worker patient, especially sidered to be between the ages of 20 an exponential relationship between one who is less than 25 years of age, and 25. Recurrence rates decrease as the degree of anterior glenoid flatten- with a traumatic anterior shoulder the patient ages; the older the patient, ing and the number of dislocations.18 dislocation, please contact a medical the lower the risk of recurrence—to Because of the high incidence of advisor in your nearest WorkSafeBC the point where the recurrence rate is recurrence in young, first-time trau- office. around 6% in patients over 40 years matic shoulder dislocators, as well —Derek Smith, MD, FRCS(C) old.4 as the detrimental effects of recur- WorkSafeBC Orthopaedic The concern with recurrence is rence, there is a movement toward Specialist Advisor twofold: increased risk of arthropa- primary surgical stabilization. Stud- thy, and bony loss necessitating a ies have shown a marked reduction References more invasive surgical stabilization in the recurrence rate when this group 1. Zacchilli MA, Owens BD. Epidemiology of procedure. Radiographic evalua- of patients is treated with a primary shoulder dislocations presenting to emer- tion for degenerative changes at 25 repair compared to conservative man- gency departments in the United States. years following initial injury found a agement using immobilization tech- J Bone Joint Surg Am 2010;92:542-549. prevalence rate of 56%, as compared niques.20-23 There is also evidence for 2. Arciero RA, Wheeler JH, Ryan JB, Mc- to approximately 20% in the general surgically stabilized shoulders having Bride JT. Arthroscopic Bankart repair ver- population.15 Shoulders with no recur- a lower rate of arthropathy, as com- sus nonoperative treatment for acute, rence were found to have less arthrop- pared to shoulders with recurrent initial anterior shoulder dislocations. Am J athy than those that became stable instability.15,24 In fact, as mentioned Sports Med 1994;22:589-594. earlier, a 25-year prospective study 3. Hovelius L, Eriksson K, Fredin H, et al. Re- This article is the opinion of WorkSafeBC found stabilized shoulders to have no currences after initial dislocation of the and has not been peer reviewed by the significant difference from solitary shoulder. Results of a prospective study BCMJ Editorial Board. dislocations in terms of moderate/ Continued on page 400

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Continued from page 399 Sports Med 1982;10:135-137. et al. Glenoid rim lesions associated with of treatment. J Bone Joint Surg Am 1983; 11. Marans HJ, Angel KR, Schemitsch EH, recurrent anterior dislocation of the shoul- 65:343-349. Wedge JH. The fate of traumatic anterior der. Am J Sports Med 1998;26:41-45. 4. te Slaa RL, Wijffels MP, Brand R, Marti RK. dislocation of the shoulder in children. J 20. Robinson CM, Jenkins PJ, White TO, et The prognosis following acute primary Bone Joint Surg Am 1992;74:1242-1244. al. Primary arthroscopic stabilization for a glenohumeral dislocation. J Bone Joint 12. Postacchini F, Gumina S, Cinotti G. Ante- first-time anterior dislocation of the shoul- Surg Br 2004;86:58-64. rior shoulder dislocation in adolescents. J der. A randomized, double-blind trial. J 5. Larrain MV, Botto GJ, Montenegro HJ, Shoulder Elbow Surg 2000;9:470-474. Bone Joint Surg Am 2008;90;708-721. Mauas DM. Arthroscopic repair of acute 13. Kralinger FS, Golser K, Wischatta R, et al. 21. Chahal J, Marks PH, Macdonald PB, et al. traumatic anterior shoulder dislocation in Predicting recurrence after primary ante- Anatomic Bankart repair compared with young athletes. Arthroscopy 2001;17: rior shoulder dislocation. Am J Sports nonoperative treatment and/or ar- 373-377. Med 2002;30:116-120. throscopic lavage for first-time traumatic 6. Rhee YG, Cho NS, Cho SH. Traumatic an- 14. Hoelen MA, Burgers AM, Rozing PM. shoulder dislocation. Arthroscopy 2012; terior dislocation of the shoulder: Factors Prognosis of primary anterior shoulder dis- 28;565-575. affecting the progress of the traumatic location in young adults. Arch Orthop 22. Kirkley A, Werstine R, Ratjek A, Griffin S. anterior dislocation. Clin Orthop Surg Trauma Surg 1990;110:51-54. Prospective randomized clinical trial com- 2009;1:188-193. 15. Hovelius L, Saeboe M. Arthropathy after paring the effectiveness of immediate 7. Wheeler JH, Ryan JB, Arciero RA, Moli- primary anterior shoulder disloca- arthroscopic stabilization versus immobi- nari RN. Arthroscopic versus nonopera- tion—223 shoulders prospectively fol- lization and rehabilitation in first traumatic tive treatment of acute shoulder disloca- lowed up for twenty-five years. J Shoulder anterior dislocations of the shoulder: tions in young athletes. Arthroscopy Elbow Surg 2009;18:339-347. Long-term evaluation. Arthroscopy 2005; 1989;5:213-217. 16. Owens B, Dickens JF, Kilcoyne KG, Rue 21:55-63. 8. Lill H, Verheyden P, Korner J, et al. Conser- JP. Management of mid-season traumatic 23. Longo UG, Loppini M, Rizzello G, et al. vative treatment after first traumatic anterior shoulder instability in athletes. J Management of primary acute anterior shoulder dislocation. Chirurg 1998;69: Am Acad Orthop Surg 2012;20:518-526. shoulder dislocation: Systematic review 1230-1237. 17. Provencher M, Frank RM, Leclere LE, et and quantitative synthesis of the litera- 9. Hovelius L, Olofsson A, Sandström B, et al. The Hill-Sachs lesion: Diagnosis, clas- ture. Arthroscopy 2014;30:506-522. al. Nonoperative treatment of primary an- sification, and management. J Am Acad 24. Chapus V, Rochcongar G, Pineau V, et al. terior shoulder dislocation in patients forty Orthop Surg 2012;20:242-252. Ten-year follow-up of acute arthroscopic years of age and younger: A prospective 18. Griffith JF, Antonio GE, Tong CW, Ming Bankart repair for initial anterior shoulder twenty-five-year follow-up. J Bone Joint CK. Anterior shoulder dislocation: Quanti- dislocation in young patients. Orthop Trau- Surg Am 2008;90:945-952. fication of glenoid bone loss with CT. Am matol Surg Res 2015;101:889-893. 10. Henry JH, Genung JA. Natural history of J Roent 2003;180:1423-1430. glenohumeral dislocation--revisited. Am J 19. Bigliani LU, Newton PM, Steinmann SP,

17 th Annual WorkSafeBC Physician Education Conference Saturday, October 22 | Hotel 540, Kamloops, B.C.

Register today at worksafebcphysicians.com For more information, contact Kerri Phillips at 604.244.6192 or 1.877.231.8765 Email: [email protected]

400 bc medical journal vol. 58 no. 7, september 2016 bcmj.org billing tips

Long-term care facility visits (fee items 00114 and 00115)

he roll-out of the GPSC Resi- Common errors item 00103, 00108, 13008, 00109, dential Care Initiative repre- seen in audits 00127, 00128, 13028, 00111, 00112, Tsents a major advance in deliv- Fee item 00114 (one or multiple 00114, 00115, 00113, 00105, 00123, ering high-quality care to residential patients, per patient): 13228, or one of the 01800 series. care residents in British Columbia. • Claims exceeding the maximum of One of the expectations of the initia- one visit every 2 weeks. If the visits Fee item 00115 (nursing home visit— tive is the provision of proactive vis- are beyond the limit of one every 2 one patient, when specially called): its. However, recent audits have iden- weeks, a note stating the medical • Visits appear to be on a set day or tified some issues with the following necessity is required. the physician’s regular round day. long-term care fee items (00114 and • Billing out-of-office visits (not ap- The visit must take place within 24 00115). propriate for day visits,* after hours hours of receiving the request from only). the nursing home. This article is the opinion of the Patterns of • Physician reviewing the chart and • No evidence the physician was Practice Committee and has not been peer not seeing the patient. A face-to- specially called. Documentation reviewed by the BCMJ Editorial Board. For face patient-doctor encounter must should include who called, the time further information contact Juanita Grant, be made. called, and the medical necessity. audit and billing advisor, Physician and Ex- *The Preamble to the General Prac- Refer to Preamble D.4.9. Long- ternal Affairs, at 604 638-2829 or jgrant@ tice section of the Doctors of BC Term-Care Institution Visits for more doctorsofbc.ca. Guide to Fees states that out-of-office information. visit fees are applicable unless the —Keith J. White, MD circumstance of the service is specifi- Chair, Patterns of Practice cally covered by the definition of fee Committee

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Three BC doctors cian who serves a large number of oration with the medical community awarded Order of BC patients with multicultural back- and the citizens of British Columbia, Three BC physicians were among the grounds in Vancouver. In addition to and created a clinical research centre group of 16 civic leaders appointed his medical practice, Dr Wong has in hepatitis and liver disease. to the Order of British Columbia, the been an advocate for strong trade province’s highest honor. The Order relations with China, participating in Congratulations, Drs Yoshida, of BC recognizes persons who have a number of trade missions with all Eaves and Wong. served with distinction and excelled levels of government and serving as in any field of endeavor to benefit the a special advisor to the Musqueam Dr Michael Klein appointed people of the province or elsewhere. Nation for Asia-Pacific affairs. to the Order of Canada Dr Michael Klein has been appointed Dr Allen Eaves Dr Eric M. Yoshida as a Member of the Order of Canada. Dr Eaves is a leukemia specialist Dr Yoshida is recognized for his Recognized for his sustained contri- and founder-owner of Vancouver’s clinical care and research excellence butions to integrating family medi- STEMCELL Technologies Inc., the in liver disease. Formerly medical cine and maternity care in Canada, largest biotechnology company in director of the BC Liver Transplant Dr Klein is one of 113 recipients who Canada. Dr Eaves also founded the Program, Dr Yoshida’s work enabled earned the honor this year. Dr Klein Terry Fox Laboratory and was its dir- patients with hepatitis B to have suc- fled to Canada in 1967 after refusing ector for 25 years, and served on the cessful liver transplants, and he estab- to serve as an officer in the US Army board and as chair of Mitacs—a non- lished the first program in Canada to Medical Corps during the Vietnam profit, national research organization. provide HIV patients with the right to War and became a family physician, be allowed liver transplantation. Dr pediatrician, leading researcher in Dr Peter K.K. Wong Yoshida built a centre for excellence maternity care, and emeritus profes- Dr Wong is a community leader, busi- in liver disease that provides treat- sor in UBC’s Department of Family nessman, philanthropist, and physi- ment, research, education, and collab- Practice and Pediatrics. The Col-

Farewell to Dr Susan Haigh Welcome After 22 years Dr Susan Haigh is leav- Dr Jeevyn Chahal ing the BCMJ Editorial Board. Susan We would like to extend a joined the Board in 1994, marking the warm welcome to Dr Jeevyn first year it had more than one female Chahal, the BCMJ Editorial member. Susan represented multiple Board’s newest member. Dr constituencies during her time on the Chahal joined the Board on Editorial Board, including female 1 July 2016. physicians, medical specialists, Born in Kamloops, Dr regional urban practitioners, and (of Chahal completed her BSc course) endocrinologists. In doing so in pharmacology at UBC she always produced practical, sensi- and her MD and CCFP at tive, and commonsense opinions, and her presence at Board the University of Saskatchewan. Following gradu- meetings will be greatly missed. Susan spoke and wrote elo- ation she moved back to Kamloops to run a busy quently on behalf of patients and office support staff, show- solo family practice. Dr Chahal shares her home ing the kind of person she is. with three dogs, one cat, a baby girl, and her hus- We wish her well as she heads toward retirement, and band. She enjoys spending time with her and her we are all grateful to her for her many contributions. Hope- husband’s amazing families and wonderful friends, fully she will soon have time to make her long-planned trip tending to her hobby farm—which includes chick- to rediscover her African roots! ens—pursuing photography, running, and hiking. —BCMJ Editorial Board —BCMJ Editorial Board

402 bc medical journal vol. 58 no. 7, september 2016 bcmj.org pulsimeter lege of Family Physicians of Canada Canadian Blood Services named him as one of the Top 20 Pion- reduces restrictions Doctors of BC eers of Family Medicine Research in for blood donation 2017 awards: Canada for his research in childbirth Thousands more people may now be Seeking nominations and maternal health, and his work on eligible to donate blood following Doctors of BC is calling for routine episiotomies. His landmark recent changes to a number of Can- nominations of members in good episiotomy study, “Does episiotomy adian Blood Services deferral policies standing for either of the follow- prevent perineal trauma and pelvic and donor restrictions. The following ing 2017 awards. floor relaxation? First North Amer- notable changes are now in effect ican trial of episiotomy,” was selected across Canada: Don B. Rix Award for Physi- as one of the “ten most notable family • The upper age limit for donating cian Leadership medicine research studies in Canada” has been eliminated. Donors over Candidates for this award may by the College of Family Physicians the age of 71 no longer need to have have achieved distinction in areas of Canada. their physician fill out an assess- such as: Congratulations, Dr Klein. ment form before donating blood. • Supporting lifelong learning • Donors who have a history of most opportunities. Reminder: Apply for cancers (e.g., breast cancer, thyroid • Promoting excellence in medi- 2016–17 benefits under the cancer, prostate cancer) will be eli- cal education. Parental Leave Program gible to donate if they have been • Providing leadership for new Are you a physician practising medi- cancer free for 5 years. This change initiatives both in business and cine in British Columbia? Are you or does not apply to those with a his- clinical practice. your spouse having or adopting a baby tory of hematological cancers (e.g., • Providing leadership and ser- or planning a pregnancy between lymphomas, leukemia, melanoma). vice to the general community 1 April 2016 and 31 March 2017? • Donors who have recently received or province either by direct sup- If so, it is important to take advan- most vaccines, such as a flu shot, port or through philanthropy. tage of the Parental Leave Program, will no longer need to wait 2 days • Building consensus among phy- one of the negotiated benefits admin- before donating blood. sicians and groups of physicians. istered by Doctors of BC. In addition • Donors who were born in or lived Doctors of BC Silver Medal of to pregnancy benefits for female phy- in some African countries (Central Service sicians, the program provides paren- African Republic, Chad, Congo, Criteria for nominees include any tal benefits for male physicians and Equatorial Guinea, Gabon, Niger, of the following: adoptive parents. Benefits are payable and Nigeria) are now eligible to do- • Long and distinguished service for up to 17 weeks at the rate of 50% nate blood. HIV testing performed to Doctors of BC of eligible income up to a maximum on blood donors can now detect • Outstanding contributions to of $1000 per week. HIV strains found in these coun- medicine or medical/political For more information or an appli- tries. involvement in British Colum- cation package, contact Lorie Lynch • Geographic deferrals affecting West bia or Canada. at 604 638-2882 or llynch@doctors ern Europe have been revised based • Outstanding contributions by a ofbc.ca, or Ann Marie O’Driscoll at on scientific evidence that indicates layperson to medicine or to the 604 638-2865 or aodriscoll@doctors the risk of variant Creutzfeldt-Jakob welfare of the people of British ofbc.ca. disease has decreased since January Columbia or Canada. 2008. Donors who spent 5 years or more in Western Europe since 1980 Closing date for nominations is Did you know? are deferred from donating blood, 30 November 2016 at 11:59 p.m. Within the last year family doc- but Canadian Blood Services is now For more information, visit www. tors have participated in more including an end date of 2007. Do- doctorsofbc.ca/resource-centre/ than 3400 PSP service offer- nors who reached the 5-year limit in awards-scholarships. ings. To learn more about how Western Europe after 2007 will now the Practice Support Program’s be eligible to donate blood. suite of services can help doc- The complete policy changes are tors build capacity in their prac- available at www.blood.ca/en/blood/ tices, visit www.pspbc.ca. recent-changes-donation-criteria. Continued on page 404

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Continued from page 403 available online at www.nature.com/ of depression in children and adoles- New donors who have never been sc/journal/v54/n1s/full/sc201688a cents accurately screen 6- to 18-year- screened can book an appointment .html. olds for the disease. Researchers online at https://blood.ca/en/user/ The Ontario Neurotrauma Foun- believe this calls into question the register, call 1-888-2DONATE, or dation and Rick Hansen Institute pro- use of these assessment tools for this visit a clinic. vided funding for the research study. group and raises worries about possible misdiagnosis of the disease in this First clinical guidelines in Seniors with undiagnosed age range. Canada for pain following hearing loss can To assess the quality of the screen- spinal cord injury become isolated ing tools that are currently being used Researchers at Lawson Health Re- UBC Okanagan researchers exam- to identify depression in children or search Institute in Ontario have de- ined the impact of undiagnosed or adolescents, researchers carried out a veloped clinical practice guidelines untreated hearing issues in seniors search of the medical evidence look- for managing neuropathic pain with age 60 to 69. The study found that ing for studies that put the screening patients who have experienced a for every 10-decibel drop in hearing tools to the test. They identified only spinal cord injury. The research team sensitivity, the odds of social isolation 17 studies where the test results from worked with care providers at Park- increased by 52%. Among the sample the screening tools were compared wood Institute, part of the St. Joseph’s of seniors, a 10-decibel reduction of with results from a diagnostic inter- Health Care London family, and an hearing sensitivity was also associ- view to determine if the children or international panel to address the ated with cognitive declines equiva- adolescents in the study actually had unique challenges for managing pain lent to almost 4 years of chronological depression. during recovery and rehabilitation. aging. Lead author Dr Michelle Rose- Dr Eldon Loh, Lawson researcher Lead author Dr Paul Mick is a man, who is affiliated with the Jewish and physical medicine and rehabili- physician and clinical assistant pro- General Hospital’s Lady Davis Insti- tation specialist at St. Joseph’s, and fessor at UBC’s Southern Medical tute for Medical Research in Mon- his team recognized that pain can be Program. The study examined data treal, and colleagues then assessed an overlooked part of a spinal cord collected between 1999 and 2010 the methodology and results of these injury and plays a major factor in the by the National Health and Nutrition 17 studies. They found that most of success of rehabilitation. The results Examination Survey, a survey that the studies were too small to make a of the 3-year process led to recom- samples 5000 people each year across valid determination about the accu- mendations for screening and diag- the United States. The survey exam- racy of the screening tools and that nosis, treatment, and models of care. ined demographic, socioeconomic, the methods of most studies fell short Important clinical considerations dietary, and health-related issues. Dr of expected standards. They also accompany each recommendation. Mick would like to expand his re- found that there was inadequate evi- The research will inform new tools search to see if interventions such as a dence to recommend any single cutoff and resources for care providers and hearing screening program similar to score for any of the questionnaires. patients. what is done for young children could (Patients scoring above a pre-defined The new guidelines have been positively impact health outcomes for cutoff score are considered likely to published in Spinal Cord and are Canadian seniors. be depressed, whereas patients below The study, “Is hearing loss asso- the cutoff are not.) ciated with poorer health in older Researchers suggest that, given Doctors of BC Annual adults who might benefit from hear- the inaccuracy of the tools currently Report survey, winner ing screening?” was published in being used, some children could end Congratulations to Dr Katharine the May/June 2016 issue of Ear and up mislabeled as depressed, and that McKeen of Victoria, winner of the Hearing. large, well-designed studies that pres- Doctors of BC 2015–16 Annual ent results across a range of cutoff Report survey contest. By com- Depression screening scores are needed to properly assess pleting a brief survey Dr McKeen tools not accurate for the accuracy of depression screening was entered into the draw and won children and adolescents tools in children. a free night at the Pan Pacific Van- According to new Canadian research, The study, “Accuracy of depres- couver, including breakfast for there is insufficient evidence to show sion screening tools to detect major two in Oceans 999. that the various short questionnaires depression in children and adolescents: physicians use to ask about symptoms Continued on page 406

404 bc medical journal vol. 58 no. 7, september 2016 bcmj.org CMA fighting for fairness in federal tax proposals

CMA is pressing to ensure federal budget proposals do not undermine group medical structures and by extension health care delivery. Learn more and register for a webinar.

CMA. Action that matters. Get involved and make an impact. cma.ca/action | #CMAaction #CDNtaxes

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 405 pulsimeter

Continued from page 404 Department of Psychiatry, identifies older adults didn’t show the same A systematic review,” is published in that a key question in current memory level of visual cortex activation when the May 2016 issue of the Canadian research concerns which changes to they recalled the information. Instead, Journal of Psychiatry. the aging brain are normal and which their medial prefrontal cortex was The research was supported by are not, and that most of the work on activated. the Canadian Institutes of Health aging and memory has concentrated Even though middle-aged and old- Research, the Arthritis Society, the on understanding brain changes later er participants didn’t perform as well Mach-Gaensslen Foundation of Can- in life. This research was aimed at ad- as younger ones in this experiment, Dr ada, and a Murray R. Stalker Primary dressing what happens at midlife in Rajah suggests that it may be wrong Care Research Bursary. healthy aging and how this relates to to regard the response of the middle- findings in late life. aged and older brains as impairment, Middle-age memory decline In the study, 112 healthy adults but rather that it may reflect changes a matter of changing focus ranging in age from 19 to 76 years in what adults deem important infor- According to a study by McGill Uni- were shown a series of faces and mation as they age. Researchers also versity researchers, the inability to were asked to recall where a particu- concluded that middle-aged and older remember details that begins in early lar face appeared on the screen (left adults might improve their recall abil- midlife (the 40s) may be the result of a or right) and when it appeared (least ities by learning to focus on external change in what information the brain or most recently). Researchers then rather than internal information. focuses on during memory formation used functional MRI to analyze which Dr Rajah is currently analyzing and retrieval, rather than a decline in parts of brain were activated during data from a similar study to discern brain function. recall of these details. if there are any gender differences Senior author Natasha Rajah, di- Dr Rajah and colleagues found in middle-aged brain function as it rector of the Brain Imaging Centre at that young adults activated their visu- relates to memory, noting that women McGill University’s Douglas Institute al cortex while successfully perform- go through a lot of hormonal change and associate professor in McGill’s ing this task, while middle-aged and at midlife. The question is, how much of these results is driven by post- menopausal women? The study, “Changes in the modu- lation of brain activity during context encoding vs. context retrieval across the adult lifespan,” was published in the October 2016 issue of Neuro Image. This research was supported by the Canadian Institutes of Health Research and by a grant from the Alzheimer’s Society of Canada.

Half of patients with depression are inadequately treated UBC research shows that about 50% of British Columbians with depression are not receiving the basic level of care, and authors say the findings highlight the challenges of accessing mental health services across Canada. It is estimated that 1 in 20 people experience depression each year. Joseph Puyat, a PhD candidate in UBC’s School of Population and Public Health and a research meth- odologist at the Centre for Health

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Evaluation and Outcome Sciences, monitoring system that could one Correction: Dr Erik and his colleagues reviewed health day replace blood draws and improve Paterson, 1941–2016 data from almost 110 000 British patient comfort. The system consists Dr Paterson’s year of graduation from Columbians diagnosed with depres- of a small thin patch that is pressed the University of Glasgow School of sion by physicians between 2010 and against a patient’s arm during medi- Medicine was incorrectly listed as 2011, and examined whether these cal treatment and measures drugs in 1960 in the In Memoriam piece pub- individuals received either one of the the bloodstream painlessly without lished in the BCMJ [2016;58:319- two recommended treatment options: drawing any blood. The tiny needle- 320]. Dr Paterson graduated from antidepressants or psychotherapy. like projection, less than 0.5 mm long, medical school in 1966. They found that only 13% of people resembles a hollow cone and doesn’t received at least four psychothera- pierce the skin like a standard hypo- Canadian technology py or counseling sessions and 47% dermic needle. uses speech to track received antidepressant medication Researcher Sahan Ranamukhaa Alzheimer disease for at least 12 weeks. Overall, about rachchi, a PhD student and Vanier A new technology that analyzes a 53% received the minimum threshold scholar in UBC’s Faculties of Ap- person’s natural speech to detect and of treatment. plied Science and Pharmaceutical monitor Alzheimer disease and other Researchers believe that their Sciences, developed this technology cognitive disorders won the AGE- findings underestimate the full extent during a research exchange at PSI. WELL Pitch Competition: Technol- of the problem since many people do Microneedles are designed to punc- ogy to Support People with Demen- not seek or receive a diagnosis for ture the outer layer of skin, but not tia. The tablet-based assessment tool their depression because of issues the next layers of epidermis and the records short samples of a person’s around stigma or access to a physi- dermis, which house nerves, blood speech as they describe a picture on cian. Mr Puyat compared these find- vessels, and active immune cells. the screen and extracts hundreds of ings to results from the Statistics The microneedle created by Mr variables from the samples. Canada 2012 Canadian Community Ranamukhaarachchi and his col- Because of word-finding diffi- Health Survey and found that the BC leagues was developed to monitor culties, people with Alzheimer dis- data are comparable. In the national the antibiotic vancomycin, which is ease will tend to pause more between survey, 4 out of 10 Canadians who used to treat serious infections and is words and the complexity of their struggle with depression indicate administered through an intravenous vocabulary is reduced. The technol- they are not accessing any services line. Patients taking the antibiotic un- ogy uses artificial intelligence to to treat depression. He suggests that dergo three to four blood draws per analyze about 400 variables, such as provinces need to look at the services day and need to be closely monitored pitch, tone, prosody (rhythm), and covered for mental health and how because vancomycin can cause life- rate of speech, as well as pauses and patients access care (e.g., Canadians threatening toxic side effects. Re- choice of words. In the laboratory, the only receive public health coverage searchers discovered that they could software can reliably identify Alz- for counseling from medical doctors, use the fluid found just below the out- heimer disease, Parkinson disease, yet many family physicians don’t er layer of skin, instead of blood, to and aphasia with between 85% and have the time or training to provide monitor levels of vancomycin in the 100% accuracy. counseling services). bloodstream. The microneedle col- Researchers are set to begin field The study, “How often do indi- lects less than a millionth of a mil- tests in assisted living and home care viduals with major depression re- lilitre of fluid, and a reaction occurs settings. The tool will be used in sen- ceive minimally adequate treatment? on the inside of the microneedle that iors’ facilities to improve ongoing A population-based, data linkage researchers can detect using an opti- monitoring of residents’ cognitive study,” was published in the July cal sensor. This technique allows re- health, provide family members with 2016 issue of the Canadian Journal searchers to quickly determine the quantifiable updates, and help people of Psychiatry. concentration of vancomycin. plan when it’s time to transition to a The microneedle monitoring higher level of care. Scientists develop system is described in a paper pub- Liam Kaufman, CEO and co- microneedle system lished in the July 2016 issue of Sci- founder of Winterlight Labs, devel- to monitor drugs entific Reports, “Integrated hollow oped the tool with Dr Frank Rudzicz, Researchers at UBC and the Paul microneedle-optofluidic biosensor Maria Yancheva, and Katie Fra- Scherrer Institut (PSI) in Switzerland for therapeutic drug monitoring in ser of the University of Toronto. Dr have created a microneedle drug- sub-nanoliter volumes.” Continued on page 409

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 407 bc centre for disease control

Influenza vaccine in pregnancy: Is it safe?

nfluenza vaccine has been admin- humoral immunity from the mother in proach to use of vaccines in pregnan- istered to pregnant women since utero, and indirectly through cocoon- cy and over two decades of recom- Ithe 1950s, initially to those with ing by immunization of close house- mendations for influenza vaccination high-risk medical conditions such hold contacts and caregivers. Direct in pregnancy mean that much of the as chronic heart or lung disease and protection by infant vaccination is data on influenza vaccine safety in later to health care workers. Since not achievable with current vaccines pregnancy originate from observa- the 1990s, use in pregnancy has been prior to 6 months of age. tional studies, including database expanded more broadly in many reviews and postmarketing surveil- countries in recognition of the risk of lance, instead of randomized trials; influenza-related complications and nevertheless, these have concluded Inactivated influenza benefits to both mother and infant, that influenza vaccine is safe during with even higher rates of use in vaccine is recommended pregnancy, including multidose prod- pregnancy during the 2009 A/H1N1 for all pregnant women at ucts containing thimerosal as a pre- pandemic because of severity of the any stage of pregnancy servative.8-10 Additionally, many more infection in pregnancy. In the United during the influenza recent studies have been conducted States, influenza vaccine coverage in season, typically from and several reviews of the literature pregnant women has exceeded 50% have been published since 2009, as- November through April since the 2009–10 season,1 and while sessing both 2009 pandemic A/H1N1 seasonal uptake data in pregnancy each year. and seasonal inactivated influenza are not available in Canada, coverage vaccines. These studies and reviews among pregnant women in BC dur- have examined the occurrence of pre- ing the 2009 pandemic A/H1N1 cam- Historically, both drugs and vac- term birth, fetal death, stillbirth, spon- paign was 54%. cines have been used sparingly in taneous abortion, and congenital mal- Inactivated influenza vaccine is pregnancy. Avoidance of vaccines formations.11-13 These reviews have recommended for all pregnant wom- has been largely based on theoreti- found an overall lack of association en at any stage of pregnancy during cal concerns about teratogenicity of between influenza vaccine receipt the influenza season, typically from live vaccines such as rubella and vari- and adverse pregnancy outcomes, November through April each year.2,3 cella, which have not been borne out. and physicians can confidently reas- Benefits include maternal protection A secondary consideration for avoid- sure pregnant women about safety of against influenza-associated morbid- ing vaccines has been that an anom- influenza vaccines in pregnancy. Re- ity, including hospitalization for car- aly will be misattributed to vaccine, view authors commented on the need diopulmonary complications, the rate especially if received in the first tri- to define standards for future studies of which progressively increases with mester. Influenza vaccination during of vaccine safety in pregnancy to en- duration of the pregnancy and is max- pregnancy is associated with a brief sure consistently defined end points; imal in the third trimester. Maternal increase in maternal inflammatory for instance, fetal death was variably immunization is also associated with biomarkers, but this response is not defined in studies at gestations rang- reduced risk of influenza and associ- associated with fetal development and ing from over 12 to over 25 weeks or ated hospitalization of the infant, and risk of congenital anomalies.5 At its over 500 grams. To this end the US infants born to vaccinated women June 2013 meeting, the World Health National Institutes of Health con- have lower rates of prematurity, low Organization Global Advisory Com- vened an international consensus con- birth weight, and being small for their mittee on Vaccine Safety concluded ference on harmonized safety moni- gestational age.4 Protection of the in- from their review of vaccine safety toring of immunization in pregnancy fant occurs through two mechanisms: in pregnancy that there is no evidence in late March 2016. Development of directly through passive transfer of of adverse pregnancy outcomes from standards should pave the way for vaccination in pregnancy with inac- more consistent reporting of results This article is the opinion of the BC Centre tivated virus (including influenza), from future studies, including pool- for Disease Control and has not been peer bacterial, or toxoid vaccines.6,7 ing of results for meta-analyses. This reviewed by the BCMJ Editorial Board. The historical precautionary ap- is increasingly important because of

408 bc medical journal vol. 58 no. 7, september 2016 bcmj.org bccdc Doctors of BC Board Officers & Delegates 2016–17 greater future use of vaccines in preg- data. Vaccine 2016;pii:S0264-410X(16) nancy beyond influenza, including 30030-5. President Alan Ruddiman for prevention of pertussis, group B 6. World Health Organization. Global Advi- Past President Charles Webb streptococcal disease, and respiratory sory Committee on Vaccine Safety, 12-13 President-Elect Tina Larsen-Soles syncytial virus infections. June 2013. Wkly Epidemiol Rec 2013; —Monika Naus, MD, 88:301-312. Chair of the 7. Keller-Stanislawski B, Englund JA, Kang General Eric Cadesky MHSc, FRCPC Assembly Medical Director, Immunization G, et al. Safety of immunization during Honorary Programs and Vaccine Preventable pregnancy: A review of the evidence of Secretary David Wilton Diseases Service selected inactivated and live attenuated Treasurer vaccines. Vaccine 2014;32:7057-7064. Chair of the Mark Corbett References 8. Tamma PD, Ault KA, del Rio C, et al. Safe- Board 1. Groom HC, Henninger ML, Smith N, et al. ty of influenza vaccination during preg- District #1 Robin Saunders Influenza vaccination during pregnancy: nancy. Am J Obstet Gynecol 2009;201:547- Influenza seasons 2002-2012, Vaccine 552. District #1 David Harris Safety Datalink. Am J Prev Med 2016; 9. Bednarczyk RA, Adjaye-Gbewonyo D, District #1 Eugene Leduc 50:480-488. Omer SB. Safety of influenza immuniza- District #2 Robin Routledge 2. BCCDC. Communicable disease control tion during pregnancy for the fetus and the manual. Chapter 2, Immunization. Section neonate. Am J Obstet Gynecol 2012;207 District #2 Anthony Booth VII, Biological products. Accessed 3 Au- (3 suppl):S38-46. District #3 Lloyd Oppel gust 2016. www.bccdc.ca/health-profes 10. Munoz FM. Safety of influenza vaccines sionals/clinical-resources/communicable in pregnant women. Am J Obstet Gynecol District #3 Joanne Young -disease-control-manual/immunization. 2012;207(3 suppl):S33-37. District #3 Alex She 3. National Advisory Committee on Immuni- 11. Fell DB, Platt RW, Lanes A, et al. Fetal District #3 Brad Fritz zation (NACI). Public Health Agency of death and preterm birth associated with Canada. An advisory committee state- maternal influenza vaccination: System- District #3 David Kendler ment (ACS). Canadian immunization atic review. BJOG 2015;122:17-26. District #3 Vanessa Breie guide chapter on influenza and statement 12. McMillan M, Porritt K, Kralik D, et al. Influ- on seasonal influenza vaccine for 2016- enza vaccination during pregnancy: A sys- District #3 Geoffrey Ainsworth 2017. Accessed 3 August 2016. www tematic review of fetal death, spontane- District #4 Tommy Gerschman .phac-aspc.gc.ca/naci-ccni/flu-2016 ous abortion, and congenital malformation District #4 Neigel Walton -grippe-eng.php. safety outcomes. Vaccine 2015;33:2108- 4. Zaman K, Roy E, Arifeen SE, et al. Effec- 2117. District #5 Vacant

tiveness of maternal influenza immuniza- 13. Bratton KN, Wardle MT, Orenstein WA, District #6 Jeffrey Dresselhuis tion in mothers and infants. N Engl J Med Omer SB. Maternal influenza immuniza- 2008;359:1555-1564. tion and birth outcomes of stillbirth and District #7 Yusuf Bawa 5. DeSilva M, Munoz FM, Mcmillan M, et al. spontaneous abortion: A systematic re- District #7 Peter Barnsdale Congenital anomalies: Case definition and view and meta-analysis. Clin Infect Dis District #8 Jacob (Jack) Kliman guidelines for data collection, analysis, 2015;60:e11-19. and presentation of immunization safety District #9 Jannie du Plessis

District #10 Barbara Blumenauer

District #11 Dan Horvat

pulsimeter District #12 Vacant

District #13 Alan Gow Continued from page 407 Rudzicz is also a scientist at Toronto Ten teams from Canada and District #13 Vacant Rehab-University Health Network. around the world competed in the District #14 Cheryl Hume Regulatory approval will be sought AGE-WELL Pitch Competition, in Canada and the United States to which showcased a variety of tech- District #15 W. Fraser Bowden make the technology available to nology solutions that address the District #16 Jasper Ghuman family doctors and speech-language challenges faced by people living pathologists. with dementia. District #16 Sanjay Khandelwal

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 409 special feature

Q&A with Dr Alan Ruddiman: Doctors of BC President 2016–17

Dr Ruddiman has practised full-service rural generalist medicine in the Okanagan Valley for the past 20 years. He lives and works in Oliver. BCMJ associate editor Joanne Jablkowski spoke with Dr Ruddiman 1 month into his presidency about his background, life experiences, and his ideas for the future of health care in BC. Here is a condensed version of their conversation. By Joanne Jablkowski Photo: Lionel Trudel Photography Ltd.

Your parents are originally from to bring their talent, come overseas, there was a one-party state in the Scotland. What took your family to build a new life—and my parents saw country, and the ruling government South Africa when you were young? opportunity in that. had been in power since 1948. So, It was opportunity. In the 1960s Brit- What ended up selling them on having come from a country where ain was going through significant South Africa was that the embassy you could promote yourself based change and the shipbuilding industry staff did a really good job promot- on your skills and abilities, in South in Scotland was starting to decline ing the fact that if you came to South Africa one was very confronted by rapidly as the world was shifting to Africa as a young immigrant couple the class system, part of the colonial a global economy. My parents were and were hardworking there was no legacy. a young couple at the time, with two ceiling to what you could achieve. My parents raised us to recognize boys—me and my younger brother— We were very privileged to move that we were going to be confronted and they wondered what opportuni- to South Africa while the country was by apartheid, but to be careful where ties would be available for young going through some transformative we raised questions, explaining that men in the country if the main indus- and difficult changes, and to have everything was not as it appeared. try was starting to tank. At the same been part of that history and change We had access to a wonderful edu- time the colonies were advertising for was phenomenal. cational system, and I have to say talent from Great Britain—places like that in the ’60s, ’70s, and ’80s, South Canada, South Africa, New Zealand, How do you think that environment Africa probably offered its citizens Australia had very active embassies in shaped your interests? one of the most reliable and complex the UK at that time, recruiting people When we arrived in the late 1960s education systems in the world, even

410 bc medical journal vol. 58 no. 7, september 2016 bcmj.org special feature though there was a significant dispar- When I started practising in Moose working in hospitality and the hotel ity in who had access to education at Jaw, Saskatchewan, even as a new industry, and our youngest is doing that time. entrant to Canada who could speak the a science degree at UBC at the Oka- After high school I selected a uni- language and was pretty well versed nagan campus. versity where race was not considered on the culture, I was confronted by as an access point, and Wits Univer- how different medicine appeared What is the best advice you were sity prided itself on challenging the to be. In South Africa people would ever given? government that there needed to be arrive at hospitals or community clin- My dad was a wonderful mentor. freedom of access to postsecond- ics with sometimes very pressing He left school at 16 with a grade 10 ary education. That was a wonderful health issues; the disease processes education and he said to me on many breeding ground for my activism and were sometimes very advanced. We occasions, “Alan, in knowledge there formed the qualities that framed my were faced with the whole spectrum is power.” He also provided me with leadership profile. of what medicine could present to an appreciation that talent comes young doctors. through hard work and application— After you earned your medical In my Canadian community clinic thousands of hours spent doing the degree in South Africa in the 1980s, I didn’t see that same spectrum of nas- same thing produces expertise. what prompted your move to ty diseases. There were more nuances Canada? to medicine here. People presented Tell me about your life in Oliver. Most people will probably antici- much earlier in the context of their ill- How do you like to spend your pate that I chose to move because of ness. The person sitting across from time? the challenging political situation. me in the clinic would often look very, It’s very busy, but balanced. Hav- It wasn’t that; it was the challenging very well, as opposed to the sick, ill, ing grown up in a family that valued economy. Interest rates were phenom- and injured people that I had seen as the outdoors, I’ve always embraced enally high. When I graduated from part of my training in South Africa. experiencing what the world can give medical school the interest rate on a us. Not all rewards have to be mon- credit card was something like 32% You have two daughters who are etary. We were an outdoor family—in per annum. Interest rates on a mortgage now developing their own career South Africa it’s called caravanning, were in the double digits. And I had a paths. What advice do you give here it’s RVing—and when looking sizable student loan—I came from a them about how they should shape at where I’d like to live and work in blue collar working family, so my fam- their futures? Canada, the Interior of BC, and par- ily didn’t finance my education. My We traveled a lot with the girls when ticularly the South Okanagan, most dad co-signed my student loan and I they were young and we’ve given closely represented the climate and accumulated that debt through 6 years them, I hope, a broad global perspec- geography that I was familiar with of medical school and then through tive on how small this planet really from my childhood. my internship and residency, so I was is, how closely connected we are as Also, because I trained at a gen- really motivated to clear my debt human beings, and that we can all eralist hospital—even though I had before I decided what my medical serve in different ways. We didn’t aspirations when I was younger to career was going to look like. raise either of our daughters to con- specialize in internal medicine or Speaking to others, Canada sider medicine or teaching, which is anesthesia—when I came to Can- seemed very welcoming to South my wife’s profession, as being the ada I embraced rural life and I felt I African–trained physicians and other only two ways of serving society and could contribute more by living and international medical graduates, and having social accountability. And it working in a rural community than it didn’t take long before I found a shows in their behaviors. They value I could in an urban or metropolitan locum opportunity on the Prairies. service; they’re connected to society. community. I think service is really The idea was to earn enough within 6 My youngest daughter is definitely important—caring about your neigh- to 12 months that I could clear my stu- the most environmentally responsible bor, caring about the health of your dent debt and decide what my medical person in our family. I think we’ve community, not just one patient at a career would look like after that. done a really good job in allowing our time as a family doctor or specialist girls to embrace diverse thought. might encounter in their practice, but Do you have a memory from your We look forward to seeing what thinking beyond that and being curi- first days in Canada that made an careers they will choose. They have ous about what can make your com- imprint on your professional direc- unique personalities and are going munity more vibrant. tion? in different directions—our oldest is Continued on page 412

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Continued from page 411 could be problematic and pointed me If I can look back on my career What life lessons stand out to you toward debating. I was never a good one day and say that my community from traveling with your family? public speaker, it was certainly one of is more vibrant because of my pres- We’ve tried to raise our girls to appre- my phobias in high school, and my ence and the influence I’ve had, then ciate that we live in a society that is dad recognized that to be a confident I’ll be a very happy professional when based on consumerism, in the first person you have to be able to share I retire. world, and whether it’s the consump- your views and opinions. tion of information or the overcon- I considered law as a career in As an avid sailor, what is your sumption of food, or having to keep high school as well. Though because dream sailing trip? up with the Joneses and have the best, the legal system is based on Dutch We’ve lived the dream. Since the girls those shouldn’t be values that drive Roman law in South Africa, my dad were very young Christina and I talk- us to feel that we’ve lived a complete saw that as being limiting if I ever ed about taking a year off for a sab- life. The bigger question we should wanted to work in other jurisdictions, batical, and when our girls were 14 all be asking is, when I look back, am and we had many good evenings ban- and 16 we did it. I going to know that I left the world in tering about what life could look like With a lot of thoughtful planning, a better place than when I entered it? and what a career could look like. we bought a boat in Florida and sailed My measure of a satisfying life And it was at that point that I started for a year—down the East Coast of is the answer to, have I valued the to reflect more on my mother’s val- Florida, we crossed the Gulf Stream people I have relationships with, and ues—she was a registered nurse. In of the Atlantic (some of the most diffi- do they value me? I think you’ve truly talking to my mum, and recognizing cult waters for sailors to cross because lived when you’re no longer anonym- there were a few doctors in our family the weather can be really unexpect- ous, when you have a connectivity lineage, I started to think more about ed), and then we landed in the Baha- within your community, and when medicine as a way of defining who I mas. There are 600 to 800 islands in you’re recognized for your work and was as a professional. And boy has it the Bahamas, and when you get out your efforts. ever turned out well. to the outlying islands you start to experience what living and working Do you have any other interests that So that explains how you acquired in the Caribbean can be like. could have swayed you to follow a your interest in medicine, or is there We lived aboard the boat for a career path other than medicine? more to that story? year. The girls were excellent crew My father had a strong and profound It goes further back than that. I often members. And the fact that we influence on me. Those who know think about whether medicine selects could all take responsibility for one me know I love telling a good story, the individual, or whether the individ- another’s well-being and safety and I love debate, and I love being pro- ual selects medicine. the wholesomeness of what we were vocative in terms of questioning the When I was in elementary school doing was fantastic. Whether it’s for 3 conventional ways of doing things or my very best friend’s father was the months or a year, I encourage all my the traditional values and views that principal, so I really admired the colleagues to consider taking a sab- society holds. family. My friend James and I did batical. It’s energizing to disconnect I also have a few health issues, everything together, and when he from the day-to-day routines that put one of which is that I was born with declared early on that he wanted to such significant demands on us. You a lazy eye, or strabismus, which was be a doctor I thought, you know what, get a chance to reflect on where you corrected through surgery when I was James wants to be a doctor, I’ll be a are in your career, your profession- young, but I’ve been challenged with doctor too, that will be a great thing to alism, to consider if you are serving my vision in the affected eye. In my do. And that stuck in my brain. in the way that you were attracted to high school it was expected that you While I was debating what my life medicine to be able to do, what parts participate in sporting activities, and would look like with my father, that of your career you are finding reward- the way that you demonstrated your thought reoccurred, and I decided to ing, what the challenging areas are. It sporting prowess at a boys-only high stick with what I had originally signed was a really good introspective year. school was to play something like up to do. In the end, James became a As a mid-career physician, I could rugby or cricket. And I wanted to pur- teacher, like his father, and I became reflect on what I would like to do sue that, but because of my eye dis- the doctor. moving forward, and to identify what ability my dad suggested I think about I think most doctors have such was truly important to me and what other activities. He knew that get- a defining moment in their life—an else could I do to support society. ting hurt and damaging my good eye experience as a child, or a circum-

412 bc medical journal vol. 58 no. 7, september 2016 bcmj.org special feature stance where the idea of medicine as rural health care leadership in BC and cial voice, and the federal Minister a potential future career shows up, a has been foundational in creating the of Health is also a doctor. This is an moment from which their desire to space for my voice to come forward excellent chance for the association to want to help others stems. for the entire profession in BC. As a invest its energies in being part of a true friend, Granger has taught me to national conversation. Do you have any professional lead with a respect for all colleagues, heroes? specialists and GPs. The so-called Can you tell me about a pivotal They shift and change throughout divide between generalists and spe- time in your career? life. One of my early heroes in medi- cialist shouldn’t exist, and it’s going On one Sunday morning in 2002 I cine was my professor of anatomy to be one of my challenges this year was the emergency department doc- at the University of Witwatersrand, to see if we can enhance the conversa- tor at my local rural community hos- Phillip Tobias. He was also a pal- tion about uniting the medical profes- pital in Oliver, and I was Doctor of the aeoanthropologist, and I remember sion in BC. Day, so I was covering all the patients one of the defining lectures he gave We have a huge opportunity to in hospital on behalf of my colleagues in medical school. He took us to a seek system improvements in BC this who had the weekend off. There was a cave west of Johannesburg called the year. We are hosting the CMA Gen- page over the hospital intercom—“Dr Sterkfontein Caves, where the earli- eral Council, where Dr Avery is to be Ruddiman to the emergency depart- est human hominids were discovered, inducted as the national president, our ment, stat!” I gave up my duties at the and he stood there, lecturing to 240 own association has a strong provin- Continued on page 414 young medical students while hold- ing a skull in his hands. That vision is embedded in my brain. He had a very gentle voice, he was very well respected in South Africa and by the international medical community, and I thought, wow, if someone from our university can command that much respect, then I should really embrace my own career. It was a principle- defining moment for me. Dr Anna Reid stands out for me in the context of Canadian health care. Dr Reid, who is a past president of the CMA, is a humble leader who has proven that women can put their footprint on service and leadership in medicine. And we need more women leaders in health care, both in BC and in Canada. I look too to the Honourable Jane Philpott, our federal Minister of Health. She’s got an incredibly pow- erful life story. She spent time practising medicine and doing volunteer work in Africa and, unfortunately, lost a young child to a treatable illness simply because there weren’t enough resources available locally when they were needed. The other person whose career I’ve admired and who has been a fantastic mentor to me is Dr Granger

Avery. Granger welcomed me into Photo: Lionel Trudel Photography Ltd.

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Continued from page 413 of health. It’s not always about health what the health care system can do nursing station, ran down the hall, and care. I think health care is only respon- to support them. The one thing I’ve ran into my wife. As soon as I saw her sible for about a quarter of what makes been delighted to have established I thought, on no, there’s something people sick. A bigger component is in my practice is the opportunity to wrong with one of our daughters, I’m the life that people have—where they have conversations around end-of- the emergency doctor, this is going to live, what level of income they have, life and advanced-care planning with be horrible. And she said, “Alan, I want what kind of education they have, the my patients. Where we have pres- you to take a big breath. Your dad has early childhood development they sure sometimes is from family mem- come into the emergency department were exposed to, whether they live bers, children, grandchildren who with crushing chest pains.” I think to with a disability. Of course, whether don’t embrace the values that elderly administer one’s skills to a member you have access to health care and patients express about how they want of your community is already some- whether you have acute or chronic ill- to be cared for when they’re con- times not at arm’s length—you know ness is really important, but genetics fronted with an incurable disease or a lot of the people socially, your kids also comes into play. Did you inherit illness, or simply when they get to a play together—but to be called upon good genes from your parents? place in life where they feel that they to administer care to your father when The other piece that I’m becom- have reached the end. he’s having a heart attack, for me, ing more aware of is the damage That is a societal conversation that helped shape where I needed to that’s being done to our planet and we have to have. Instead of always provide advocacy. We need the right the related health issues. We have a deploying maximal resources and the resources across all of our commun- huge responsibility as doctors to exer- most specialized care options, which ities across BC—metropolitan, rural, cise our professional voice on issues may be futile, we should be asking, urban, and remote. of social determinants of health. The what can we do to support you to have I activated all the protocols I would Council on Health Promotion has the best quality of life at this point in for any other patient, but to have to done stellar work over the years to your life? My elderly patients have deliver emergency medical care to my highlight areas where doctors can helped and educated me to become an father was a sobering reminder that if advocate for social changes that can advocate in that regard. I hadn’t embraced all the generalist produce health. It shouldn’t just be pieces of being a family doctor my dad about managing sickness. Do you find that’s a difficult shift may not have had an opportunity that for doctors? day to receive the best care. I’m for- Have your patients’ expectations I think we have to be careful in how tunate to have had a great team—all changed as well? we characterize medicine. A fulfill- the nurses were phenomenal—and I The family practice I inherited almost ing medical career as a specialist or called a colleague in as soon as could. 20 years ago was from a doctor who a general family physician isn’t about I didn’t want to be the person respon- had been the family doctor for these saving all lives all the time, it’s about sible for my dad’s success or failure patients for 20 to 30 years, so the making a fundamental difference in with his acute health crisis, but I’m average patient was in their early- to the life of the person sitting in front sure glad that I was trained to admin- mid-60s. Jumping forward 20 years, of you when they’re confronted by ister the care that he needed while I got my latest practice profile tells me that acute or chronic illness. We shouldn’t the rest of the team together. my average patient is now 76 years be in the business of simply focusing There are communities across the old. So I’ve got a 20-year relationship on saving lives, we should be focus- province where patients present every with people who have, for the most ing on making a difference in the lives day with pressing medical needs, and part, moved into the later part of their of the people we encounter as part of to not have skilled professionals in lives. When I have interviews with this wonderful profession. those communities to deliver care to these patients I hear the most pro- those people when they need it would found and provocative things because What do your patients think of simply be underservicing British Col- these people have lived sometimes your role as president? umbia. very full lives, and their expectations I have developed relationships with and understanding of what it means my patients over the past 20 years— How has your role as a general to have a healthy life is very different and many of them are now individu- practitioner evolved since you from the opinion of someone who is als who are closer to the end of their started practising? 20. Elderly people are very clear on life than to the part of their life when What’s evolved is a deeper under- how they want their care delivered. they were most productive—so for standing for the social determinants They have very well-shaped ideas on me to be absent from my community

414 bc medical journal vol. 58 no. 7, september 2016 bcmj.org special feature multiple times per week is quite chal- going through profound change, I feel My biggest concern would be that we lenging for them. I’m very fortunate a little disappointed and embarrassed promote sub- and superspecializa- to have a young female physician that I didn’t do more in terms of activ- tion as the only ways to derive satis- locum, a recent graduate from the ism for change in the country. I was faction from a medical career. We’re UBC family medicine program, who politically active, but I didn’t do it in very privileged to gain a world-class, embraces the same values that I do, is as brave a way as I probably could strong, scientific education in Canada, very professional, is a generalist phy- have concerning the social injustices and we don’t want to dilute that sci- sician, and has made a commitment to that were occurring in the country. entific capital by gaining a significant supporting me in my practice and my My parents raised us to question what medical education and then stream- patients for the year. I feel reassured appeared to be the real world—how ing off into a superspecialized area. knowing there are colleagues like law was applied, how a large portion I don’t think that serves society well. my locum who are willing to step up, of society was disadvantaged—and When it comes to serving individual though I do know there is angst within considering the empathy that was patients, communities, regions of the my patients about when I’m going to generated in our home I’m disap- province I think it’s the generalism in be in the office next. I’m back filling pointed in myself when I think back. medicine that needs to be promoted in my practice right now for when my as the primary way that we invest our locum is away and when there are oth- Having taught Family Medicine R1 energies as taxpayers and as society er gaps in coverage to make sure I can residents in their family medicine looking after the health care needs of continue to practise clinical medicine. rotation, what is your impression our populations. of the challenges that medical stu- Could you tell me about a personal dents and residents face today? What health care issue do you think achievement that stands out for you? They’re coming into medicine at a is not getting enough attention right There are many moments that have time when so many changes are oc- now? made me smile. Being recognized by curring—just the exponential growth We’ve recently seen the formation of your peers in a way that is uninvited, in how we access and share informa- the First Nations Health Authority, for example, is humbling—there are tion is unprecedented—and as ex- and I think we have a lot to do sur- so many good doctors in this province citing as that is it’s also incredibly rounding Aboriginal health in BC. We who fly under the radar and aren’t rec- challenging because we need to filter don’t give it enough attention, and we ognized for their contributions and what is factual, what is scientifically have to build that into the social fab- service. We need to do more of that— based. As doctors we pride ourselves ric. We need to be culturally sensitive. recognize these contributions to med- on being the experts in medicine, and We need to respect the custodianship icine, to patients, to communities. there are so many career opportun- that First Nations in our province A number of years ago, I think it ities available for young doctors, but have for being responsible to the plan- was 2008, I was recognized by the we have to understand that the foun- et. They are leaps and bounds ahead Society of Rural Physicians of Can- dation of a general medical education of where we are in understanding that ada to be awarded a Fellowship of is generalism. We also have to think if we don’t look after our planet, it Rural and Remote Medicine in Can- about social accountability—there’s a won’t look after us. We can do bet- ada. At that point I probably had social contract that we have in Can- ter in terms of building relationships arrived at a place where my career ada with the federal and provincial with our First Nations partners across was evolving and I was starting to governments—we are responsible for health care and beyond. contribute beyond one patient at a giving back to society. To this end, The other piece that deserves on- time. To this day I wear the lapel-pin we need to require from our univer- going attention is simply bringing I was presented with as a reminder to sities and medical students as broad- specialists and generalists back to- myself of being recognized for serv- based a generalist training in medical gether as a united profession so we ing well. And I think that is part of school as possible before they choose can tackle these tough issues. why we choose medicine—we have an area of specialty. There needs to to embrace the tenants of profession- be a strong foundation of generalism, What technological developments alism, advocacy, and service. both in specialty practice and family in medicine are you excited about? medicine. One of the greatest investments that Conversely, could you tell me about governments and societies can make a challenge or regret? What are your concerns about the in health care is around how we Thinking back to when I was in uni- future of family medicine in this choose to organize, fund, and support versity, and when South Africa was province? Continued on page 416

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Continued from page 415 greater collaboration will result in access, and we need to admit the right activities around information technol- that are currently underdeveloped? patient to hospital at the right time. ogy and information management. When we talk about team-based care Having a patient medical record that we need to understand who all the Recruitment and retention chal- is dynamic, current, accurate, and that partners are who are responsible for lenges in BC continue to be top truly reflects the health of a patient producing outcomes. The doctor- of mind. What do you envision as will go a long way to reducing unnec- patient relationship is fundamental. a way to overcome the enduring essary health care costs and the burden It is the most-valued relationship in obstacles? of medical errors, and ensuring safely health care, so we can’t undo that. Recruitment and retention is no delivering care to patients. We need to There has to be a strong physician longer on the radar of only our rural look at how we integrate information voice, and a credible and safe place communities; there’s a desperate technology effectively to reduce the for the patient voice to land. But we need for recruitment both in urban duplication and multiple layers of bar- also need to recognize who the other and rural and remote communities. riers that we have by trying to accom- partners in health care are. We cer- Yes, there continues to be a dispro- modate 6, 8, 10 different information tainly look to the provincial govern- portionate allocation of where phys- technology delivery systems. ment for its leadership and we look icians choose to live and work—25% I hear citations of privacy as the to the societies that support family of BC’s population lives and works issue that’s limiting us from remov- physicians and specialists. We need in rural communities, yet only 11% ing various IT barriers, but if you ask to bring those voices together and to to 14% of doctors choose to work in patients if privacy is the biggest issue work with allied health care profes- these communities. We need to invest for them, they’ll say absolutely not, sionals, our nursing colleagues, our in rural-proofing BC, but we need to it’s about access. They want health pharmacy colleagues, licensed prac- talk about the greater need as well. If care providers to have their most cur- tical nurses, social workers, physio- we look at where the biggest invest- rent medical information in front of therapists, the list goes on. We need ment in health care is, it goes back to them when they’re being asked to be to bring the right providers together the conversations around generalism, partners in their own health care. If and have meaningful conversations and those occur at our postsecondary we can’t deliver that, we’re doomed about delivering timely and efficient education institutions. Universities to fail in health care in 2016. care to patients, reducing unnecessary need to grow their understanding of admissions to hospital, and rooting why investment in generalist med- You are also highly engaged on out areas where there is unnecessary ical training is going to serve society Twitter. How has social media risk to patients. well. Absolutely, we need the broad affected your practice and your Two pertinent research examples range of world-class specialists in this interactions with your patients and come to mind. First, the Common- province that we already have, who colleagues? wealth Fund released a report in late can continue to support patients when We have a responsibility as a profes- 2014 showing that Canada scores they need that type of care most, but sion to engage with one another, and 10th out of 11 in First World nations we’re now at a place where, because social media is a huge opportunity to when you look at the matrices of how of the system of delivering care that share our voice and express our opin- their health care systems are mea- we’ve developed in rural commun- ions with the public and with govern- sured. We need to sit down with the ities, we’re better prepared to inform ment. I encourage my colleagues to governments of the day and have a the urban conversation about what look at social media as a way to get conversation about transforming, not organizing services can look like. their professional voice out there, just tweaking, health care for the gen- Maybe we can take the rural model to talk about their concerns. It has erations ahead. and have a conversation with urban helped my career in cutting through Second, OECD data tells us that and metropolitan communities and red tape—being able to reach leaders the safest hospitals in the world have get back to the day when generalist, who I might otherwise not have tradi- a maximum bed occupancy of about hospital-type care was the foundation tional relationships with. 85% at any given time. When I listen for what most people need. to colleagues both close to me and You’ve spoken about the import- around the province, it’s not unusual What drives you? ance of collaborative efforts be- to hear that our hospitals have occu- I grew up with two brothers and a tween all health care providers and pancies of over 100%. That’s a prob- younger sister, so there was always partners. What specific improve- lem. We need to make our hospitals a competitive streak in our house- ments or opportunities do you think more efficient, we need to improve hold, and I think competition is very

416 bc medical journal vol. 58 no. 7, september 2016 bcmj.org special feature healthy. Those who know me recognize that I can be impatient, sometimes tenacious, but I tend to organize We have a huge responsibility as doctors to those qualities around opportunities. exercise our professional voice on issues of Yes, I can be impatient when I see social determinants of health. The Council that we are not organizing our ener- on Health Promotion has done stellar work gies efficiently in health care across over the years to highlight areas where the province, but it’s also about taking those energies and recognizing doctors can advocate for social changes that if we can’t produce meaningful that can produce health. It shouldn’t just be change, we’re going to tire out a lot about managing sickness. of the people who are demonstrating leadership in BC’s health care system. We need to move from collaboration to truly enacting the partnerships that we’ve created, and I see this as one Do you have any concerns about with having a collective will across of the most important areas that I can achieving everything you set out for those partners to transform health contribute to as the Doctors of BC your year as president? care in 2016. If the Commonwealth president. All of the goals I promoted in my Fund tells us we are 10th out of 11, campaign, I think, are achievable. But then we’re failing. As president, what are you most I think it’s most important that I lay We don’t yet have a renewed Ca- interested in doing straight out of a stronger foundation for the associa- nadian Health Accord, so I look for- the gate? tion to stand on when it moves forward to working with the provincial The trajectory for the president is ward. We’ve got a strategic plan that’s government and the presidents of short—365 days—so I didn’t come about to be renewed and updated, other provincial and territorial medi- out with a clearly defined 100-day ac- we’re looking at governance reform cal associations and starting a con- tion plan because I think that’s arti- within the association, these are versation with the federal Minister ficial. I have a strong mandate that’s important pillars. of Health if the opportunity allows. organized around embracing diverse The profession points its fingers Let’s talk about creating a sustainable thought, so I’m traveling extensively at the association sometimes and says health care system in Canada for the around the province right now, going that we’re simply not addressing cer- next 30 to 50 years. to small communities, meeting with tain needs, but we need to understand individual doctors, hearing the indi- why we’re organized as an associa- Recognizing, as you do, that change vidual physician’s voice, and giv- tion. Let’s not forget, we have the Col- takes time, where would you like to ing them the chance to tell us what’s lege of Physicians and Surgeons, we see the association in 10 years? working well, or where the health have the Health Professions Act, we I would like to see Doctors of BC con- care system needs to improve; that’s have the provincial government and tinue to be the strong representative important. health authorities. The Doctors of BC voice for all doctors in the province, I’ve made a promise to myself that mission is to promote a social, eco- with a high-functioning Board that I’m going to keep physically and emo- nomic, and political environment in does executive work on behalf of the tionally healthy, as I could exhaust which members can provide BC citi- association while allowing the asso- myself if I have to reach as many phy- zens with the highest quality of health ciation’s committees to grow their sicians in their own communities as care while allowing the doctors that relationships with health authorities I can if they themselves can’t get to we’re serving to have a great profes- and government to make sure we’re Vancouver from time to time. sional life and receive fair economic addressing the basic health care needs Being a connector, I have some reward. And that occurs in a public- of all BC citizens. phenomenal relationships with phy- ly funded health care system, so we In 10 years I would love to see that sicians around the province, and I have to partner with society through there are no wait lists or access issues think my role as president is to help the government and health authorities in the province. It occurs in other promote and support the activities of and other professions to ensure we countries; we should have the same in these physicians in their own roles as can produce an improved system as this province. physicians of influence. we move forward. That change starts

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MEDICAL CBT based, group learning curriculum 604 875-5078, e-mail cpd.info@ubc. Various locations and dates enhances the effectiveness of prima- ca, web ubccpd.ca. When you learn medical cognitive ry care and community-based physi- behavior therapy’s ultra-brief tech- cians in dealing with occupational MINDFULNESS IN MEDICINE niques, you’ll feel much more com- medicine cases including fitness-to- Tofino, 28 Sep–2 Oct (Wed–Sun) fortable handling the many “supraten- work determinations and disability Mindfulness in Medicine— torial issues” in your practice. Choose prevention and management. Course Foundations of Theory and Practice from the following workshops, each enrollment is limited to 15 partici- is a 4-day experiential workshop accredited for at least 12 Mainpro- pants to enhance the small-group approved for 16 Mainpro-C credits. C credits: Vancouver—Westin Van- experience. This course (Part A) has The workshop’s focus will be mind- couver Airport (16–17 Sep); Scotts- been accredited by the CFPC for up fulness and meditation as it relates to dale—Fairmont Scottsdale Princess to 111 M1-MainPro credits. Those the unique challenges and blessings (24–26 Nov); Caribbean cruise— completing Part A can progress to the of our work as physicians. As chronic Disney Fantasy (10–17 Dec); Disney Part-B course. Participants who pass stress and its associated mental and World—Grand Floridian Resort (19– written exams on both parts are eli- physical health challenges continue 21 Dec); Mexico—Iberostar Mayan gible for accreditation from the Cana- to rise in epidemic proportions, the Riviera (18–20 Jan), Bahamas— dian Board of Occupational Medi- application of mindfulness in clinical Atlantis Resort (9–11 Feb 2017); Las cine. For further information visit the practice settings has gained promi- Vegas—Aria Resort (15–17 Feb); Foundation’s website at www.foun nence both in terms of evidence-based Whistler—Delta Whistler Village dationcourse.ualberta.ca. research and in the popularity of its Suites (20–22 Mar); Maui—Sheraton use. Learn about the latest clinical Ka’anapali (27–29 Mar); Kauai— ST. PAUL’S EMERG MED evidence and neuroscience on mind- Grand Hyatt (10–12 Apr 2017); South UPDATE fulness in medicine, find out about Pacific cruise—Paul Gauguin (15–29 Whistler, 22–25 Sep (Thu–Sun) programs offered throughout BC and Apr 2017); Mediterranean cruise— Join us at the Whistler Conference Canada, and explore practical medi- Celebrity Reflection (9–20 Oct 2017). Centre for the 14th annual St. Paul’s tation tools for yourself and for your CBT Canada is a national winner of conference—4 exciting days of learn- patients. Visit www.drmarksherman. the CFPC’s CME Program Award and ing, networking, and, of course, recre- ca for more information, or register at is celebrating its 20th anniversary this ation! Last year more than 300 people [email protected]. year. Lead faculty Greg Dubord, MD, attended this meeting, so don’t miss has given over 300 CBT workshops out this year. Pre-conference work- WORKSAFEBC PHYSICIAN ED and is a recent University of Toronto shops: AIME, CASTED, EDE, EDE2, CONF CME Teacher of the Year. For details ACLS, CARE. Target audience: Kamloops, 22 Oct (Sat) and to register visit www.cbt.ca or Any physician providing emergency The 17th annual WorkSafeBC Physi- call 1 877 466-8228. Look for early- care—from rural to urban, part-time cians Education Conference will be bird deadlines. to full-time, residents to seasoned held at Hotel 540 in downtown Kam- veterans, and emergency nurses and loops. Physicians are invited to learn, OCCUPATIONAL MEDICINE paramedics. Special guests the Hair share, and network at this Work- COURSES Farmers will be featured at our Fri- SafeBC-hosted conference. Attend- Self-learning course, Sep–May day night reception at the newly ren- ees can expect a full day of discussion, The Foundation Course in Occupa- ovated GLC. Keynote speakers: Dr dialogue, and workshops relating to tional Medicine, developed at the Grant Innes (University of Alberta), the role of physicians in work-related University of Alberta, is now being Dr Stuart Swadron (Keck School of injuries, and the latest protocols in presented across Canada in two parts. Medicine, USC), Dr Judith Tintinalli disability management. The confer- Our British Columbia Part-A course (UNC School of Medicine), and Sam ence agenda includes 3 plenary ses- is facilitated by three BC occupation- Sullivan (CM, MLA for Vancouver- sions, 12 workshops to choose from, al physicians and runs from Septem- False Creek). Conference registra- and 2 “short snapper” sessions that ber to May by monthly teleconfer- tion, information, program details, feature a brief presentation followed ences and two full-day face-to-face and online registration is available by an opportunity for Q&A. Register Vancouver-based workshops (21 Jan at http://ubccpd.ca/course/sphemerg before 1 Oct to receive the early-bird and 27–28 May). This practical, case- -2016. Phone 604 875-5101, fax discount. Accreditation: Applications

418 bc medical journal vol. 58 no. 7, september 2016 bcmj.org calendar for Mainpro-M1 credits for the ple- Sea Courses has provided almost 300 will allow for the repeated practice of nary sessions and Mainpro-C credits unique CME conferences onboard invasive procedures without harming for the workshop sessions are in prog- cruise ships over the past 20 years. the human models. Formative evalu- ress. More details will be available Programs are accredited for specialists ation in the form of immediate feed- soon. For more information, contact and family physicians, have no phar- back provided by the instructor will Kerri Phillips at kerri.phillips@work ma-sponsorship and include a compli- help the students to monitor their safebc.com or visit www.worksafebc mentary enrichment program for trav- progress and guide their learning. physicians.com. elling companions. All Sea Courses Maximum course capacity: 24 partic- trips offer group pricing, special air- ipants. Target audience: emergency, SEMP COURSE fares, and free cruising for compan- rural, intensive care, and family phy- Vancouver, 27 Oct (Thu) ions. Contact Sea Courses Cruises for sicians, pediatricians, anesthetists, The Simulation Assisted Emergency more information and details of cur- trauma physicians, residents, IMGs. Medicine Procedures course allows rent promotions. Phone 604 684-7327 Accreditation: up to 15 Mainpro-M1/ physicians to acquire, review, and or toll free 1-800-647-7327; e-mail MOC Section-3 credits. Register for practise their skills in essential life- [email protected]. Visit www. 28 Oct at http://ubccpd.ca/course/ saving emergency procedures. Before seacourses.com for a complete list of UGEMP-Oct28-2016 and for 18 Nov the course, students will have access CME cruises and tours. at http://ubccpd.ca/course/UGEMP to web-based learning modules to -Nov18-2016. Tel 604 875-5101, complete the self-directed learn- UGEMP COURSE e-mail [email protected]. ing. The hands-on portion of the Vancouver, 28 Oct (Fri), 18 Nov (Fri) course at the Centre of Excellence The use of bedside ultrasound by cli- LIVE WELL WITH DIABETES for Surgical Education & Innovation, nicians to guide invasive emergency Richmond, 4–6 Nov (Thu–Sun) Vancouver General Hospital, 3602– and critical care procedures improves Come check out the conference for 910 W. 10th Ave., will have experi- success and reduces complications, health care professionals at the Radis- enced instructors demonstrating the and is rapidly becoming established son Hotel, our new venue in Rich- procedures and supervising the stu- as the standard of care. The Ultra- mond, close to the Canada Line sta- dents as they practise on animal and sound Guided Emergency Medicine tion! Building on the success of our realistic plastic models. Students will Procedures course will be held at the new 3-day format, this year’s agen- have the opportunity to integrate per- Centre of Excellence for Surgical da includes presentations designed formance of these procedures into Education & Innovation, Vancouver for family physicians, allied health the real-time resuscitation of a criti- General Hospital, 3602–910 W. 10th professionals, podiatrists, and other cally ill patient using the latest human Ave. Pre-course work includes web- health care professionals who have an patient simulator technology to create based learning modules to complete interest in recent advances in diabe- realistic scenarios. Maximum course the self-directed learning. Human tes. Featured topics: Diabetes and the capacity: 24 participants. Target audi- models will allow for demonstration elderly; Ambulatory glucose moni- ence: emergency physicians and rural of human surface landmarks, and toring/CGMS; Combination therapy: physicians. Accreditation: up to 15 ultrasoundable task-trainers that sim- Does 1 + 1 equal 3; Economics of Mainpro-M1/MOC Section-3 credits. ulate the tactile feel of human tissue Continued on page 420 Register at ubccpd.ca/course/SEMP -Oct27-2016. Tel 604 875-5101, e-mail [email protected].

FALL/WINTER CME CRUISES FROM SEA COURSES November 2016–March 2017 Travel with the CME cruise experts. Discover new destinations. Return to favorite ports. Costa Rica (Nov), Tahiti & Marquesas (Nov), Caribbean (Dec, Mar & Apr), South America (Jan), Australia/New Zealand (Feb), Mexi- co (Feb), Bali–Singapore (Feb). Trips planned by physicians for physicians.

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Continued from page 419 will take place at the Child & Family Reports Advanced and Testifying in diabetic foot complications: Impor- Research Institute at BC Children’s Court: Becoming a Great Expert, will tance of risk reduction; How to dis- Hospital in Vancouver and provide be held 9 a.m. to 4 p.m. on 4 Mar (Sat) cuss obesity—A family physician’s an effective way to learn about new and will provide advanced training on perspective. A public health fair has oncology resources and support in writing more complex medical legal been scheduled for Sunday, 6 Nov, at BC. Register now at www.fpon.ca. reports and provide tips on how to the same venue. Conference registra- For more information contact Jenni- reduce stress while testifying in court. tion, information, program details, fer Wolfe, jennifer.wolfe@bccancer These courses will be taught by medi- and online registration are available at .bc.ca or 604 219-9579. cal legal professionals with extensive www.ubccpd.ca. Tel 604 875-5101, experience—faculty who have busy fax 604 875-5078, e-mail cpd.info@ ESSENTIAL MEDICAL-LEGAL personal injury practices and know ubc.ca. TOOLKIT exactly what they want from medi- Vancouver, Various dates cal legal reports and expert testimo- FP ONCOLOGY CME DAY This program is suitable for family ny in court. Fees: $480/course. For Vancouver, 19 Nov (Sat) physicians and specialists and will be registration and further information The BC Cancer Agency’s Family held at UBC Robson Square. Medical call 604 525-8604, e-mail manager@ Practice Oncology Network invites Legal Reports: The Essentials, will be coremedicalcentre.com, or visit www family physicians and primary care held 9 a.m. to 4 p.m., 26 Nov (Sat), .medlegaltoolkit.com. professionals to attend its annual and 25 Feb (Sat). If writing medical Family Practice Oncology CME legal reports causes you stress, if you GP IN ONCOLOGY TRAINING Day certified by the College of Fam- are not sure what to write when asked Vancouver, 20 Feb–3 Mar (Mon– ily Physicians of Canada and the BC about prognosis, unsure of what to do Fri), and 11–22 Sep 2017 (Mon–Fri) Chapter for up to 6.5 Mainpro+ cred- about patients’ subjective complaints, The BC Cancer Agency’s Family its. Attendees will gain up-to-date or how much you should be billing for Practice Oncology Network offers oncology knowledge and build useful your reports, then this is the course an 8-week General Practitioner in cancer care connections. The session you want to attend. Medical Legal Continued on page 422 Haughton_SCF_BCMJ_1/2H_Sep2016_Haughton_SCF_BCMJ 1/2.qxd 2016-08-24 12:28 PM Page 1

Join the Section of Clinical Faculty (SCF) of Doctors of BC The Section of Clinical Faculty (SCF) has worked on your behalf for years. Payment for bedside teaching, payment for didactic lectures, stipends for clinical rounds, open criteria for advancement - things we now expect and take for granted as doctors who teach – all were achieved through the efforts of the SCF. Adequate resources are needed to allow physicians to provide both timely care to their patients and excellence in teaching. In order to help you, we need you to become a member of SCF. Your first year of membership is free, and $50/ year thereafter. Sign up via Doctors of BC website or the Section website: http://www.ucfa.ca/how-to-join

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Continued from page 420 .fpon.ca, or contact Jennifer Wolfe at men mutinied to stay put), Mo’orea Oncology training program begin- 604 219-9579. (Arthur Frommer’s vote for “the most ning with a 2-week introductory beautiful island on earth”), Taha’a session every spring and fall at the HAWAIIAN CME: MAUI/KAUAI (French Polynesia’s vanilla-scented Vancouver Centre. This program pro- Maui, 27–29 Mar 2017 (Mon–Wed); isle), Bora Bora (celebrities’ exclusive vides an opportunity for rural fam- Kauai, 10–12 Apr 2017 (Mon–Wed) hideaway), the Cook Islands (New ily physicians, with the support of Aloha! Please join us in the happi- Zealand’s private paradise), the King- their community, to strengthen their est American state next spring for dom of Tonga (proudly never colo- oncology skills so that they may pro- award-winning CME in medical cog- nized), and three idyllic islands of Fiji vide enhanced care for local cancer nitive behavior therapy—Medical (Viti Levu, Vanua Levu, and postcard- patients and their families. Follow- CBT: Ultra-brief techniques for real perfect Beqa). You’ll be enchanted by ing the introductory session, partici- doctors. The Maui workshop (CBT the South Pacific’s craggy volcanic pants complete a further 6 weeks of for Depression/Happiness) will be peaks, sugary beaches, warm lagoons customized clinic experience at the held at the idyllic Sheraton Maui on teaming with fish, glistening black cancer centre where their patients are Ka’anapali Beach. With 23 acres of pearls, and Tamure dancing suggestive referred. These can be scheduled flex- lush Hawaiian grounds, you’ll never enough to make you blush. The CME ibly over 6 months. Participants who feel crowded! Maui has been voted provides a rock-solid foundation in complete the program are eligible for best island by the readers of Condé medical CBT for depression, review- credits from the College of Family Nast Traveler for more than a dozen ing a plethora of ultra-brief office tech- Physicians of Canada. Those who are years. Attractions include 10 000 foot niques to help patients defeat depres- REAP-eligible receive a stipend and Hale’akala (Hawaiian for house of the sion and be happy. CBT Canada is a expense coverage through UBC’s sun), 14 golf courses (including some national winner of the CFPC’s CME Enhanced Skills Program. For more of the world’s top-rated), the scenic Program Award, and is celebrating information or to apply, visit www road to Hana, the Seven Sacred Pools its 20th anniversary this year. Lead of Oheo, and over 500 restaurants. The instructor Greg Dubord, MD, is a Uni- Kauai workshop—CBT Tools, will be versity of Toronto CME Teacher of held at the spectacular Grand Hyatt on the Year. Assistant faculty includes The KEY to SUCCESS with sunny Poipu Beach. The Grand Hyatt the inimitable Fijian psychiatrist Ben- SPEECH RECOGNITION Kauai is ranked among the world’s jamin Prasad, MD, FRCPC, from top resorts by both the Condé Nast the University of Manitoba. Super Traveler and Travel+Leisure. Kauai early bird rates for ocean-view state- Certifi ed Dragon® is the most tranquil and pristine of the rooms aboard the spectacular m/s Paul Medical Software main Hawaiian Islands, with beach- Gauguin start at $11 750 (includes Sales & Training es fringing nearly 50% of its tropi- all beverages, all taxes, all gratuities, cal coastline. Attractions include the return airfares, and companion cruis- world-famous Kalaulua Trail on the es free). Book with Canada’s largest One-on-one training sessions Napali Coast, red-rocked Waimea cruise agency, CruiseShipCenters. See Customized to your workfl ow Canyon, 17-mile Polihale Beach CBT Canada at www.cbt.ca or call and specifi c needs (Hawaii’s longest), crescent-shaped 1 888 739-3117. Complete initial, basic, and Hanalei Bay, and Hawaii’s only navi- advanced instruction available gable river, the Wailua. See www.cbt Exclusive and professionally .ca for details about both the Maui and BCMJ’s CME listings written training materials Kauai workshops. Warning: Our sig- Rates: $75 for up to 150 words Follow up assistance and support nificantly discounted guestrooms for (maximum), plus GST per month; these two workshops will sell out far there is no partial rate. If the course in advance. or event is over before an issue of Solutions the BCMJ comes out, there is no discount. VISA and M/C accepted. SOUTH PACIFIC CRUISE CONTACT US TODAY! Deadlines: Online: Every Thursday 15–29 Apr 2017 (Sat–Sat) (listings are posted every Friday). The world’s most romantic destina- Print: The first of the month 1 speakeasysolutions.com tions, from French Polynesia to Fiji. month prior to the issue in which 1-888-964-9109 Join us for a 13-night cruise exploring you want your notice to appear. exotic Tahiti (where Captain Bligh’s

422 bc medical journal vol. 58 no. 7, september 2016 bcmj.org council on health promotion

Let’s help our children as parents and as doctors

s fall rolls around and a new entary time. These are all factors that As we move into the fall we, as school year begins, those of we as parents need to be aware of. health care professionals, have oppor- A you with school-age children Do we as health professionals tunities to lead the way in promoting or grandchildren will be anxious as also have a responsibility to educate good health to our children. Schools they start a new year. It’s a time for school-age children in these impor- will have a renewed focus on pro- new classmates, new teachers, and tant areas? This begs the question of moting physical activity to children, new challenges. As parents, we focus what our role is in health promotion led by the Directorate of Agencies on academics and ensuring our chil- for School Health (DASH) BC and dren get the best education that will Action Schools BC, with new govern- give them a good start to their lives. ment funding. However, do we also consider the During October the Doctors of importance for our children to be For children BC Be Active Every Day initiative physically active? A lot of our chil- age 5 to 13 years, will be challenging school children dren will be involved in sports and 9 to 11 hours of sleep is to follow the Live 5-2-1-0 message: this will help them reach the goal of recommended, 5 or more fruits and vegetables each being active for 60 minutes per day, day, no more than 2 hours of recre- the recommended amount of physical and 8 to 10 hours ational screen time per day, at least activity for children aged 5 to 17. But per night is 1 hour of physical activity per day, what if our children are not involved recommended for and 0 sugar sweetened drinks per day. in sports? How can we ensure they those age 14 to 17. As well this year we will incorporate also get the recommended amount of the importance of adequate sleep. We activity? hope to work with schools to engage In addition to being physically as many students as possible. That active, the amount of sleep children means we need doctors in every com- get is increasingly being recognized for children. How can we play a role munity to step up and help us lead as important. The 2016 ParticipAC- in promoting the importance of being the way in promoting these important TION Report Card on Physical Activ- physically active to children when health habits. October will also see ity for Children and Youth1 empha- we typically see children in the office an initiative for children to be active sized the importance of sleep. As a only when they present with an ill- in Walk and Wheel to School Week result, 24-Hour Movement Guide- ness? The ParticipACTION Report (3 to 7 October). Let’s make it hap- lines for Children and Youth2 have Card continues to rank our kids’ activ- pen! To learn more about Be Active been released, which emphasize the ity level at a D-, which means less Every Day, e-mail Patrick Higgins at importance of an appropriate amount than 20% reach the guidelines of 60 [email protected]. of sleep for children. For children age minute per day. There is no silver bul- —Ron Wilson, MD 5 to 13 years, 9 to 11 hours of sleep let that will magically make children Chair, Athletics and is recommended, and 8 to 10 hours suddenly become more active. Every- Recreation Committee per night is recommended for those one needs to do their part to help age 14 to 17. Without adequate sleep increase activity levels, reduce screen References children are too tired to be active, time, and help kids get the sleep they 1. ParticipACTION. Report card on physical and when they are not being active need and eat and drink healthy foods activity for children and youth, 2016. Ac- it makes it more difficult for them to and beverages. This means parents, cessed 3 August 2016. www.partici sleep. These guidelines also empha- day-care operators, schools, parent paction.com/en-ca/thought-leadership/ size the importance of limiting recre- advisory committees, community report-card/2016. ational screen time to minimize sed- and recreation centres, sports teams, 2. Canadian Society for Exercise Physiology. transportation systems, built environ- 24-hour movement guidelines for children This article is the opinion of the Council on ments, governments, and, yes, health and youth, 2016. Accessed 3 August Health Promotion and has not been peer care professionals and systems all 2016. www.csep.ca/en/guidelines/ reviewed by the BCMJ Editorial Board. play a role. get-the-guidelines.

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 423 guidelines for authors

he British Columbia Medical Journal on request. The BCMJ is posted for free access or text to [email protected] or call 604 is a general medical journal that seeks on our web site. 638-2858 to discuss. Less than 300 words. T to continue the education of physicians through review articles, scientific research, FOR ALL SUBMISSIONS CLINICAL ARTICLES/CASE REPORTS and updates on contemporary clinical practices Avoid unnecessary formatting, as we strip all Manuscripts of scientific/clinical articles and while providing a forum for medical debate. formatting from manuscripts. case reports should be 2000 to 4000 words in Several times a year, the BCMJ presents a theme Double-space all parts of all submissions. length, including tables and references. Elec- issue devoted to a particular discipline or disease tronic submission prefer red (e-mail to journal entity. Include your name, relevant degrees, e-mail @doctorsofbc.ca). 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424 bc medical journal vol. 58 no. 7, september 2016 bcmj.org guidelines for authors

4. Consent. If the article is a case report or if an 2. Kim-Sing C, Kutynec C, Harris S, et al. Provide internal scale markers for photomi- individual patient is described, written consent Breast cancer and risk reduction: Diet, crographs. from the patient (or his or her legal guardian or physical activity, and chemoprevention. Ensure each figure is cited in the text. CMAJ. In press. substitute decision maker) is required. Color is not normally available, but if it is Personal communications are not included in Papers will not be reviewed without this docu- necessary, an exception may be considered. ment, which is available at www.bcmj.org. the reference list, but may be cited in the text, with type of communication (oral or written) communicant’s full name, affiliation, and date Units References to published material (e.g., oral communication with H.E. Marmon, Report measurements of length, height, weight, Try to keep references to fewer than 30. 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bc medical journal vol. 58 no. 7, september 2016 bcmj.org 425 classifieds

recruitment and retention benefit eligibility, on site. Contact Ammy Pitt at 250 390-5228 or practices available including 38 days of rural locum coverage for e-mail [email protected]. Visit VANCOUVER—PEDIATRICS holidays. World-class wilderness at your door- our website at www.caledonianclinic.ca. Busy pediatric practice available. Solid referral step for skiing, hiking, fishing, white-water base. Recently renovated 1000 sq. ft. office, in- kayaking, and mountain biking. Full-service NEW WEST—FAMILY PHYSICIAN cluding four exam rooms and two MD rooms. rural hospital with GP surgeon and anesthe- New Westminster: Columbia Square Medical EMR in place. Conveniently located near BC tist on staff. For more information e-mail Clinic is looking for a family physician for a Children’s Hospital. Options to buy or rent com- [email protected] or full- or part-time position. Partnership and mercial unit. E-mail [email protected] or visit www.betterhere.ca. options to buy are available. Flexible hours, call 778 233-6543 for more information. competitive split. The clinic is newly renovat- MAPLE RIDGE (DWTN)—FAMILY ed with bright rooms, Oscar EMR, excellent PHYSICIAN friendly and efficient staff, 20 minutes from employment Excellent opportunity for family physician downtown Vancouver. We have 800 families to join collaborative, multidisciplinary full- waiting for a family doctor who wants to es- ABBOTSFORD—LOCUMS service birth program and women’s clinic pro- tablish a permanent practice or work part-time. Full-service East Abbotsford walk-in clinic re- viding preconception care, infertility treatment, Considering a change of location or practice quires locum physicians for a variety of shifts midwifery care, and contraceptive options. style? Call Irina at 778 886-6511 or e-mail including weekends and evenings. Generous Team of midwives, nurse practitioners, doulas, [email protected]. split: pleasant office staff and patient popula- and RMTs will work collaboratively to provide tion. Please contact Cindy at 604 504-7145 if comprehensive care. Contact 778 996-3447. POWELL RIVER—PERMANENT FPs & you are interested in obtaining more info. E-mail [email protected]. LOCUMs Powell River is a rural community of 20 000 KAMLOOPS—HOSPITALISTS MERRITT—FP people on the Sunshine Coast of British Co- Royal Inland Hospital, a 246-bed tertiary Rolling hills, sparkling lakes, and over 2030 lumbia, a 25-minute flight from Vancouver. hospital and referral centre, is seeking perma- hours of sunshine every year make Merritt a It’s known for its waterfront location, outdoor nent full-time physicians to join our collegial haven for four-season outdoor recreation. We beauty, urban culture, and international mu- hospitalist service. You will provide general have a need for family physicians in their choice sic festivals. Supported by a 33-bed general medical care of hospitalized adult patients and of clinic. Nicola Valley Hospital and Health hospital, the close-knit medical community co-management of surgical and psychiatric pa- Centre is a 24-hour level-1 community hospital consists of 26 general practitioners, 4 ER and tients. The hospitalist service is supported by with a 24-hour emergency room. Royal Inland anesthesia physicians, 2 NPs, and 7 specialists. a complement of specialty services including Hospital in Kamloops is a tertiary-level hospi- We are looking for permanent general practi- anesthesia, general internal medicine, general tal located only 86 km away. Remuneration is tioners and locums. Please visit divisionsbc.ca/ surgery, orthopedics, psychiatry, radiology, fee-for-service ($250 000 to $450 000-plus per powellriver/opportunities for details. and urology. Opportunity to teach. Income of year), rural retention incentives and on-call $244 200 supported through a service contract availability payment. For more information RICHMOND—FP with on-call stipend and no overhead. For more e-mail [email protected] Best clinic to work at in Richmond! Full- or information e-mail physicianrecruitment@ or view online at www.betterhere.ca. part-time physician needed for busy, mod- interiorhealth.ca or visit www.betterhere.ca. ern walk-in/family medicine clinic. We are a N VANCOUVER—FP LOCUM team of caring physicians and staff looking for KELOWNA—HOSPITALISTS Physician required for the busiest clinic/family a like-minded addition to our team. Central Kelowna General Hospital, a tertiary hospital practice on the North Shore! Our MOAs are Richmond, OSCAR EMR, large rooms, on-site and referral centre with 400 beds, is seeking known to be the best, helping your day run pharmacy. E-mail: [email protected]; permanent full-time and part-time physicians smoothly. Lucrative 6-hour shifts and no head- Website: www.livewellmedicalcentre.com. to join our progressive hospitalist service. You aches! For more information, or to book shifts will provide general medical care of hospital- online, please contact Kim Graffi at kimgraffi RICHMOND—FP ized adult patients, and co-management of sur- @hotmail.com or by phone at 604 987-0918. Opportunity to practise in a busy family prac- gical and psychiatric patients. The hospitalist tice in Richmond, BC. Great location. Excel- service is supported by a complement of spe- N VANCOUVER—FPs WELCOME lent staff. Please call Lesily at 604 270-1998 or cialty services including anesthesia, general Family practice/walk-in seeking F/T or P/T e-mail [email protected]. internal medicine, general surgery, orthope- physicians. Spacious, Oscar EMR, Wi-Fi. Lo- dics, psychiatry, radiology, urology, and oncol- cated near SeaBus. Convenient to downtown RICHMOND—FP & LOCUMs ogy. Income of $244 200 supported through a Vancouver. Offering highest splits on North Opportunities for physicians looking to do service contract with on-call stipend and no Shore (up to 72.5%). No OB or ED mandatory. walk-in shifts, build a practice, or relocate in overhead costs. For more information e-mail Flexible hours. Great staff. Contact Francis: our busy modern clinic. EMR OSCAR. Great [email protected] or e-mail [email protected]. location next to a 24-hr Shoppers Drug Mart. visit www.betterhere.ca. No hospital work, no call, 70/30 split—walk-in NANAIMO—GP shifts at $100 per hour minimum—and bonus LILLOOET—FP General practitioner required for locum or available. Contact us at healthvuemedical@ Five-physician, unopposed fee-for-service permanent positions. The Caledonian Clinic gmail.com, 604 270-9833/604 285-9888. practice seeks sixth family physician with ER is located in Nanaimo on beautiful Vancou- skills. Clinic group focus is on balancing work ver Island. Well-established, very busy clinic SURREY (WHALLEY)—METHADONE- and lifestyle. Easy access to Lower Mainland, with 26 general practitioners and 2 specialists. LICENSED GP Whistler, and Interior of the province. Call is Two locations in Nanaimo; after-hours walk-in Methadone-licensed GP needed to joint an ad- currently 1 in 5. Regular schedule includes 1 clinic in the evening and on weekends. Com- diction clinic. No overhead if available week week off every fifth week. Full rural physician puterized medical records, lab, and pharmacy Continued on page 428

426 bc medical journal vol. 58 no. 7, september 2016 bcmj.org Your Professional Practice Lifecyle By Don Murdoch

Where Are You in Your Professional Practice Lifecycle?

We often have conversations with our medical professional Wealth Accumulation: At this stage, you are enjoying a very profitable clients that start something like this: “I was visiting with a practice that is creating the financial resources for an expanding list of colleague the other day between cases and they were telling personal and financial goals. You are not likely ready to retire but you me I should…” The ideas shared during these visits are likely can start thinking about how you want your retirement to look and good ideas, but the key is to understand that what might be structure a plan to get there. the right idea at the right time for your colleague may not be After Practice: A very common reminder to our medical professional the right idea for you at this time. It is important to recognize clients is “you don’t give the money back after you stop practicing.” your career decisions will uniquely match your personal The wealth you have accumulated now needs a plan that works with circumstances and needs. your retirement savings (RRSP or IPP), government benefits and other income sources. This will include estate planning, income tax minimization and capital gains considerations. Every professional practice goes through a series of stages in its evolution. From a tax perspective, failure to plan properly at each stage of Over the next several articles, we will look at each of these stages in your practice lifecycle may result in significant financial consequences or more depth to point out how your tax structure and strategies should lost opportunities down the road. The first step to effective tax planning evolve as your practice grows. is to understand what stage your practice is at today.

Getting Started: As you embark on your medical practice, you need to With 20 locations throughout British Columbia, MNP provides choose an initial structure that will match your initial financial goals. support to medical professionals at all stages of their careers. These goals likely include retirement of any remaining education debt Contact Don Murdoch, B.C. Leader, Professional Services at and looking towards a possible home purchase. Consideration should 1.877.766.9735 or [email protected] also include your current personal circumstances. Do you know where you plan to build your practice? Are you married? Do you have children For more information about MNP’s Professional Services, or other dependents? visit our website at Creating a Financially Efficient Practice: At this point, your practice www.mnp.ca/en/professionals has demonstrated to you that you will be able create financial resources to meet your personal cost of living and accumulate wealth for your future financial goals. If you have not already done so, incorporation of your practice can usually add more power to your savings.

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 427 classifieds

Continued from page 426 70% on evenings/weekends. Contact Dr Chris breathtaking natural beauty and enviable qual- days other than Tuesday and Thursday. Patient Watt at [email protected]. ity of life. Combine a rewarding career with a loads guaranteed. Staffed with MOA and coun- satisfying lifestyle. E-mail [email protected]. selor. MSP billing available. Please apply by VANCOUVER—PRIVATE PRACTICE/ e-mail to [email protected] WALK-IN VICTORIA—WALK-IN or contact 604 715-6011 for more info. Our clinic is located in the heart of Vancouver Walk-in clinic shifts available in the heart of in the Cambie Village/Broadway corridor and lovely Cook St. Village in Victoria, steps from SURREY/DELTA/ABBOTSFORD—GPs/ right beside the Canada Line SkyTrain (Broad- the ocean, Beacon Hill Park, and Starbucks. SPECIALISTS way–City Hall Station). This is a large 1890 sq. For more information contact Dr Chris Watt at ft. facility with large windows. The front staff Considering a change of practice style or loca- [email protected]. tion? Or selling your practice? Group of seven will consist of an office manager and multiple locations has opportunities for family, walk-in, full-time medical office assistants. The clinic WEST VAN—FAMILY PHYSICIANS or specialists. Full-time, part-time, or locum will be looking for: walk-in physicians, locum doctors guaranteed to be busy. We provide physicians, family physicians, and specialists. West Vancouver, FP/walk-in. Continuum administrative support. Paul Foster, 604 572- Full-time and part-time positions are available. Medical Care is a large multidisciplinary clinic 4558 or [email protected]. Standard 30%/70% for remuneration. Please located in the heart of West Vancouver. We are contact [email protected] to e-mail your again expanding and are looking for primary resume and cover letter. Three months free care physicians to join our team of 12 FPs, 7 THROUGHOUT BC—CORRECTIONS rent. specialists, and a variety of allied health pro- MEDICINE fessionals. With over 17 000 patients, we are Curious about prison medicine? Interested in a blend of general medicine, psychiatry, ad- VERNON—AESTHETICS/VEIN/LASER seeking primary care physicians to work in dictions, infectious diseases, HCV, and HIV? Outstanding opportunity to join a well-estab- our recently opened walk-in clinic and in our lished and thriving GP derm/aesthetics/vein/ Opportunities exist in centres throughout newly renovated main clinic, offering full- laser practice in one of the best places to live in BC—Prince George, Interior, Lower Main- service family practice care. Specialty training Canada. We are looking for an associate/equity land, Vancouver Island. Mostly part-time. Fee- or diploma in sport medicine, geriatrics, life- partner(s). The office has all the latest technol- for-service. No overhead. EMR. No call. Full style medicine, concierge medicine, or execu- ogy and an excellent, congenial staff. Training nursing support. [email protected]. tive health would be an asset. Please contact provided but a special interest in dermatology Dr Bryce Kelpin at 604 928-8187, or e-mail a definite asset. The Okanagan has some of the [email protected]. VANCOUVER/RICHMOND—FP/ best weather, lakes, wineries, golf courses, ski SPECIALIST hills, and overall lifestyle anywhere in Canada, We welcome all physicians, from new gradu- if not the world. Contact Dr William Sanders: WILLIAMS LAKE—FP EMERGENCY ates to semiretired, either part-time or full- 250 558-9606, [email protected]. Seeking CCFP-EM or CCFP with ER expe- time. Walk-in or full-service family medicine rience. Cariboo Memorial Hospital services and all specialties. Excellent split at the busy VICTORIA (OAK BAY)—MD PARTNER a population of approximately 26 000 with South Vancouver and Richmond Superstore Derma Spa is a well established, medical/ 20 000 visits to the ER annually. ER is staffed medical clinics. Efficient and customizable cosmetic practice located in the charming sea- by six full-time ER physicians and a variety Oscar EMR. Well-organized clinics. Please side neighborhood of Oak Bay, Victoria. Our of part-time ER physicians (staffed 24/7). We contact Lisa at [email protected]. business is growing and we have an experi- have a 28-bed hospital with 3-bed ICU. Ex- enced medical, financial, and marketing team cellent collegial specialist support including VANCOUVER—FP in place to support you. Please contact Alex at general surgery, OB/GYN, pediatrics, inter- Mainland Medical Clinic is seeking a fam- 250 580-9428 or [email protected]. nal med, radiology, anesthesia, and psychia- ily doctor for our modern, multidisciplinary try. Further specialist support available at our street-level clinic in Yaletown, downtown VICTORIA—FAMILY PRACTICE referral centre in Kamloops. Williams Lake Vancouver. We have been operating for over ASSOCIATES is known for its outdoor opportunities and 13 years in a comfortable setting shared with Two well-established family physicians look- full range of amenities (including local col- a chiropractor, massage therapists, and a nutri- ing for associates. Bright, centrally located lege and airport). Contact 1 877 522-9722 or tionist to complement our three family doctors. family practice with extensive office space: six [email protected]. Ideally seeking someone with an existing prac- exam rooms including a minor surgical suite. tice—perhaps relocating or cutting back. We Excellent support staff. Work full- or part-time serve a broad spectrum of patients, both walk- and enjoy all the amenities and recreational medical office space ins and appointments. Excellent revenue split. activities in beautiful Victoria, BC! Contact The clinic offers a pleasant work environment [email protected]. ABBOTSFORD—MED OFFICE SPACE in an upbeat, fun neighborhood. Contact Dr Fully developed doctor’s offices available Brian Montgomery at brian@mainlandclinic. to lease. Includes seven examination rooms, VICTORIA—GP/WALK-IN com or 604 240-1462, or just drop by. treatment room, doctor’s offices, large recep- Shifts available at three beautiful, busy clinics: Burnside (www.burnsideclinic.ca), Tillicum tion centre, administration/storage area, filing VANCOUVER—FT/PT DERM (www.tillicummedicalclinic.ca), and Uptown shelves, etc. Located at Garden Park Tower, a Dermatologist wanted to join busy Aesthetic (www.uptownmedicalclinic.ca). Regular and modern 20-storey high-rise complex situated Medical Clinic in Vancouver. Full- or part- occasional walk-in shifts available. FT/PT GP in a densely populated area in the City of Ab- time. Please reply by e-mail to kt.crawford03@ post also available. Contact drianbridger@ botsford on Clearbrook Road. Contains two gmail.com. gmail.com. floors of professional services, and 111 fully developed and occupied condominiums. All VANCOUVER—LOCUM VICTORIA—SHARED PRACTICE professional space is well lit, easily accessible, Busy walk-in shifts in Kitsilano at Khatsahlano Ideal opportunity for Mandarin/Cantonese– air conditioned, and professionally maintained. Medical Clinic, three-time winner of Georgia speaking physician to join a turnkey, EMR Includes free parking (above ground and under Straight reader’s poll for Best Independent practice with a view to building the practice. ground). Excellent lease rates available. Call Medical Clinic in Vancouver. Split is 65%; Escape the high-cost accommodation in Van- 604 853-5532 or e-mail nadia.baran@garden couver and relocate to Victoria, known for its parktower.ca.

428 bc medical journal vol. 58 no. 7, september 2016 bcmj.org classifieds

sidized by pharmacy operating beside clinic. ABBOTSFORD—OFFICE SPACE Contact Rob at 778 235-8137 or e-mail robd@ CANADA-WIDE—MED Fully furnished, ready-to-go medical office claytonwellness.com. TRANSCRIPTION available for lease in heart of Abbotsford. Medical transcription specialists since 2002, Rent-free for 6 months! Clinic includes four Canada wide. Excellent quality and turn- VAN (VGH AREA)—MED OFFICE large exam rooms, reception area, large wait- around. All specialties, family practice, and SUBLEASE ing room with TV, two washrooms, large pri- IME reports. Telephone or digital recorder. Office space for psychiatrists, psychologists, or vate office, on-site free parking. Located in Fully confidential, PIPEDA compliant. Dicta- any other specialist MD. No secretary or other a professional building at a busy intersection tion tips at www.2ascribe.com/tips. Contact us additional overhead expenses. Top floor. Great with lots of walk-in traffic. Great opportunity at www.2ascribe.com, [email protected], or view. Two offices for sublease. One office is for someone looking for an existing space with toll free at 866 503-4003. bigger and has a sink and space for an exami- the flexibility to design their own practice and nation table. E-mail [email protected]. hours of operation. Please contact Frank Dyks- FREE MEDICAL RECORD STORAGE tra at 604 835-6300 or [email protected]. Retiring, moving, or closing your family prac- VANCOUVER (DWTN)—MED OFFICE tice? RSRS is Canada’s #1 and only physician- SPACE NEW WEST/VANCOUVER—MED managed paper and EMR medical records stor- Two established psychiatrists seeking a third OFFICE SPACE age company. Since 1997. No hidden costs. psychiatrist to share office space in the Rob- We have two locations suitable for a small Call for your free practice closure package: son Professional Building located on Robson medical practice and/or walk-in clinic. Space everything you need to plan your practice clo- Street. The space features two bright offices; is shared with existing pharmacy. Both loca- sure. Phone 1 866 348-8308 (ext. 2), e-mail reception/waiting room area; kitchen with sink, tions have three exam rooms and a small recep- [email protected], or visit www.RSRS.com. fridge, and microwave; and includes full secre- tion area. First location is in New West ready tarial services (reception, typing, and billing). for use. The second location is in Vancouver Opportunity for mentoring in assessment and PATIENT RECORD STORAGE—FREE on Commercial Drive and is to be ready in 3 treatment of ADHD and comorbidities avail- Retiring, moving, or closing your family or months, but can be viewed by appointment. able. Very reasonable rent. Available: January general practice, physician’s estate? DOCU- The space available is for physicians willing 2017. Call 604 687-0654 or e-mail inquiries to davit Medical Solutions provides free storage to run their own clinic, which means you will [email protected]. for your active paper or electronic patient re- not be splitting anything. Call 778 316-7111 or cords with no hidden costs, including a patient e-mail [email protected] for more information. mailing and doctor’s web page. Contact Sid VANCOUVER—WEST BROADWAY Soil at DOCUdavit Solutions today at 1 888 Fully furnished space for one or multiple doc- 781-9083, ext. 105 or e-mail ssoil@docudavit PORT COQUITLAM—MED OFFICE tors. Space can be used part-time or full-time SPACE .com. We also provide great rates for closing with short- or long-term arrangement possible. specialists. Approximately 1500 sq. ft. space in a high- Use some or all of the large space. MOA pro- traffic strip mall available. You will have a den- vided if needed. Extraordinary views. Con- tist office, massage therapist, physio, and much crete professional building with elevators, VANCOUVER—TAX & ACCOUNTING more available as your neighbors. Building is underground parking, and three restaurants. SVCS 16 years young. End unit. The neighborhood Available immediately. Please call Neil at 604 Rod McNeil, CPA, CGA: Tax, accounting, would love a doctor’s office. Available for im- 644-5775. and business solutions for medical and health mediate possession. Call for details: 403 828- professionals (corporate and personal). Spe- 9596/604 941-7025. cializing in health professionals for the past 11 WEST VAN—MED OFFICE SPACE years, and the tax and financial issues facing Medical office space available for part-time RICHMOND—MED OFFICE SPACE them at various career and professional stages. use on weekdays and weekends. Two rooms. The tax area is complex and practitioners are New modern EMR clinic in Steveston Village Great view, lots of natural light, ideal location looking for physicians to join our team. Oppor- often not aware of solutions available to them in Ambleside. Located in medical building and which avenues to take. My goal is to help tunities to start a practice or relocate existing with pharmacy, lab, X-ray, etc. Please e-mail practice without worrying about administra- you navigate and keep more of what you earn [email protected] or call 778 919- by minimizing overall tax burdens where pos- tive headaches. We offer base 70/30 split and 0585 or 604 356-3282. sible, while at the same time providing you higher for complex care and forms. Visit www with personalized service. Website: www. .HealthVue.ca or contact healthvuemedical@ rwmcga.com, e-mail: [email protected], gmail.com, 604 285-9888. WHISTLER—VISITING SPECIALISTS New office space for rent for visiting special- phone: 778 552-0229. ists in Whistler. Day rate, reception and book- RICHMOND—PSYCHIATRIST or ing, wheelchair accessible, free parking, avail- THERAPIST able now. For more information please call 604 Psychiatrist (and owner) wishes to share fully 905-1500 or e-mail [email protected]. furnished aesthetic office; 200 sq. ft. suitable for group or individual counselling. Wheelchair ac- BC Medical Journal cessible, ground floor, in-office sink. One parking spot. Quiet setting, trees and pond nearby. miscellaneous Available immediately weekdays and week- CME Cruise CANADA-WIDE—E TRANSCRIPTION 12-Night Quintessential Mexican ends from $95 per half-day. E-mail jasbhopal SVCS [email protected] or call 604 616-3250. E Transcription Services allows hospitals, clinics, and specialists to outsource a critical Family Practice Refresher SURREY (CLAYTON HEIGHTS)—NEW business process, reduce costs, and improve February 9–21, 2017 CLINIC, RENT FREE the quality of medical documentation. By out- San Diego, CA, USA • Roundtrip Brand new furnished medical clinic opening in sourcing transcription work you will be able to Surrey (Clayton Heights). An opportunity for increase the focus on core business activities Tel: 1-888-647-7327 a group of family physicians looking to lower and patient care. Our goal is to exceed your ex- [email protected] existing overhead or new physicians looking to pectations. Call for free trial 1 877 887-3186. www.seacourses.com start a practice. Lease and operating costs sub- www.etranscription.ca.

bc medical journal vol. 58 no. 7, september 2016 bcmj.org 429 back page

Proust questionnaire: Harvey Thommasen, MD

What profession might you have What is your greatest fear? What medical advance do you pursued, if not medicine? I have no fears; every day I live is a most anticipate? Conservation officer. bonus. Targeted immunotherapy therapy for cancer. Which talent would you most What is the trait you most like to have? deplore in yourself? What is your most marked I wish I could sculpt wildlife. I do not suffer fools gladly. characteristic? I have the ability to focus on complet- What do you consider your What characteristic do your ing tasks/projects without getting too greatest achievement? favorite patients share? distracted by the small stuff. I recently received a Nuxalk Indian My favorite patients remind me of my name: Ni-niits-m-layc, which means parents—both were disabled (deaf What do you most value in your “He who restores life,” from the Bella mute), poorly educated, but kind- colleagues? Coola hereditary chief’s family. hearted, hardworking, and keen to Hard work and commitment to im understand the world. proving community health. Who are your heroes? My grandfather, Victor Goresky, who Which living physician do you Who are your favorite writers? was a solo family physician working most admire? Roderick L. Haig-Brown (e.g., A Riv- in Castlegar. Dr Charles Helm of Tumbler Ridge. er Never Sleeps).

What is your idea of perfect What is your favorite activity? What is your greatest regret? happiness? Floating down the Bella Coola River That I did not have more time for my I am living it now. I just quit medicine on a warm September day watching wife and family when I was a young because there are no jobs for rural phy- for surfacing northern coho. doctor. sicians who do not want to do call, and I now just wander the woods, drift the Which words or phrases do you What is your motto? river, raise honeybees and ducks, bird most overuse? A Henry David Thoreau quote: “If a watch, and enjoy my wife’s company. “Hey man.” man does not keep pace with his companions, perhaps it is because he hears On what occasion do you lie? Where would you most like to a different drummer. Let him step to When I don’t want the person I am practise? the music which he hears, however with to get in trouble if they were I have worked in all the places I most measured or far away.” to know about something I probably wanted to practise—Masset (Chinook should not have done. salmon and halibut), Dease Lake How would you like to die? (pike, grayling, and large rainbow In my sleep or on a glacier like Otzi Dr Thommasen is a recently retired rural trout), Houston (steelhead), Tumbler the Iceman—someone I am genetical- family physician and has been a frequent Ridge (fossil fish), and Bella Coola ly related to according to 23andMe. contributor to the BCMJ. (sea-run trout, salmon, and char).

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bc medical journal vol. 58 no. 7, september 2016 bcmj.org 431 Essential Medical Legal Toolkit

For FAMILY PHYSICIANS and SPECIALISTS

Medical Legal Reports: Medical Legal Reports Advanced The Essentials and Testifying in Court: Saturday, November 26, 2016 or Becoming a Great Expert Saturday, February 25, 2017 (9 am–4 pm) Saturday, March 4, 2017 (9 am–4 pm) Does writing medical legal reports cause you Physicians and all health care professionals generally prefer stress? Not sure what to write when asked about not to testify in court. This course will provide advanced prognosis? Need help figuring out how much training on writing more complex medical legal reports as you should be billing for your reports? What to well as how to reduce the stress of testifying in court. do when patients have subjective complaints? This course will outline: This course will outline: • Advanced skills for successful medical legal report • The essential components of a medical legal writing report • How to address issues of patient compliance/adherence • How to clearly narrate the patient’s history, and possible secondary gain in a medical legal report physical examination findings, diagnosis and • How to answer complex questions related to Cost of prognosis Future Care and Future Treatment • The steps to complete a medical legal report • The role of the medical/health professional expert efficiently witness in court • How to streamline the payment/invoicing for • How to prepare for court testimony medical legal reports • How to succeed in the various parts of expert testimony: • How lawyers, juries and judges identify the Qualifying the expert, direct testimony, good, bad and ugly medical legal report cross examination, re-direct • Common challenges with medical legal • Common pitfalls and traps in court—and reports and how to easily resolve them how to avoid them

Teaching Faculty: Register at www.medlegaltoolkit.com These courses will be taught by medical and legal professionals Cost: $490/course who have extensive medical More information: 604-525-8604 or email legal experience and have taught [email protected] numerous courses for health care professionals and lawyers. The legal teaching faculty have busy personal injury practices and know exactly what they want from medical legal reports and expert 432Dr Gurdeepbc medical Parhar journal testimonyvol. 58 no. 7, septemberin court. 2016 bcmj.org