Telephone-based interpretation in October 2016; 58: 8 family physician offices in BC Pages 433–488 Electronic wound monitoring after breast cancer surgery Chikungunya: A disease risk for Canadians traveling in the tropics

Children’s mental health: Is poverty the diagnosis? bcmj.org October 2016 Volume 58 • Number 8 contents Pages 433–488

A R T I C L E S 442 A pilot study of telephone-based interpretation in family physician offices in British Columbia Patricia Gabriel, MD, Adaora Ezeaputa, MD, Cristina Liciu, MD, Sarah Grant, MD, Sarah Grant, MD, Emma Preston, MD Established 1959 448 Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app Hamish Hwang, MD 454 Children’s mental health: Is poverty the diagnosis? Ivana Jakovljevic, MD, Ashley P. Miller, MDCM, Barbara Fitzgerald, MD 461 Chikungunya: A disease risk for Canadians traveling in the tropics Derryck H. Smith, MD, John P. Wade, MD

On the cover: Children living in poverty have higher O P I N I O N S rates of mortality, hospital- ization, asthma, obesity, and Editorials psychiatric conditions. Phy­ 436 sicians can give them a Not an all-access pass, David R. Richardson, MD (436) hand up by screening for Anonymity, Anne I. Clarke, MD (437) poverty and making treat- ment recommendations that address the family’s lack of 438 Personal View income and resources. Arti­ I wash my hands of this: A plea for emotional hygiene cle begins on page 454. Justine Spencer, MD 439 President’s Comment Opioid prescribing: The profession and the patients we serve and support Alan Ruddiman, MBBCh, Dip PEMP, FRRMS 486 Back Page Proust Questionnaire: David Patrick, MD

ECO-AUDIT: Environmental benefits of using recycled paper D E P A R T M E N T S Using recycled paper made with post- consumer waste and bleached without the use of chlorine or chlorine compounds results in 440 BC Centre for Disease Control measurable environmental benefits. We are pleased to report the following savings. Incidence of infectious syphilis continues to increase in BC • 1399 pounds of post-consumer waste used Christine Lukac, MPH, Troy Grennan, MD, Muhammad Morshed, PhD, instead of virgin fibre saves: • 8 trees Jason Wong, MD • 760 pounds of solid waste • 837 gallons of water • 1091 kilowatt hours of electricity (equivalent: WorkSafeBC 1.4 months of electric power required by the 465 average home) Canadian Chiropractic Guideline Initiative for effective knowledge • 1382 pounds of greenhouse gases (equivalent: Jeffrey A. Quon, FCCSC 1119 miles traveled in the average car) translation, • 6 pounds of HAPs, VOCs, and AOX combined • 2 cubic yards of landfill space College Library Environmental impact estimates were made 466 using the Environmental Paper Network Paper ClinicalKey is mobile Calculator Version 3.2. For more information visit www.papercalculator.org. Karen MacDonell, PhD

434 bc medical journal vol. 58 no. 8, october 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

D E P A R T M E N T S ( Continued) 467 Pulsimeter BCMJ survey: Thank you and congratulations (467); Order of Canada recipients (467); Congratulations to all 2016 CMA Honorary Membership Award winners (467); Two BC docs editor recognized by their Alberta alma mater (467); Private wide-area David R. Richardson, MD network technical support available (467); STI testing and cervical editorial board cancer screening: Need for continued STI screening among young David B. Chapman, MBChB people in the era of new cervical cancer screening guidelines, Dirk Anne I. Clarke, MD Brian Day, MB van Niekerk, MD, Troy Grennan, Gina Ogilvie, MD (468); BC at GC: Susan E. Haigh, MD Home sweet home, Eric Cadesky, MD (469); Seeking nominations Timothy C. Rowe, MB for Doctors of BC 2017 awards (469); Online resource simplifies Cynthia Verchere, MD Willem R. Vroom, MD billing codes (470); Transitioning patients to the Modernized (470); managing editor Reference Drug Program CareCard to be retired in February Jay Draper 2018 (470); Crohn disease discovery (472); A virtual scalpel for senior editorial and UBC medical students (472); Noninvasive technique to monitor production coordinator migraines (472); Synthetic heart valves to help improve surgical Kashmira Suraliwalla skills (473) associate editor Joanne Jablkowski Calendar copy editor 474 Barbara Tomlin Council on Health Promotion proofreader 477 Ruth Wilson Driving stoned: Marijuana legalization and drug-impaired driving Chris Rumball, MD design and production Scout Creative Classifieds COVER CONCEPT 479 & ART DIRECTION Jerry Wong In Memoriam Peaceful Warrior Arts 482 Dr D’Arcy D. Lawrence printing Richard Mark, MD Mitchell Press advertising Billing Tips Kashmira Suraliwalla 484 604 638-2815 Advice about a patient in community care (fee item 13005) [email protected] Keith J. White, MD

ISSN: 0007-0556 484 Advertiser Index 485 Club MD

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bc medical journal vol. 58 no. 8, october 2016 bcmj.org 435 editorials

Not an all-access pass “ xcuse me, are you wearing one ing program in our province. SPARC snide comment, “Well, just wait until of those new Fitbits?” I asked isn’t a misspelling of a small fiery par- you get old, doctor.” Ea healthy looking woman in ticle thrown from a fire; it stands for Family members also request her 40s while shopping. Social Planning and Research Coun- parking passes for their disabled non- “Oh, yes, I am. Not only is it cil. I perused their website and a few driving relatives. They plan to use the stylish but it tracks my activity. I do rules jumped out at me. Specifically, pass when taking grandma out shop- between 5000 and 10 000 steps per only the permit holder is allowed to ping or on other errands. I frequently day,” she answered proudly. use the parking pass, and they can’t get the impression that the pass will “Wow, that’s really good, espe- use it unless they actually get out of become a well-used regular fixture in cially for someone with a physical the vehicle after parking. their vehicle. When asked why they disability,” I replied. I’m sure many of you get requests can’t drop grandma off at the door and “What are you talking about?” she to fill out the medical information then go park the car, more snide com- queried. on the SPARC application. The cri- ments drift my way. Again, the indi- “On the way in I noticed that you teria are quite strict, and I am often viduals making these requests often parked in a disabled parking spot,” I surprised by the patients who ask me have BMIs that would benefit from remarked, at which point our conver- to complete a request for a permit. I an increase in physical activity. sation came to an abrupt end. have patients who have been begging Now, the majority of the requests As I was driving up to the store all me for years to complete the form I receive are legitimate. And I am of the parking spaces were full except because walking is painful for them. I struck by the courage and fortitude of for the disabled one so I parked down have been called cruel and mean when the majority of my disabled patients the block. I was a little taken aback I decline, despite explaining that their and aging seniors who would only when this woman pulled in to the dis- obesity-related illnesses of diabetes apply for a permit as a last resort, abled spot and came into the store I was and mechanical back pain would be and often have to be coerced into tak- in. Perhaps I shouldn’t have said any- better served by parking as far away ing this necessary step. I hope to act thing, but I get tired of the way people as possible and walking. similarly if I am faced with new chal- misuse these parking passes. I should One senior patient who requested lenges as the years pass. So, lastly, I mention that this woman did have a a pass became quite offended when would like the physicians of BC who valid SPARC BC pass hanging from I asked them to outline the nature of complete SPARC applications to keep the rearview mirror of her vehicle. their disability. “Well, I’m old,” was in mind that this valuable program is SPARC BC is the organization the answer. The statement that age a privilege that shouldn’t be abused. that administers the disabled park- wasn’t a disability was met with the —DRR

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436 bc medical journal vol. 58 no. 8, october 2016 bcmj.org editorials

Anonymity

here are pros and cons to be- In public forums it can be advan- trained with him and we had worked ing part of a small community tageous for physicians to be profes- together for more than 2 years. T when you are a physician. sionally incognito, so to speak, but on “Well, Ms Clarke, your baby is Some days it seems that everyone the other hand, when you need health big and you are not, and I am not sure knows who you are and what you are care, it’s a perk to be recognized as if you can deliver this baby on your like, and other days you are a total a physician. My family doctor asked own.” stranger—when you see someone out me if I wanted to deliver at my own “John,” I said, “it’s me, Anne.” of context they can be completely un- hospital or if I would be more com- There was a very pregnant pause, par- familiar. fortable going a bit farther down the don the pun, as the light of recogni- My first job was in a bustling bed- tion suddenly shone over his face. room community, 15 minutes north “Oh, OOHH, I didn’t recognize down a country road from where we After about 2 minutes you.” To this day I put this oversight lived. There was not a single stoplight I informed them I wanted down to it being four in the morning on my brief commute to the hospi- an epidural, like now. and not my pudgy face, unwashed tal—just one grocery store, a Cana- hair, and sweaty brow. dian Tire, and a local watering hole. All went well, I didn’t need a I did most of the family food shop- road. Labor tends to be the time in C-section and was soon up in my ping in those days. One day, as I was a woman’s life when modesty and room with a baby I had no idea how waiting patiently at the deli counter decorum go out the window. Could I to care for. I had so many staff coming for the salami I ordered to be sliced, face my colleagues if I were a raving to visit and congratulate me that I left the woman behind the counter asked, lunatic in the delivery suite? ASAP so I could get on with the busi- “Are you one of the doctors who Like any typical patient with a ness of neonatal care. —AIC works in emergency?” busy life, convenience matters a lot! These conversations can go well, I decided to stay local and was ready or not so well. After a slight hesita- when the contractions started. With tion I answered, “Yes, I am.” Coming angelic patience, I made my husband The KEY to SUCCESS with from big, anonymous Toronto I was turn off the US Open Golf Tourna- SPEECH RECOGNITION taken aback that anyone who I didn’t ment NOW (“but Honey, this is a know would recognize me. really crucial putt!”) and we drove ® “Well, you looked after my mother down the quiet country road to the Certifi ed Dragon last month [she was in her 80s] with a labor ward. Medical Software sore back, and it is still sore! You said Many of the nurses recognized Sales & Training you didn’t know what was causing her me, which made me feel very com- pain and it has not gone away.” fortable, but it didn’t mean that I was By then my package of thin-sliced about to leave my ER persona at the One-on-one training sessions salami was sitting tantalizingly on the door and be a patient. After about 2 Customized to your workfl ow glass countertop. We both had our minutes I informed them I wanted an and specifi c needs hands on it—me pulling one way and epidural, like now. All laughter and Complete initial, basic, and the deli clerk not letting go. Extrica- smiles, the staff thought I was hilari- advanced instruction available tion was foremost on my mind. First, ous. I made it very clear that I was not Exclusive and professionally I honestly couldn’t remember this joking. “This pain is really, really bad. written training materials woman, and second, it was clear my Please get rid of it.” Follow up assistance and support care had not met their expectations. “But we haven’t even finished “I am sorry she is not feeling bet- booking you in; you just arrived.” Solutions ter, I hope she will go see her family In retrospect, I don’t think the seat doctor.” By that point I was firmly in was even warm yet. CONTACT US TODAY! control of the cold cuts and quickly When the obstetrician arrived he moving toward the checkout. I made sat down beside me, introduced him- a mental note that it was time for my self, and starting getting my history. speakeasysolutions.com 1-888-964-9109 husband to start doing more of the It became quite apparent he had no food shopping. idea who I was, despite the fact that I

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 437 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.

I wash my hands of this: trained, and even selected, by medical In a busy practice there is simply A plea for emotional hygiene schools and residency programs to be no time to fully address our emotional As a recent graduate of a Canadian compassionate and empathetic; this reaction to every situation. However, a medical school, it has been cement- means we will feel the pain alongside small amount of recognition, respect, ed in my brain that I am to wash my our patients. Even the emotional trau- and mindfulness around the effects hands before and after every patient ma of a devastating physical diagno- of these events may help to prevent interaction. I’m grateful for this prac- sis can leave us feeling depleted and many of the negative consequences. tice, which keeps me and my patients raw. I will make a proposal, even a plea, safe from contagious infections. What In medical school we are taught to my medical colleagues: just as you is taught with much less emphasis, about transference and countertrans- wash your hands between patients, however, is the transmission of emo- ference; the former being when a acknowledge the emotional baggage tions from one patient interaction to patient projects their experiences with that you bring with you from the pre- the next. I suspect that just as bacte- another person onto the practitioner, vious patient encounter, and greet rial and viral infections can be passed the latter being from practitioner to your next patient with presence and from one patient to the next, then even patient. If traumas are not acknowl- a clean heart. Just as I do a thorough taken home with the practitioner, so edged and given the space to dissi- hand washing before heading home too can emotional trauma. pate, it is inevitable that we will end each day, I would argue for instituting As medical practitioners we are up projecting our experiences onto a type of emotional scrub in the form given the immense privilege of being future patients. Similarly, initiating a of a check-in, either with yourself or welcomed into the personal emo- patient encounter with depleted psy- with a colleague, to address the bur- tional world of many of our patients. chological reserves may lead to infe- dens of the day so you don’t take them Trauma, mental health issues, and rior patient care. At the end of the day home with you. difficult social situations are common we take the compounded trauma back —Justine Spencer, MD reasons why a patient seeks care from to our personal lives, with possibly UBC Family Practice PGY-2 their health care provider. We are few reserves left to manage them.

438 bc medical journal vol. 58 no. 8, october 2016 bcmj.org president’s comment

Opioid prescribing: The profession and the patients we serve and support et’s consider a patient named prescription twice the amount of opi- The new College standards make Jack—an active 26-year-old oids per capita compared with Que- BC doctors the first in Canada to be Lmale who developed a depen- bec, the lowest dispensing Canadian legally bound by strict opioid and dency on opioids after suffering a province. In the late spring, on the narcotic prescribing practices, and lower-back injury that caused him heels of the declared opioid crisis, the include requirements such as talking acute, then chronic, severe lower- College of Physicians and Surgeons frankly with patients about alterna- back pain. With there being no medi- of BC swiftly introduced its new stan- tives to opioids—clearly communi- cally identifiable reason for his pain, dards, Safe Prescribing of Drugs with cating that these medications aren’t he was treated with opioids prescribed Potential for Misuse/Diversion, which pain killers but pain reducers and not by his GP, as well as ER and walk- all doctors were urgently required to stand-alone long-term solutions. This in clinic doctors—prescriptions that familiarize themselves with. While doesn’t mean we should shy away were renewed and refilled regularly. the method and manner in which from prescribing opioids in a safe Over time Jack became dependent and appropriate manner when clini- on the prescriptions, requiring them cally necessary. We offer great value to function on a daily basis and suf- to society by continuing to support fering terrible withdrawal symptoms Accordingly, and treat patients who are experienc- without them. His increased reliance as opiate prescribers, ing acute and chronic pain-related caused him to turn to illicit drugs— conditions. But it’s time to recon- we have a significant something he was embarrassed to sider the landscape surrounding how confess to his doctors even though he responsibility and role we prescribe these potentially highly wanted help—but he feared the street to play in helping end addictive substances. The bottom line drugs could be laced with fentanyl or this crisis. when prescribing is patient safety— that he could accidentally overdose ensuring the potential risk or harm to and die. patients is fully realized, discussed, In the first 7 months of 2016 there and mitigated. were 433 deaths from drug overdos- Not all patients who are prescribed es in BC—an increase of more than the College launched this initiative opioids are or will become addicts, 70% from the same period in 2015, has been questioned by many within but we need to screen for and listen and enough to spark BC to be the first the profession, this is without doubt to those who are indeed addicted to province to declare a public health an urgent call for action and atten- opioids; suspend any judgments we emergency. I want to express some tion to address our provincial and have that label them as drug seekers; personal views on this topic—views national prescription opioid crisis and and recognize that their addiction is that I suspect will be provocative but epidemic. a medical condition no different than that I’m sharing in the hope that they There’s a great deal physicians diabetes, hypertension, or chronic encourage an open discussion. can do to support patients and the pro- kidney disease. We need to offer long- While these deaths may seem be- fession in this crisis. As professionals term, evidence-based solutions. yond the reach and scope of our own who have an obligation to provide We should take a collaborative practices, as a profession we must the very best care to our patients, I approach to support the seamless in- acknowledge how many of these pa- believe there are a number of steps tegration of professional tools and tients have arrived in their desperate we can take now to ensure this occurs. resources such as PharmaNet into circumstances—not unlike Jack— Some examples include increasing physicians’ practices, but in a way and that we are in the midst of a ma- efforts to improve and enhance iden- that isn’t cumbersome to physicians jor public health crisis. Accordingly, tification of patients at risk for opi- or staff—in a way that allows for ease as opiate prescribers, we have a sig- oid addiction and enacting strategies of use and prescriber efficiency while nificant responsibility and role to play within our own prescribing habits for ensuring patient safety. in helping end this crisis. improved and safer prescribing prac- Physicians, the Ministry of Health, As a province, BC dispenses on tices, among others. Continued on page 441

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 439 bc centre for disease control

Incidence of infectious syphilis continues to increase in BC

he incidence of infectious syphilis (i.e., primary, second- 35.0 T ary, early latent) has increased 30.0 nearly fivefold from 2010 to 2015 25.0 in BC, and is projected to further 20.0 increase in 2016 ( Figure 1 ). Men who have sex with men (MSM) are dis- 15.0

proportionately affected by infectious Incidence per 100 000 10.0

syphilis. In the first half of 2016 over 5.0 86% of men diagnosed with syphilis 0.0 identified as MSM. 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 While relatively few cases of Men 9.7 12.1 11.5 13.2 8.6 6.4 8.0 15.2 23.5 22.8 31.5 31.6 Women 4.1 3.6 2.5 1.9 1.3 0.6 0.6 1.1 0.9 1.0 1.2 1.5 infectious syphilis are diagnosed BC population 6.9 7.8 7.0 7.5 4.9 3.4 4.2 8.1 12.2 11.9 16.2 16.4 among women, incidence is increas- Years ing among women of childbearing age, raising concerns for congenital Figure 1. Incidence of infectious syphilis diagnoses by gender in BC, 2005–16. syphilis. In the United States a 40% *Annual incidence of infectious syphilis in 2016 was estimated based on data collected between increase in congenital syphilis was January and June 2016. observed from 2012 to 2014.1 In the first half of 2016, there were two in- fectious syphilis cases diagnosed in All positive syphilis results (serology or PCR) are pregnant women in BC. No congeni- reviewed by a physician at BCCDC to help diagnose, tal syphilis cases have been reported since 2012, likely owing to a strong stage, and treat syphilis infections. Nurses at the prenatal screening program. BCCDC follow up with all diagnosed individuals to Syphilis and HIV co-infection is provide education, arrange treatment and follow-up a significant concern, as HIV impacts testing, and discuss partner notification. the clinical manifestations of syphi- lis2 and may lead to poorer treat- ment responses.3 As well, syphilis patients, particularly those present- reminders by text message or e-mail, can increase the risk of transmission ing with a new lesion or rash. Since available at www.smartsexresource and acquisition of HIV.4 In BC about syphilis can present without obvi- .com/get-tested/testing-reminders. 40% of syphilis cases are co-infected ous symptoms, routine screening for Serology is the primary means to with HIV. However, over 80% of co- sexually transmitted infections is rec- diagnose syphilis. However, with the infected cases had undetectable HIV ommended. Individuals at higher risk appropriate transport medium, PCR viral loads (i.e., < 40 copies/mL), sug- of acquiring syphilis, such as those testing of oral, anal, and genital le- gesting that the risk of HIV transmis- with multiple sexual partners and sions can also be done. All positive sion is very low. those belonging to groups with high syphilis results (serology or PCR) are Counseling patients to use safer rates of syphilis like MSM, should be reviewed by a physician at BCCDC to sexual practices, such as consistently screened every 3 to 6 months. Among help diagnose, stage, and treat syphi- using condoms, can help prevent the pregnant women syphilis screen- lis infections. Nurses at the BCCDC spread of syphilis. Clinicians should ing should be performed during the follow up with all diagnosed indi- consider syphilis as part of their differ- first trimester. Screening should be viduals to provide education, arrange ential diagnosis in all sexually active repeated at 28 to 32 weeks and at treatment and follow-up testing, and delivery for women at high risk of discuss partner notification. This article is the opinion of the BC Centre syphilis (e.g., those with new sexual Benzathine penicillin G delivered for Disease Control and has not been peer partners).5 The BC Centre for Dis- intramuscularly is the preferred treat- reviewed by the BCMJ Editorial Board. ease Control (BCCDC) offers testing ment; oral doxycycline is an alter-

440 bc medical journal vol. 58 no. 8, october 2016 bcmj.org bccdc president’s comment

native in case of penicillin allergy. Continued from page 439 talk and engage openly with your Sexual partners exposed in the past 3 the College, other stakeholders, and patients about the opioid crisis we months should be tested and treated, patients all have a role to play, and as are facing. I also encourage you to as it can take up to 3 months before partners in health care, together we let me know your thoughts on this syphilis can be diagnosed by serol- can make a difference. For doctors, topic. E-mail me at president@ ogy.6 the health and safety of our patients doctorsofbc.ca, and I will share For further information about is of utmost importance. We must do some of the feedback I receive on syphilis screening or treatment, con- everything in our power as a profes- my President’s Blog. Let’s start the tact the BCCDC public health nurse sion to help support and protect our conversation. at 604 707-5607 or physician at patients—most of whom are often —Alan Ruddiman, MBBCh, Dip 604 707-5610. unknowingly vulnerable—by elimi- PEMP, FRRMS —Christine Lukac, MPH nating the judicious overprescribing Doctors of BC President —Troy Grennan, MD, FRCPC of opioids. I ask you all, please —Muhammad Morshed, PhD —Jason Wong, MD, CCFP, FRCPC

References 1. Bowen V, Su J, Torrone E, et al. Increase in incidence of congenital syphilis – Unit- ed States, 2012-2014. MMWR Morb Mortal Wkly Rep 2015;64:1241-1245. 2. Rompalo AM, Joesoef MR, O’Donnell JA, et al. Clinical manifestations of early Image-guided Pain Management? syphilis by HIV status and gender: Re- sults of the syphilis and HIV study. Sex Transm Dis 2001;28:158-165. 3. Knaute DF, Graf N, Lautenschlager S, et al. Serological response to treatment of syphilis according to disease stage and HIV status. Clin Infect Dis 2012;55: 1615-1622. 4. Fleming DT, Wasserheit JN. From epide- miological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Inf 1999;75:3-17. 5. Public Health Agency of Canada. Cana- dian guidelines on sexually transmitted MedRay now offers MSP-funded infections. Accessed 18 August 2016. www.phac-aspc.gc.ca/std-mts/sti-its/ cgsti-ldcits/section-5-10-eng.php. 6. BC Centre for Disease Control. British Spinal Procedures in the Tri- Columbia treatment guidelines – sexu- ally transmitted infections in adoles- cents and adults, 2014. Accessed 18 August 2016. www.bccdc.ca/resource or visit our website at www.medrayimaging.com -gallery/Documents/Communicable -Disease-Manual/Chapter%205%20 MedRay Imaging Medical Corp -%20STI/CPS_BC_STI_Treatment_ 108-3001 Gordon Ave, Coquitlam, BC Guidelines_20112014.pdf. Medical Director - Dr Brad Halkier, MD, FRCPC

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 441 Patricia Gabriel, MD, MSc, CCFP, Adaora Ezeaputa, MD, CCFP, Cristina Liciu, MD, CCFP, Sarah Grant, MD, Emma Preston, MD, PhD

A pilot study of telephone-based interpretation in family physician offices in British Columbia

The use of telephone-based professional medical interpreters in fee-for-service family physicians’ offices improves quality of care, is feasible, and is affordable. Access to this service is recommended across the province.

ABSTRACT Background: Evidence shows that and residents. Over the course of the address difficulties, positive experi- patient care is affected by language study, physicians from New West- ences with telephone-based inter- barriers and that health disparities minster, Coquitlam, Port Coquitlam, pretation, challenges with telephone- can result when care providers can- and Port Moody, with later additions based interpretation, and support for not communicate with patients. In from Burnaby and Comox, partici- ongoing provision of interpretation British Columbia there is currently pated. Data collected by the Pro- services. Physicians who used the no province-wide system to support vincial Language Service, including telephone-based interpretation ser- the use of interpreters in community- the language of interpretation and vice noted that doctor-patient com- based fee-for-service family physi- length of each call, were analyzed munication was improved and found cian offices. Due to the negative con- to determine usage patterns for the the service particularly valuable for sequences of language barriers for quantitative evaluation. Physician more complex or sensitive health patients, physicians, and the health responses from semi-structured issues. Overall, physicians were pos- care system, a pilot study was pro- telephone interviews were analyzed itive about the prospect of using the posed to evaluate the provision of to identify common themes for the interpretation service in future. professional medical interpreters by qualitative evaluation. Conclusions: This pilot study dem- telephone to fee-for-service family Results: Interpretation was provid- onstrated the feasibility and afford- physicians in several BC cities. ed in 17 different languages during ability of providing interpretation Methods: From October 2013 until the 30-month study period, with 26 March 2016, members of the Fra- physicians participating in 145 calls. Dr Gabriel is a clinical associate profes- ser Northwest Division were given The average length of a call was 12.4 sor in the Department of Family Practice access to interpreters­ through the minutes and the average cost per call at the University of British Columbia, and Provincial Language Service. Physi- was approximately $22. A total of 17 a family physician and maternity care pro- cians were informed of the division- physicians were interviewed about vider at Royal Columbian Hospital in New funded telephone-based interpre- their experience with language bar- Westminster. Dr Ezeaputa is a family physi- tation support available during the riers, including 8 physicians who had cian practising in Agassi. Dr Liciu is a family study through division meetings, the used the interpretation service and 9 physician practising in New Westminster. division newsletter and website, the physicians who had not. Analysis of Dr Grant is a family practice resident at the Pathways online resource, and office physician responses identified five University of Calgary. Dr Preston is a family visits by volunteer medical students themes: common difficulties with practice resident at the University of British language barriers, methods used to This article has been peer reviewed. Columbia.

442 bc medical journal vol. 58 no. 8, october 2016 bcmj.org A pilot study of telephone-based interpretation in family physician offices in British Columbia

by telephone in family physician of- ry care settings based on concerns for have acted systematically to imple- fices to address language barriers. health quality, equity, ethics, law, eco- ment interpretation programs.9,11,12 In Physicians who used the service nomics, and precedence. Care provid- British Columbia interpretation ser- were generally very positive regard- ed with the help of professional medi- vices for 150 languages are provided ing their experience and found the cal interpreters is superior to care through the Provincial Language Ser- interpreters to be professional and provided with ad hoc interpreters,7 vice (PLS), which has professional accurate. Despite this positive expe- and is comparable to care received medical interpreters available to work rience and the need for interpreta- by patients who do not have language in person, by telephone, or by video- tion in BC family practices, utiliza- barriers.8 Ethical arguments for inter- conference 24 hours a day. Access tion of interpreters during the study pretation are supported by evidence to this service is provided by health was low and uptake for the service that health care inequity can result authorities for use in hospitals and in was slow. Interviews with physicians from language barriers, and in the some community health care clinics. suggest that underutilization may be the result of concerns about accu- racy, logistical challenges, and the amount of time needed for an ap- pointment involving interpretation by telephone. Based on pilot study findings, access to professional medical interpreters for all family Ideally, every Canadian would receive physicians across the province is language-concordant health care. recommended.

Background Communication is integral to the provision of health care services. In Canada, language barriers have been shown to result in health disparities,1,2 with a wealth of evidence indicating United States the provision of inter- However, only 2.5% of longitudinal that equity, effectiveness, communi- pretation services is viewed as a legal care by family physicians takes place cation, patient safety, patient centred- obligation for health care providers.9 in these settings.13 In the more com- ness, and timeliness of care are all Although there is no Canadian legis- monly used fee-for-service setting, affected. 1,3-5 Ideally, every Canadian lation requiring the provision of inter- either the physician or the patient would receive language-concordant pretation, health care providers may must pay for any interpretation ser- health care, where the health care be considered negligent and found vice. Historically, no system has been provider and patient are both able to liable for harm resulting from poor in place for funding this service in speak the same language. According communication. Several malpractice community-based fee-for-service to Statistics Canada,6 15.8% of BC suits in Canada demonstrate that this family physician offices. residents (25.8% in Metro Vancouver) is a risk.1 Economic arguments for A 2013 qualitative study of fam- speak a language other than English interpretation show there is a cost for ily physician experience in British at home and 3.4% of the population not providing interpreters, including Columbia confirmed that practitioners (5.7% in Metro Vancouver) have no unnecessary interventions and tests, have observed the negative conse- English language skills. While inter- and increased hospital utilization.1 As quences of language barriers for their pretation is obviously needed to care for the expense of providing interpret- patients, for themselves, and for the for the non-English-speaking patient ers, most studies have demonstrated health care system.14 Most physicians population, professional language only a short-term increase in costs.10 studied relied on informal interpreta- services are unavailable in most pri- Other countries have identified tion from family or staff members, mary care settings in BC. the need for interpreters in primary but recognized that this was subopti- Strong arguments have been made care settings. Australia, New Zealand, mal because of a lack of confidential- for providing interpretation in prima- and the United States, among others, ity, inaccurate interpretation, and the

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strain put on family relationships. To tings. Physicians were informed of two residents and the research lead follow up on this qualitative research, the availability of PLS interpreters assigned codes and identified themes a pilot study was proposed to provide through division meetings, the divi- for the nine interviews completed to and then evaluate interpretation in the sion newsletter and website, the Path- date. In 2015, two medical students fee-for-service primary care setting in ways online resource, and office vis- trained in qualitative analysis repeat- British Columbia. its by volunteer medical students and ed the coding and theme identification residents. for all 17 interviews completed. Methods For the quantitative evaluation Ethics approval for this research This pilot study ran from October 2013 we analyzed PLS data, including the was obtained from the UBC Behav- to March 2016 with communities in physician’s name, when the service ioural Research Ethics Board. the Fraser Northwest (FNW) Divi- was used, the language of interpre- sion of Family Practice: New West- tation, and the length of the call. For Results minster, Coquitlam, Port Coquitlam, the qualitative evaluation, we issued During the 30-month study period, and Port Moody. The Comox Valley an invitation by e-mail or phone to interpretation was provided in 17 dif- and Burnaby Divisions of Family any physician accessing the service ferent languages, with 26 physicians Practice were added later in the study. for the first time and asked all new participating in 145 calls. The aver- Accounts were set up for each divi- service users to participate in a semi- age length of a call was 12.4 min- sion with the Provincial Language structured telephone interview. We utes and the average cost per call was Service, and a unique division code also randomly selected other physi- approximately $22 (12.4 minutes x was used by family practices arrang- cians from the FNW and Comox divi- $1.80 per minute). The languages ing for PLS to provide interpretation sions who were nonusers of the ser- used most frequently were Nepali, by telephone for office-based appoint- vice and invited them to participate in Korean, Vietnamese, Punjabi, Man- ments. Costs were covered by the a similar interview. The interviews for darin, Farsi, and Arabic ( Figure ). The Divisions of Family Practice at a rate users consisted of open-ended ques- predominance of Nepali speakers re- of $1.80 per minute. Interpreters were tions about physician experience with quiring interpretation was the result not available for office visits because professional medical interpreters. of including data from one clinic with of the added in-person service cost (a The interviews for nonusers focused a large number of Bhutanese refugees 1.5-hour minimum charge at a rate of on determining if there was a need for who were seen for prenatal care. $45 per hour). interpretation and, if so, what barri- In total, 17 physicians were inter- Study participants were restricted ers had prevented the physician from viewed, including 8 physicians who to those division members working using the service. All interviews were had used the service and 9 physi- in fee-for-service primary care set- audiotaped and transcribed. In 2014, cians who had not. Analysis of the interviews identified five themes ( Table ) and confirmed that most phy- sicians had personal experience with 60 language barriers that had affected 50 patient care. As well, most physicians relied on family members and friends 40 to provide interpretation informally, leading to concerns about confiden- 30 tiality and accuracy of interpretation. Some physicians asked medical office 20 Interpretation calls assistants and caseworkers to serve as 10 interpreters or used the Google Trans- late app. 0 Physicians who used the phone- Thai FarsiArabic Karen based interpretation service noted that NepaliKorean Punjabi Russian Tagalog Mandarin SpanishJapanese Amharic Ukrainian Vietnamese Cantonese Portuguese doctor-patient communication was improved and found the service par- Figure. Languages interpreted during pilot study, 2013 to 2016. ticularly valuable for more complex

444 bc medical journal vol. 58 no. 8, october 2016 bcmj.org A pilot study of telephone-based interpretation in family physician offices in British Columbia

Table. Themes identified in interviews with physicians during pilot study, 2013 to 2015.

Theme Sample responses

Physicians had previous difficult • So often you get to see patients and you’re unable to characterize their pain because of language barriers. experiences with language • Sometimes it’s just charades and gestures and trying to work out mutual understanding. barriers • It can get a bit tricky when you’re trying to ensure that they [friends or family members serving as interpreters] have consent to talk about sensitive or potentially sensitive issues or parent/child relationships where you might be asking for information . . . you’re worried you might not get appropriate or complete information.

Physicians had tried various ways • In the quick pace of the office I relied on the friend rather than going to any other method. to address language barriers, • The family member is going to be intentionally or unintentionally biased towards translating and doesn’t primarily using family and friends know exactly how to translate . . . medical words . . . and who knows if they [are] . . . telling me what the to interpret patient actually said.

Physicians had positive • [The PLS interpreter] was well trained in medical terminology and medical interviewing and she really experiences with telephone- picked up on some of the nuances and wasn’t shy to ask some of the questions around sexuality or sexual based interpretation history, and so it was very helpful. • [There was] someone ready to go. Yes. That was the most useful, especially when you’re talking about the efficiency of an office day. That was the biggest sell for me. The next time I didn’t hesitate to call because I knew that it was going to be effective and efficient.

Physicians had challenges with • It was strange to use [the service] for the first time because it’s on the phone and it’s just different. I never telephone-based interpretation used a system like that before. • Obviously, I would still need to book a longer visit for these patients if they’re coming in and I know they need a translator, but at least I’d have that service if needed. • The other thing that I found tricky was whether or not to stay on the line with the service while I was doing the physical examination.

Physicians supported ongoing • [With regular] use it would be much easier. Like starting a new technology . . . or new system, it feels provision of telephone-based strange at the beginning. interpretation • I can speak [my patient’s] language well enough . . . but I’ve referred her on to specialists, and I’ve had a couple of letters back saying patient arrived without interpreter or without family member and it was . . . a waste of everybody’s time . . . I could see that definitely specialists would probably benefit from [the service] even more than GPs. or sensitive health issues. Many felt cians also commented on the need to service primary care setting is best using a professional medical inter- expand telephone-based interpreta- supported by the average phone call preter was superior to using friends tion for specialists. length of 12.4 minutes. Physicians and family because of the greater who had not used the service ex- accuracy of the interpretation and the Conclusions pressed concerns about the process preservation of confidentiality. Addi- Results from this pilot study, the first taking too long. Understandably, tionally, many commented on the to evaluate the use of professional many family physicians in the fee- convenience and speed of telephone- medical interpreters in the fee-for- for-service setting struggle with find- based interpretation. Physicians did service primary care setting in Cana- ing adequate time for each patient en- remark on challenges, including the da, demonstrate that telephone-based counter given the volume of patients “foreignness” of the system, the need interpretation in family physician that must be seen in a day. While for longer appointment times, and offices is feasible, is affordable for the the optimal time per consultation occasional technical difficulties. health care system, and is appreciated is highly contextual, a 12.4-minute Overall, physicians were positive by physicians. The study results also appointment reflects the typical ex- about the prospect of using the inter- suggest why telephone-based inter- perience for general practitioners in pretation service in future. Many rec- pretation is underutilized. BC. We can conclude that the use of a ognized the need to improve the qual- professional medical interpreter does ity of care for patients with language Feasibility and affordability not create unreasonably long patient barriers while acknowledging that The feasibility of using professional encounters. In fact, some physicians change can be difficult. Some physi- medical interpreters in the fee-for- noted that appointments were actually

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more efficient, especially when com- patients and were generally very with one patient or more within the pared with an appointment relying on positive about their experience. They previous month because of a lan- the use of Google Translate or another found the interpreters to be profes- guage barrier. When asked which ser- translation app. sional and accurate. Physicians were vices they would likely use to address The affordability of telephone- impressed that they were connected language barriers, 53% of 81 respon- based interpretation was also estab- to an interpreter within minutes of dents selected “Free access to pro- lished in this study. The average cost contacting PLS and that the interpre- fessional interpreters by telephone.” per call was approximately $22. The tation process was smooth. Physi- These survey findings suggest a much higher need for interpretation services than was demonstrated by the study results. Possible reasons for underutiliza- Physicians who used the tion include some concerns revealed in the qualitative analysis. Physicians interpretation service in the who chose not to use the service were pilot study noted improved concerned about accuracy and not be- ing able to read body language cues. communication with their patients. They were also concerned about lo- gistical challenges, the extra time they assumed would be needed for the appointment, and the prospect of technical challenges, including poor decision to use an interpreter rather cians who used the service expressed speakerphone sound quality. Compar- than to rely on a family member or a a preference for professional medical ing the responses of user and nonus- patient’s limited language abilities is interpreters when dealing with more er physicians highlighted a common made on a case-by-case basis by the complex or sensitive subject matter misconception that access to PLS physician and patient. While there is that might be difficult to discuss in the requires making arrangements far a health system cost for interpretation presence of a family member. They in advance. Despite not having used (one covered in the pilot study by the also felt that having the PLS service PLS interpreters because of such con- Divisions of Family Practice), phy- available would reduce the burden cerns, many nonuser physicians were sicians are already familiar with the placed on patients and their families still grateful that the service is avail- need to make appropriate decisions to find their own interpreter for every able to them and that it could permit that incur a health system cost, such medical appointment. patients with language barriers to re- as ordering laboratory tests and other ceive effective care if a friend or fam- costly investigations. The $22 cost Underutilization ily member was not available. The of telephone-based interpretation is Even though telephone interpretation majority of the physicians who used comparable to the cost of a plain film was offered to physicians and patients the system were open to using it again single-view X-ray ($34) or blood- at no charge during the study, utiliza- and felt the service was particularly work for CBC, ferritin, and TSH tion of the service was low and uptake valuable for walk-in patients, patients ($30), and is far less than the cost of was slow. These findings, however, with complex or sensitive health is- an abdominal ultrasound ($105) or a should not be taken to mean that there sues, and patients needing frequent standard MRI ($721),15 all tests that is no need for language services in appointments, such as those receiving might reasonably be ordered if an the communities studied. Such under­ prenatal care. adequate history cannot be obtained utilization of interpretation services because of language barriers. is a recognized problem in health Recommendations care.16 Furthermore, an unpublished This pilot study demonstrates that Communication benefits 2013 survey of the FNW Division using professional medical interpret- Physicians who used the interpreta- prior to the onset of the pilot study ers is feasible in the fee-for-service tion service in the pilot study noted revealed that 81% of the 93 respon- primary care setting, is affordable for improved communication with their dents had difficulty communicating the health care system, and is viewed

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positively by family physicians. As among immigrants to Canada. Health Rep 12. New Zealand Office of Ethnic Affairs. In- with any new technology or process, 2011;22:15-23. terpreting in New Zealand—Let’s keep time is needed to change practice, and 3. Bischoff A, Bovier PA, Rrustemi I, et al. talking: Guidelines for agencies using in- to date the service has been under- Language barriers between nurses and terpreters. Accessed 11 December 2015. utilized. Work is underway with the asylum seekers: Their impact on symp- http://ethniccommunities.govt.nz/sites/ health authorities, the General Prac- tom reporting and referral. Soc Sci Med default/files/files/Lets_Keep_Talking tice Services Committee, and addi- 2003;57:503-512. _Online.pdf. tional Divisions of Family Practice 4. Flores G. The impact of medical interpret- 13. Brcic V, McGregor MJ, Kaczorowski J, et (including the Vancouver Division er services on the quality of health care: A al. Practice and payment preferences for as of January 2016 and the Surrey– systematic review. Med Care Res Rev newly practising family physicians in Brit- North Delta Division in August 2016) 2005;62:255-299. ish Columbia. Can Fam Physician 2012; to increase access to interpretation 5. Green AR, Ngo-Metzger Q, Legedza AT, 58:e275-281. services. et al. Interpreter services, language con- 14. Gabriel P, Hassani R, Hosseinieh R. Lan- We recommend providing ongo- cordance, and health care quality. Experi- guage barriers in family practice offices in ing education to family physicians ences of Asian Americans with limited British Columbia: A qualitative study of about the availability, use, and ben- English proficiency. J Gen Intern Med physicians’ experiences and their pro- efits of the interpretation service to 2005;2:1050-1056. posed solutions. Presented at University increase utilization where indicated. 6. Statistics Canada. Language highlights of British Columbia Family Practice Re- Furthermore, we recommend estab- tables, 2011 census. Accessed 2 August search Day, Vancouver, BC, 21 June 2013. lishing access to professional medical 2016. www12.statcan.gc.ca/census 15. Hale I. Add to cart? Can Fam Physician interpreters for all family physicians -recensement/2011/dp-pd/hlt-fst/lang/ 2015;61:937-939. across the province. We also recom- index-eng.cfm?Lang=E. 16. Diamond LC, Schenker Y, Curry L, et al. mend that fee-for-service specialists 7. MacFarlane A, Dzebisova Z, Karapish D, Getting by: Underuse of interpreters by consider assessing the feasibility of et al. Arranging and negotiating the use of resident physicians. J Gen Intern Med using such a service in their practice informal interpreters in general practice 2009;24:256-262. settings. consultations: Experiences of refugees and asylum seekers in the west of Ireland. Competing interests Soc Sci Med 2009;69:210-214. None declared. 8. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve Acknowledgments clinical care for patients with limited Eng- Thank you to those who volunteered to help lish proficiency? A systematic review of with both research and advocacy work with the literature. Health Serv Res 2007; the Divisions in Comox, Vancouver, and 42:727-754. Burnaby, including Dr Ramin Hajeb Hossei- 9. Chen AH, Youdelman MK, Books J, et al. nieh and Dr Alka Kurra. Thank you also to the The legal framework for language access participating Divisions of Family Practice for in healthcare settings: Title VI and beyond. their personnel and financial support. This J Gen Intern Med 2007;22:362-367. research was supported by the Canadian 10. Jacobs EA, Shepard DS, Suaya JA et al. Institutes of Health Research (CIHR) Stra­ Overcoming language barriers in health tegic Training Program, Transdisciplinary care: Costs and benefits of interpreter Understanding and Training on Research– services. Am J Public Health 2004;94: Primary Health Care (TUTOR-PHC). 866-869. 11. Australian Government Department of References Immigration and Border Protection. Trans- 1. Hyman I. Literature review: Costs of not lating and Interpreting Service. About the providing interpretation in health care. free interpreting service. Accessed 11 De- Toronto: Access Alliance; 2009. cember 2015. www.tisnational.gov.au/ 2. Ng E, Pottie K, Spitzer D. Official language en/Agencies/Charges-and-free-services/ proficiency and self-reported health About-the-Free-Interpreting-Service.

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 447 Hamish Hwang, MD, FRCSC, FACS

Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

Study results suggest that the demand on health care resources resulting from hospital readmissions and emergency department visits can be reduced with the use of a virtual care platform.

ABSTRACT Background Background: Ambulatory surgery for group than the e-monitoring group Ambulatory surgery for breast can- breast cancer is commonplace, but (22% vs 3%, P<.05) required read- cer has become commonplace, with complications can lead to unsched- mission to hospital, an unscheduled most patients being discharged on uled care, including readmission to visit to the emergency department the day of surgery.1,2 Compared with hospital and visits to the emergency or walk-in clinic, or both. Most of the in­patient surgery, outpatient surgery department or walk-in clinic. A study e-monitoring patients (83%) used has proved to be more cost-effective3,4 was proposed to determine if un- the smart phone app to ask questions and to increase patient satisfaction.3,5,6 scheduled care could be prevented and have their concerns addressed. This change has been facilitated by a with the use of a secure smart phone In 10 cases in the e-monitoring group move toward more breast conserving application that allows patient and (29% of 35 surgeries), unscheduled surgery7 and better postoperative pain surgeon to communicate and share care was avoided by reassuring pa- control.8 images of the wound postoperatively. tients or providing early treatment Complications of breast surgery of surgical site infections. Almost all still occur, however, and include sur- Methods: Clinical details and out- e-monitoring patients felt that elec- gical site infection, hematoma, sero- comes were compared for two groups tronic wound monitoring improved ma, and bleeding, which can all lead of surgeries: 37 breast operations their care (95%) and would recom- to unscheduled visits to the emer- where patients received convention- mend such monitoring to a friend gency department (ED) or walk-in al follow-up vs 35 breast operations or colleague (90%). All trusted the clinic and readmission to hospital.3,5,6 where patients received electronic virtual care platform to keep their Readmission rates for ambulatory wound monitoring (e-monitoring) in personal information private and breast surgery are reported to be as addition to conventional follow-up. secure. high as 7%.3,5,6 Patients in the e-monitoring group Fortunately, evolving technology photographed their wounds on post- Conclusions: The study found that has provided new ways for patients op days 1, 3, 7, and 14 and sent the electronic wound monitoring was and surgeons to communicate, and images to the surgeon via a smart associated with less unscheduled many have been willing to use the tools phone app. The e-monitoring pa- care, a high degree of patient satis- now available.9 In the past, patient- tients were also asked to complete faction, and a likely reduction in cost a satisfaction survey online. to the health care system. These promising results justify further re- Dr Hwang is a general surgeon at Vernon Results: Significantly more surgeries search with a prospective random- Jubilee Hospital and a clinical assistant pro- in the conventional follow-up control ized controlled trial. fessor in the Faculty of Medicine at the Uni- This article has been peer reviewed. versity of British Columbia.

448 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

surgeon encounters were restricted to compare conventional follow-up data collection start date for the to either a hospital or a surgeon’s with additional e-monitoring of breast e-monitoring group because that is office. Now smart phone applications cancer outpatients by smart phone when the technology became avail- can allow patients to participate in a app. The study aimed to determine if able. videoconference or send secure mes- unscheduled visits for care and hospi- Only cases where patients were sages and images to their surgeons, tal readmission could be prevented by discharged on the same day or the day who in turn can respond immediately e-monitoring and to assess patient sat- following surgery were included in or at their convenience.9 App-based isfaction with the use of e-monitoring the study. technology has been employed to technology for this. In the conventional follow-up monitor pressure ulcers,10 diabetic group, care consisted of referral to foot ulcers,11 chronic venous ulcers,12 Methods the ambulatory wound clinic if the and postoperative surgical sites in All breast cancer patients in the care patient had a Jackson-Pratt drain and breast and orthopedic patients.13 Data of a single surgeon over a 1-year peri- an office visit with the surgeon around collection was completed recently for od (February 2015 to January 2016) 3 weeks post-op. In the e-monitoring a randomized trial at Women’s Hos- were prospectively enrolled in an group, patients were invited to par- pital in Toronto that compared home electronic wound monitoring study. ticipate in additional follow-up using monitoring by app with conventional The outcomes of 35 surgeries in this Medeo ( Figure 1 ), a virtual care plat- follow-up in breast reconstruction.14 e-monitoring group of patients were form that consists of a smart phone Based on the premise that electron- compared with the outcomes of 37 app and secure password-protected ic wound monitoring (e-monitoring) surgeries in a control group of patients online account ( Figure 2 ). Patients fills both a clinical and a temporal who received conventional follow-up in the e-monitoring group were asked gap between the day of outpatient the previous year (February 2014 to to take a photo of their wounds post- surgery and the follow-up office visit January 2015). operatively on days 1, 3, 7, and 14 3 weeks later, a study was proposed February 2015 was chosen as the ( Figure 3 ), and to attach the photos to

Figure 1. Patient receives e-mail invitation from surgeon to communicate using smart phone app and Medeo virtual Figure 2. Patient logs in to secure Medeo Figure 3. Patient receives instructions care platform. account. from surgeon.

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 449 Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

Figure 4. Patient takes photo of wound with smart phone and then sends message and photo to surgeon. Figure 5. Surgeon receives message on secure site, views photo, and replies to patient.

electronic messages and send them to Results of the surgeries are summarized in the surgeon using the smart phone app The mean age of patients in the con- Table 2 . While four bilateral mastec- ( Figure 4 ). The patients were encour- ventional follow-up group was 65.5 tomies were performed in the conven- aged to ask questions and raise any years (range 49 to 90), and the mean tional follow-up group and none in the concerns. The surgeon then respond- age in the e-monitoring group was e-monitoring group, the number and ed to each patient message within 24 60.1 years (range 38 to 78) (P < .05). kind of procedures were otherwise hours ( Figure 5 ). Patients who suc- In the conventional follow-up similar. cessfully attached and sent a wound group, 34 women with an average Operative time for the conven- photo to the surgeon were considered ASA score of 2.2 underwent 37 sur- tional follow-up group was 65.0 (SD to have made meaningful use of the geries (3 patients required 2 operations 31.0) minutes and for the e-monitoring smart phone app. each). In the e-monitoring group, 28 group was 51.4 (SD 15.5) minutes (P Data on patient demographics, patients (27 women and 1 man) with < .05). The majority of patients in both breast cancer pathology, operative an average ASA score of 2.0 under- groups were discharged on the day of times, complications, and unsched- went 35 surgeries (7 patients required surgery. Same-day discharge was 94% uled care were recorded in a Microsoft 2 operations each). in the e-monitoring group and 78% Excel 2010 spreadsheet. Responses The pathology, tumor characteris- in the conventional follow-up group to a patient satisfaction survey com- tics, and hormone receptor status of (P=ns). The indications for next-day pleted online were analyzed. The chi- the breast cancers in each group of discharge were bilateral mastectomy square test, student 2-tailed t test, and patients are summarized in Table 1 . in 3 patients, age older than 75 in 4 Wilcoxon signed rank test were used While seven cases of ductal carci- patients, personal request in 1 patient, on an Internet-based statistical calcu- noma in situ (DCIS) were seen in the recent acute coronary syndrome in 1 lator.15 A probability value of less than e-monitoring group and none in the patient, and post-op bleed requiring .05 was considered significant. conventional monitoring group, the hematoma evacuation in 1 patient with breast cancers were otherwise similar. a 20-cm phylloides tumor with exten- The clinical details and outcomes sive varices surrounding the tumor.

450 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

Significantly more patients in the Table 1. Pathology of breast cancers for conventional follow-up group and electronic conventional follow-up group (22% wound monitoring group. versus 3% in the e-monitoring group, Conventional follow-up Electronic wound P < .05) were readmitted to hospital, patients monitoring patients had an unscheduled visit to the emer- n/37 (%) n/35 (%) gency department or a walk-in clinic, Primary pathology or both. Of the five patients in the con- Invasive ductal carcinoma 32/37 (86) 25/35 (71) ventional follow-up group who had Invasive lobular carcinoma 2/37 (5) 2/35 (6) unscheduled visits to the ED, three Ductal carcinoma in situ 0/37 (0)* 7/35 (20) presented twice and one presented Mucinous carcinoma 3/37 (8) 0/35 (0) four times. The two conventional fol- Mixed ductal and lobular carcinoma 0/37 (0) 1/35 (3) low-up patients who had unscheduled Borderline phylloides tumor 0/37 (0) 1/35 (3) visits to a walk-in clinic each pre- Multifocal disease 2/37 (5) 4/35 (11) sented twice. The single patient in the Lymphovascular invasion 6/34 (18) 4/27 (15) Tumor characteristics e-monitoring group who presented to 1.53 1.37 Tumor stage the ED with pneumonia on day 3 after (mean for 34 cancers) (mean for 28 cancers) surgery did not use the smart phone 2.06 1.64 Tumor grade (excluding DCIS) app. (mean for 34 cancers) (mean for 25 cancers) There was meaningful use of the Hormone receptor status app in 30 of the 35 e-monitoring sur- ER positive 30/34 (88) 24/27 (89) geries (86%). Three patients either did HER-2 positive 6/34 (18) 2/27 (7) not own a smart phone or did not have * P < .05 an e-mail address. Two patients were unable to use the smart phone app. Table 2. Clinical details and outcomes for surgeries with conventional follow-up and surgeries with electronic wound monitoring. A total of 29 patients (83%) used the smart phone app to ask questions Conventional follow-up Electronic wound surgeries monitoring surgeries and the same number used the app to n/37 (%) n/35 (%) communicate about a concern that Procedure was then addressed by the surgeon. Bilateral mastectomy 4/37 (11)* 0/35 (0) Fourteen patients raised multiple con- Total mastectomy 25/37 (68) 20/35 (57) cerns. Five patients asked for reassur- Partial mastectomy 8/37 (22) 12/35 (34) ance about minor hematomas or skin Sentinel lymph node biopsy 24/37 (65) 22/35 (63) blisters that subsequently resolved. Axillary dissection 7/37 (19) 5/35 (14) Five cases of early wound infection Complication and one case of skin edge necrosis Pressure sore 1/37 (3) 0/35 (0) were detected using the app and treat- Bradycardia 1/37 (3) 0/35 (0) ed without the need for an extra visit. Severe neuralgia 1/37 (3) 0/35 (0) In two cases, extra electronic visits Leaking drain 1/37 (3) 0/35 (0) were scheduled after the office visit Wound infection 2/37 (5) 6/35 (17) to address patient concerns about the Minor hematoma 0/37 (0) 2/35 (6) wound. In one case, an extra sched- Skin edge necrosis 0/37 (0) 1/35 (3) uled office visit was arranged. In a Hemorrhage requiring evacuation 0/37 (0) 1/35 (3) total of 10 cases (29% of 35 surger- Pneumonia 0/37 (0) 1/35 (3) Unscheduled care ies), an unscheduled visit to the ED or 30-day readmission 2/37 (5) 1/35 (3) walk-in clinic was made unnecessary Emergency department visit 5/37 (14) 1/35 (3) by reassuring patients or providing Walk-in clinic visit 2/37 (5) 0/35 (0) early treatment of surgical site infec- 30-day readmission, unscheduled 8/37 (22)* 1/35 (3) tions. emergency department visit, or both† Of the 28 patients in the *P < .05 e-monitoring group who were invited † One patient had both an unscheduled visit to the ED and readmission to hospital within 30 days.

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 451 Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

to complete an anonymous online In this study, survey responses sions, further reducing the per capita survey, 20 patients (71%) did so. indicate clearly that use of a smart cost of health care. Responses indicated that 90% did phone app improved the patient ex- not have difficulty using the app and perience of care. Communicating Challenges would recommend e-monitoring to a with the surgeon electronically eased Technical difficulties or lack of friend or colleague, while 95% found patients’ anxieties and lessened their familiarity with technology chal- the app convenient to use and felt it inclination to visit the emergency lenged a minority of study subjects was better for patient care when com- department. In 10 cases (29% of 35 and prevented five patients from par- pared with standard post-op follow- surgeries) the surgeon provided reas- ticipating in a meaningful way. Argu- up. All patients trusted the virtual surance or early diagnosis and treat- ably, the patients who need support care platform to keep their personal ment of wound infections that might the most—the elderly and the finan- information private and secure. have required visits to the ED at a cially insecure—are also more likely A sample of responses to an open- later date. The e-monitoring patients to face barriers to using technology. ended survey question gives a sense had significantly fewer hospital read- The five subjects in the e-monitoring of overall patient satisfaction: missions and unscheduled visits to the group who did not participate includ- “Response time excellent and ED or walk-in clinic than the conven- ed the two oldest patients, aged 75 with this monitoring service I was tional follow-up patients. The only and 78, and three others aged 49, 51, able to have antibiotics without going patient in the electronic wound moni- and 69. Identifying ways to remove to see my doctor.” toring group to have an unscheduled barriers to meaningful use of new “I found it amazing, very comfort- visit to the ED did not use the smart technology for these vulnerable ing to know my wounds were fine and phone app. Importantly, 100% of pa- patients needs to be prioritized, per- not have to worry about whether they tients felt their confidential informa- haps with a publicly funded smart were okay or not.” tion was private and secure. phone loan program and one-on-one “It took a number of tries to get On a population health basis, the instruction sessions. into the system to start, and then a use of smart phone apps and similar The fact that post-op days 1, 3, 7, while to figure out how to upload the technology can also lead to improve- and 14 did not always fall during the pictures, but after that it was easy ments. If unnecessary visits to the surgeon’s work week presented an to use. Very reassuring to know that ED can be eliminated this not only unexpected challenge to providing things were progressing as expected. improves the health of postoperative prompt responses to patients. Although Perhaps more online assistance would patients but also of other patients the ease of access to technology means help get things off to a better start.” who can receive treatment more a surgeon can be out of town or even “It was nice to hear on days 1 and promptly in the emergency depart- out of the country and still view and 3 that everything looked good. Defi- ment because of reduced demand on respond to patient messages, it would nitely made me feel better and less ED resources. be preferable to arrange for electron- anxious about how I was healing. Unscheduled care places a demand ic cross-coverage on weekends and Response time was surprisingly fast.” on physicians, hospital personnel, di- while surgeons are away. agnostic services, and other health Conclusions care resources. In this study, 22% of Study limitations New app-based technology9,16 is be- surgeries in the conventional follow- Although subjects for the e-monitoring ing accepted more widely by both up group required unscheduled care group were accrued in a prospective patients and physicians and can help compared with 3% in the electronic manner, patients were not selected with all three objectives of the Insti- monitoring group. Considering only randomly, and as a result the study tute for Healthcare Improvement’s patients who made meaningful use of is subject to bias. Also, because the triple aim17 initiative: the smart phone app, there were no control group was studied retrospec- • Improving the patient experience of instances of unscheduled care in the tively, it was not possible to reliably care (including quality and satisfac- e-monitoring group. Electronic fol- assess patient satisfaction with con- tion). low-up is not only cost-effective by ventional follow-up and compare this • Improving the health of populations. itself when compared with in-person for the two groups. • Reducing the per capita cost of health follow-up,18 it also prevents unsched- The patients in the convention- care. uled visits to the ED and readmis- al follow-up group were older than

452 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Electronic wound monitoring after ambulatory breast cancer surgery: Improving patient care and satisfaction using a smart phone app

patients in the e-monitoring group, breast cancer surgery. Am Surg 1997; al. Using a mobile app for monitoring post- which may have had an impact on 63:865-867. operative quality of recovery of patients at the number of unscheduled visits to 3. Rovera F, Ferrari A, Marelli M, et al. Breast home: A feasibility study. JMIR Mhealth the ED. The mean age of the eight cancer surgery in an ambulatory setting. Uhealth 2015;3:e18. patients in the conventional follow- Int J Surg 2008;6(suppl 1):S116-S118. 14. Armstrong KA, Coyte PC, Bhatia RS, up group who had unscheduled visits 4. Kåresen R, Jensen HH, Sauer T, et al. Lo- Semple JL. The effect of mobile app was 65.8 compared with 65.5 in the gistics of referral, diagnostic assessment home monitoring on number of in-person conventional follow-up group as a and treatment of patients with breast visits following ambulatory surgery: Proto- whole (P =.903). symptoms and signs. Scand J Surg 2002; col for a randomized controlled trial. JMIR A confounding factor in the con- 91:232-238. Res Protoc 2015;4:e65. trol group surgeries was a higher 5. Marla S, Stallard S. Systematic review of 15. Statistics Online Computational Re- number of bilateral mastectomies day surgery for breast cancer. Int J Surg source. Accessed 26 July 2016. www with a corresponding increase in 2009;7:318-323. .socr.ucla.edu/SOCR.html. operative time. Two of the four bilat- 6. Marchal F, Dravet F, Classe JM, et al. Post- 16. Kummerow Broman K, Oyefule OO, Phil- eral mastectomy patients each had operative care and patient satisfaction af- lips SE, et al. Postoperative care using a at least one unscheduled visit to the ter ambulatory surgery for breast cancer secure online patient portal: Changing the ED. If the bilateral mastectomies patients. Eur J Surg Oncol 2005;31:495- (inter)face of general surgery. J Am Coll are excluded from the analysis, the 499. Surg 2015;221:1057-1066. number of unscheduled visits made 7. Hoehn JL. Definitive breast cancer sur- 17. Institute for Healthcare Improvement. IHI by conventional follow-up patients gery as an outpatient: A rational basis for triple aim initiative. Accessed 26 July is still significantly higher (6 visits the transition. Semin Surg Oncol 1996; 2016. www.ihi.org/engage/initiatives/ for 33 surgeries in the control group 12:53-58. tripleaim. versus 1 visit for 35 surgeries in the 8. Huang TT, Parks DH, Lewis SR. Outpa- 18. Armstrong KA, Semple JL, Coyte PC. Re- e-monitoring group; P = .038). tient breast surgery under intercostal placing ambulatory surgical follow-up vis- block anesthesia. Plast Reconstr Surg its with mobile app home monitoring: Summary 1979;63:299-303. Modeling cost-effective scenarios. J Med In this study, electronic wound moni- 9. Wiseman JT, Fernandes-Taylor S, Barnes Internet Res 2014;16:e213. toring was associated with signifi- ML, et al. Conceptualizing smartphone cantly fewer unscheduled visits to use in outpatient wound assessment: Pa- the emergency department, a high tients’ and caregivers’ willingness to use degree of patient satisfaction, and a technology. J Surg Res 2015;198:245- likely reduction in cost to the health 251. care system. These results justify con- 10. Rodrigues JJ, Pedro LM, Vardasca T, et al. ducting a multicentre, prospective, Mobile health platform for pressure ulcer randomized controlled study to learn monitoring with electronic health record more about electronic monitoring. integration. Health Informatics J 2013; 19:300-311. Competing interests 11. Wang L, Pedersen PC, Strong DM, et al. At the time this article was submitted to Smartphone-based wound assessment the BCMJ, Dr Hwang owned shares in system for patients with diabetes. IEEE QHR, the health care technology compa- Trans Biomed Engineering 2015;62:477- ny responsible for the Medeo virtual care 488. platform. Dr Hwang does not currently 12. Quinn EM, Corrigan MA, O’Mullane J, et own shares in QHR. al. Clinical unity and community empow- erment: The use of smartphone technol- References ogy to empower community manage- 1. Margolese RG, Lasry JM. Ambulatory ment of chronic venous ulcers through surgery for breast cancer patients. Ann the support of a tertiary unit. PLoS One Surg Oncol 2000;7:181-187. 2013;8:e78786. 2. Tan LR, Guenther M. Outpatient definitive 13. Semple JL, Sharpe S, Murnaghan ML, et

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 453 Ivana Jakovljevic, MD, Ashley P. Miller, MDCM, FRCPC, Barbara Fitzgerald, MD, FRCPC

Children’s mental health: Is poverty the diagnosis?

Some of the concerns seen by childhood health professionals may not be diagnosable psychiatric conditions, but emotional and behavioral responses to family financial insecurity.

ABSTRACT: The case of a 6-year-old status. Poverty is a risk factor for Case data boy who was referred to a physician mental health conditions in child- A 6-year-old boy was referred for by his school counselor for inves- hood and is associated with lower assessment and treatment recom- tigation of anxiety and possible at- academic achievement and impaired mendations by his school counselor tention deficit hyperactivity disor- cognitive development secondary because of anxiety, school difficul- der illustrates the need to consider to direct effects on the developing ties, and possible attention deficit the role of poverty when addressing hypothalamic-pituitary-adrenal axis hyperactivity disorder (ADHD). The mental health concerns. After deter- and indirect effects on a child’s en- boy was from a two-parent family mining that income insecurity could vironment. British Columbia’s child- and had a 14-year-old brother. Both be contributing to the boy’s symp- hood poverty rate is well above the parents were employed, the father toms, the physician used a poverty national average and is compounded as a cargo delivery driver and the intervention tool to screen for the by significant unmet core housing mother in a hospital cafeteria. The effects of poverty and make rec- need and widening provincial income boy’s mother had started shift work 6 ommendations to prevent adverse disparity. We recommend screening months previously and was working 6 health outcomes. Mental health and for poverty with office-based inter- days a week so that the family could behavioral concerns are common ventions and accounting for income meet increasing rent costs. They in children and youth presenting insecurity in all mental health diag- lived in a small two-bedroom apart- with undifferentiated complaints in noses and treatment plans. We also ment and the boy slept on the pull-out both pediatric and primary care set- strongly recommend implementing a couch in the living room because his tings. Psychiatric disorders are fre- national poverty reduction strategy 14-year-old brother demanded priva- quently multifactorial and require a to address social determinants of comprehensive assessment of the health in the early years and improve Dr Jakovljevic is a PGY-5 resident in the De- patient’s environmental context, in- the health of future generations. partment of Psychiatry at the University of cluding the family’s socioeconomic British Columbia. Dr Miller is an assistant professor in the Department of Psychiatry at UBC and a child and adolescent psychia- trist at BC Children’s Hospital and Vancou- ver Community Mental Health Services. Dr Fitzgerald is a developmental pediatrician at Sunny Hill Health Centre for Children. She is also medical director of Alderwood Family Development Centre and a clinical associate professor in the Department of This article has been peer reviewed. Pediatrics at UBC.

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cy. The family could no longer afford below the diagnostic threshold for care had placed stress on the family after-school care for the boy as they ADHD. Written reports indicated the and affected the boy’s sense of secu- had done the previous year, so he was boy was slightly behind in reading rity. The impact of sleep on the boy’s picked up from school by the broth- skills for his age. The father stated ability to pay attention and manage er and watched TV and played video that the separation anxiety and prob- emotions was discussed and infor- games every day after school while lems at school had begun 6 months mation about sleep hygiene and good his parents were working. earlier, coinciding with his mother’s asthma management was provided.

First visit The boy attended the first visit to the physician with his mother, who reported that the child had no previ- ous history of anxiety or psychiatric concerns but did have a medical his- The World Health Organization tory of asthma. The mother described has declared poverty the single the boy’s recent separation anxiety, difficulty concentrating, trouble fall- largest determinant of health ing asleep, and tantrums during tran- for both adults and children. sitions at school. Teachers reported the boy was frequently anxious and inattentive in class. In the past the father had been diagnosed with a mild learning disability and the mother described herself as “frequently anx- ious,” although she had never been increased work hours, and that he had The parents were advised to file tax diagnosed with a psychiatric condi- started sleeping with his son on the returns so the family would be eligi- tion. During the visit the boy was shy, pull-out couch because of the boy’s ble for income supplements and sub- clung to his mother, and looked at her anxiety. sidized housing. Psychoeducational for answers. He occasionally gave Given the family’s economic sit- testing was recommended to rule one-word answers to questions. There uation, the physician chose to use a out a learning disability, even though were no other significant findings on screening and intervention tool for there was likely to be a long wait for the mental status exam. Teacher and poverty. The father disclosed that the testing in the public system, the only parent checklists were provided to family had not had enough money for option for the family. The parents collect further details and a second necessities for the previous 9 months were advised to enquire about getting visit was scheduled to complete the and had recently started going to the their son extra help with homework assessment. food bank. The father also said he was through the school and were referred too ashamed to talk to his son’s school to a parenting group for parents of Second visit about their circumstances and asked children with anxious temperaments. At the second visit with the physi- the physician about resources for sub- The physician emphasized the parents cian, the boy was accompanied by his sidized housing. The family had not were doing their best to care for their father. The boy’s growth charts and filed a tax return for the previous year son and had given him a good founda- hearing and vision test results were because of the mother’s transitional tion. A follow-up visit was scheduled. reviewed. No deficits were identi- employment. fied and he was found to be on track Information gathered at the sec- Third visit developmentally. His asthma, while ond visit led to a number of recom- At the third visit the parents reported relatively mild, was found to be con- mendations for the family. The par- that their son was attending a subsid- tributing to sleep disturbances. Occa- ents were told that although their ized summer camp through his school. sional inattention and concentration child did not have a clinical anxiety The family had filed tax returns, ob- difficulties were noted on the teach- disorder or ADHD, their recent finan- tained low-cost transportation passes, er checklists, but the symptoms fell cial struggles and changes in child and been waitlisted for subsidized

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housing. The boy was receiving a or ensured the boy received learning undifferentiated complaints. These free breakfast and lunch at school and assistance for reading and tutoring conditions can include anxiety disor- seeing the school counselor regular- from a local high school student. With ders, ADHD, and other neurodevel- ly. The parents, however, were still the physician’s help, the parents even- opmental disorders. In addition, child struggling financially and reported tually obtained a subsidy for quality abuse, trauma, and early adversity that their experiences had affected after-school care and established a can have a significant impact on all their relationship. Although they were clear routine for their son, including aspects of child development and be- very eager to join the parenting group, two 30-minute sessions a week when havior. As children are embedded in they were unable to attend because of he would go to the park or have spe- their environments, a comprehensive their work schedules and lack of child cial play time with his mother. Within assessment and consideration of their care options. 3 months, the boy’s separation anxi- psychosocial circumstances is crucial for accurate diagnosis and treatment recommendations.

Childhood poverty in BC According to most recent estimates, approximately one in five BC children age 0 to 17 (20.4%) are living in pov- Poverty becomes biologically embedded, erty,3 and the numbers are significant- ly higher for children of immigrants, leading to both functional and structural visible minorities, and Aboriginal cit- changes of the developing brain. izens. British Columbia’s child pov- erty rate has remained consistently higher than the national average since 2000, and has increased significantly since the 1989 House of Commons all-party resolution to eliminate child poverty.3 Children of various fam- ily types live in poverty, but there is The mother was tearful during ety had improved significantly and an increase in working poor families the appointment, and said she would his teacher noted better focus in class living in British Columbia, with one love to be able to spend quality time despite the family’s continued high in three poor children having at least with her son at home, like her own stress level and hectic work schedule one parent who works full time. As mother had with her, but was unable in attempts to make ends meet. of 2013, one-half of children in lone to leave her job. The mother was told parent families were living in poverty. that staying at home with children is Discussion Food bank use has increased by 25% not the only way to make them feel An estimated 12.6% of children and in British Columbia since 2008. Over secure, and that the quality of time youth age 4 to 17—almost 84 000 97 000 people used the food bank last spent together counts. The physician young British Columbians—are ex- year in BC, with 31% of users being acknowledged the family’s hard work periencing a mental health disorder at children.4 Furthermore, families with and provided information on parent- any given time.1 Mental health prob- the fewest economic resources are ing children with anxious tempera- lems in childhood and adolescence spending more of their income for ments and emphasized the impor- have a significant impact on child de- inadequate housing, with one-third of tance of regular follow-up with the velopment and have been identified all children in lone parent families in school counselor. by many as today’s leading pediatric BC living in core housing need, repre- problem.2 senting the highest rate of inadequate Outcomes Multiple childhood psychiatric housing for all provinces in Canada.3 Subsequently, the boy’s parents met conditions come to mind when young Income inequality is on the rise with the school counselor for two children present to primary care phy- in Canada, and particularly in British parenting sessions, and the counsel- sicians or pediatric specialists with Columbia, where a family in the high-

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est income decile earns 13 times more environments rather than diagnosable food, adequate housing in safe neigh- than a family in the lowest income primary mental illnesses, as illustrat- borhoods, quality day care, and regu- decile. This staggering income dis- ed by the case. lar access to health care. Poor children parity is explained in part by the fact are also less likely to benefit from that individuals in BC’s lowest earn- Effects on cognition environmental complexity, exposure ing decile have the lowest income of Children from low-income house- to educational activities and materi- all Canadians.3 holds are less prepared for formal als, and positive parent-led experi- schooling and perform below their ences such as reading and conversa- Effects of poverty on children middle-class counterparts on tests tion.12 Moreover, children growing The World Health Organization has of intelligence and school achieve- up in poverty are disproportionately declared poverty the single largest ment.10 A recent Vancouver study more likely to be exposed to trauma determinant of health for both adults found that 38% of kindergarten chil- and stressful life events, including and children.5 Children affected by dren living in the lowest income divorce, domestic violence, and puni- poverty have higher rates of infant neighborhoods demonstrated vul- tive parenting practices. Poverty fur- mortality, low birth weight, childhood nerabilities in at least one area mea- ther negatively affects mental health hospitalizations, asthma, obesity, and sured by the Early Development through larger community factors, functional health impairments.6 Pov- Instrument, which considers physi- including social isolation, marginal- erty in early childhood is also asso- cal health and well-being, language ization, and violence.1 ciated with increased morbidity and and cognitive development, social The mechanism that allows pov- decreased lifespan in adulthood, an competence, emotional maturity, and erty to directly affect the developing association that persists irrespective communications skills.11 Children brain and contribute to psychopa- of the social status one acquires as living in poverty have also been found thology is now being elucidated by an adult.7 A large and growing body to have deficits in working memory, neuroscientists. Several explanations of research, including studies in Can- language abilities, and cognitive flex- have been proposed regarding the re- ada, the US, and the UK, demon- ibility when compared with their lationship between poverty and men- strates that children living in poverty middle-class counterparts.12 Recent tal health. The concept of allostatic are significantly more likely to have neuroimaging research suggests that load, or cumulative damage over psychiatric conditions and inferior these deficits are mediated by under- time, suggests that the excessive, mental health when compared with development of several brain areas, persistent, and uncontrollable adver- peers from families with higher soci- including the frontal and temporal sity experienced by children living in oeconomic status. This relationship lobes and the hippocampus. This poverty intensifies the activation of holds across developmental periods, underdevelopment is estimated to the hypothalamic-pituitary-adrenal and remains when operationalizing account for 15% to 20% of achieve- (HPA) axis and has an impact on the poverty through income, parental ment deficits.13 The longer children developing brain.14 Physiological re- employment, and neighborhood in- live in poverty, the greater their aca- sponses to stressful events are medi- come. Children from families living demic deficits and the more likely ated by the glucocorticoid and cat- in poverty are 3 times more likely, on they are to experience a lifetime of echolamine system, and prolonged average, to suffer from psychiatric reduced occupational achievement exposure to stressful environments conditions, including both externaliz- and the persistence of poverty across and subsequent heightened neuro- ing disorders such as ADHD, oppos- generations. endocrine responses are associated itional defiant disorder (ODD), and with the development of both depres- conduct disorder, and internalizing Impact on mental health and the sive symptomatology and the hippo- disorders such as depression, anxiety, developing brain campal neuron damage implicated in and poor coping skills.1,8,9 Further- Living in poverty increases the likeli­ impaired learning and memory.15,16 If more, experts in the field have recent- hood of vulnerabilities and adverse early adversity during critical devel- ly questioned whether some of the childhood events that are themselves opmental periods leads to permanent behavioral concerns seen by child- known risk factors for the develop- changes in the functioning set-point hood mental health professionals are ment of mental illness. Children liv- of the HPA axis, then lasting and actually emotional and behavioral ing in poverty are more likely to lack potentially permanent alterations in responses to inadequate and chaotic basic resources such as nutritious neuroendocrine behavioral responses

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23 Table 1. Medication and medical services plans. .pdf), an evidence-based instrument developed by Dr Gary Bloch from the Plan Benefits University of Toronto, can be used to screen for poverty as a health-related Psychiatric Medications Covers psychiatric medications for individuals registered (Plan G) with a mental health service and demonstrating clinical and risk and to factor poverty into all financial need. clinical decision making. A positive answer to the screening question “Do Recipients of BC Income Covers eligible prescription costs for BC recipients of Assistance (Plan C) income assistance. you ever have diffculty making ends meet at the end of the month?” has a Fair Pharmacare Covers some of eligible prescription costs based on family income. sensitivity rate of 98% for identify- ing patients living in poverty.23 The Pharmacare Special Authority Grants full benefit status to a medication or medical supply targeted interventions outlined in the otherwise not covered for patients with specific medical circumstances. tool are designed to reduce the effects of poverty and adverse health out- Non-Insured Health Benefits for Covers medically necessary health services, equipment, and First Nations and Inuit medications not covered through private insurance or comes in low-income patients, and provincial programs for First Nations and Inuit. include specific questions for fami- lies with children, seniors, people Table 2. Income supplement programs. with disabilities, and First Nations patients living in poverty. Original- Program Benefits ly developed for use in Ontario, the tool is now available in BC-wide and Canada Child Tax Benefit Nontaxable monthly amount provided for families with (CCTB) www.cra-arc.gc.ca/E/ children under age 18. Kootenay-Boundary versions that pub/tg/t4114/README.html include resources and interventions Child Disability Benefit (CDB)/ Monthly amount for families caring for children under age 18 specific to British Columbia (www Disability Tax Credit (DTC) with a severe and prolonged impairment in physical or .divisionsbc.ca/kb/povertyinterven mental functioning (benefit included in the CCTB amount). tion).24 (DTC: www.cra-arc.gc.ca/E/pbg/tf/t2201/README.html) As demonstrated by the case de- Universal Child Care Benefit Taxable monthly amount for families with children under scribed here, a health care provider (UCCB) age 6. can attempt to mitigate the effects BC Early Childhood Tax Benefit Nontaxable monthly amount for qualifying families with of poverty by providing information children under age 6. about support available. This can in- BC Family Bonus Nontaxable monthly amount for low- and modest-income clude plans for low-cost or no-cost families with children under age 18. medications and medical services Registered Disability Savings Matching contribution from the Canadian government made ( Table 1 ) and programs for income Plan to registered savings plan for children with disabilities. supplements ( Table 2 ). Health care providers can also inform families working with the BC Ministry of Chil- can increase the likelihood of develop- cognitive flexibility, these brain struc- dren and Family Development that ing mental illness.14 Thus, poverty be- tures are particularly vulnerable to the they may be eligible for coverage of comes biologically embedded, lead- environmental effects of poverty.21 medically necessary treatments with a ing to both functional and structural physician’s letter of support. Finally, changes of the developing brain,17,18 a Assessing and addressing because families attempting to deal finding supported by studies demon- poverty with a mental health concern using a strating heightened baseline activa- Physicians often recognize the wide- first-line treatment recommendation tion of the stress response system in reaching impact of poverty on their may encounter barriers, including the children living in poverty.19,20 And be- patients but report feeling unable to cost of psychotherapy and academic cause of the protracted development address the issue in a systematic way.22 tutoring, health care providers can of brain structures critical for learning The poverty intervention tool (http:// also suggest solutions for overcom- and educational functioning, includ- ocfp.on.ca/docs/default-source/cme/ ing these barriers ( Table 3 ). ing sustained attention, planning, and poverty-and-medicine-march-2013 We recommend screening for

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Table 3. Possible solutions for families encountering barriers when attempting to obtain first-line treatment for behavioral and mental health concerns.

First-line treatment Barrier Possible solution

Medication for Cost • Government benefit programs: BC Pharmacare Plan G, Fair Pharmacare, psychiatric condition Special Authority program, Non-Insured Health Benefits (NIHB) program.

Medication for Cost • Substitutions medical condition • Generic preparations • Second-line therapies • Government benefit programs: BC Pharmacare Plan C, Fair Pharmacare

Psychotherapy Cost ($175–$200/hour for private • Free counseling through local community services. psychologist) • Counseling offered at a reduced rate or on a sliding scale by supervised psychology trainees at UBC, SFU, and University of Victoria psychology clinics.

Parenting support Difficulty attending free parenting • Free weekly telephone coaching for parents of children affected by temper group sessions because of work outbursts, behavioral difficulties, and anxiety through Confident Parents schedule or lack of child care options Thriving Kids program (http://cmha.bc.ca/programs-services/confident- parents-thriving-kids/). Referral from health care professional required. Materials provided include psychoeducation, manuals, and behavioral charts.

Psychoeducational Cost (~ $2000 for private testing) • Free testing in the public school system (wait list up to 2 years long). testing • Testing offered free or on a sliding scale for a limited number of clients at UBC and other university-based psychology training centres.

Academic tutoring Cost (> $20/hour) • Free tutoring or homework help offered through child’s school or by teacher and homework help Difficulty ensuring child attends after- or student volunteers. school sessions because of work schedule poverty and using office-based inter- and behavioral symptoms. Given the affordable housing, quality child care, ventions that account for income importance of the psychosocial envi- and regular health care, should be our in­security in all mental health diagno- ronment to child development, an top health priority if we want to ensure ses and treatment plans. And because assessment of the family and social the well-being of future generations. office based interventions don’t reach circumstances is important because all families living in poverty, we symptoms of living in poverty can Competing interests strongly advocate for implementation at first glance mimic the symptoms None declared. of a national poverty reduction strat- of mental illness. Income insecurity egy to address social determinants of is increasingly common in working References health in the early years and improve poor families and a growing number 1. Waddell C, Offord DR, Shepherd CA, et al. the health of future generations. of children live below the poverty line Child psychiatric epidemiology and Cana- in British Columbia. Poverty is a risk dian public policy-making: The state of the Summary factor for mental illness and can affect science and the art of the possible. Can J The case of a 6-year-old boy referred early cognitive development. Screen- Psychiatry 2002;47:825-832. by his school counselor because of ing for poverty and making treatment 2. Lipman EL, Boyle MH. Linking poverty anxiety and school difficulties illus- recommendations that address a fam- and mental health: A lifespan view. Otta- trates the need to consider the role ily’s lack of income and resources can wa: Provincial Centre of Excellence for of poverty when addressing mental lead to significant change for children. Child and Youth Mental Health at CHEO; health concerns. Children and youth Early childhood interventions that sup- 2008. Accessed 28 July 2016. www seen in primary care settings frequent- port the basic needs of children, includ- .excellenceforchildandyouth.ca/sites/ ly present with undifferentiated mood ing access to nutritious food, safe and default/files/position_poverty.pdf.

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3. First Call: BC Child and Youth Advocacy Socioeconomic disadvantage and behav- mood disorder effects on the brain. Biol Coalition. 2015 BC child poverty report ioral problems of children in Canada. J Psychiatry 2003;54:338-352. card. Accessed 28 July 2016. October Consult Clin Psychol 2002;70:378-389. 17. McEwen BS. Protective and damaging core combined.dochttp://firstcallbc.org/ 10. Bradley RH, Corwyn RF. Socioeconomic effects of stress mediators. N Engl J Med publications/2015-bc-child-poverty status and child development. Annu Rev 1998;338:171-179. -report-card. Psychol 2002;53:371-399. 18. McEwen BS. The neurobiology of stress: 4. Food Banks Canada. Hunger count 2014. 11. Hertzman C, McLean SA, Kohen DE, et al. From serendipity to clinical relevance. Brain Res 2000;886:172-189. 19. Lupien SJ, King S, Meaney MJ, McEwen BS. Child’s stress hormone levels corre- late with mother’s socioeconomic status and depressive state. Biol Psychiatry 2000;48:976-980. Screening for poverty and making treatment 20. Lupien SJ, King S, Meaney MJ, McEwen BS. Can poverty get under your skin? Bas- recommendations that address a family’s al cortisol levels and cognitive function in lack of income and resources can lead children from low and high socioeconom- ic status. Dev Psychopathol 2001;13:653- to significant change for children. 676. 21. Hair NL, Hanson JL, Wolfe B, Pollak SD. Association of child poverty, brain devel- opment, and academic achievement. JAMA Pediatri 2015;169:822-829. 22. Brcic V, Eberdt C, Kaczorowski J. Develop- ment of a tool to identify poverty in a fam- Accessed 28 July 2016. www.foodbanks Early development in Vancouver: Report ily practice setting: A pilot study. Int J Fam canada.ca/getmedia/d8b36130-cc83 of the Community Asset Mapping Project Med2011;2011:812182. -46ba-8183-d33d484c7591/Hunger (CAMP). Vancouver: Human Early Learn- 23. Bloch G. Poverty: A clinical tool for Count2014_revised.pdf.aspx?ext=.pdf. ing Partnership; 2002. Accessed 10 De- primary care in Ontario. Toronto: Ontario 5. World Health Organization. Poverty and cember 2015. https://secure.cihi.ca/free College of Family Physicians and Family social determinants. Accessed 28 July _products/ecd_van_e.pdf. and Community Medicine, University of 2016. www.euro.who.int/en/health 12. Farah MJ, Shera DM, Savage JH, et al. Toronto; 2013. Accessed 10 December -topics/environment-and-health/urban Childhood poverty: Specific associations 2015. http://ocfp.on.ca/docs/default -health/activities/poverty-and-social with neurocognitive development. Brain -source/cme/poverty-and-medicine -determinants. Res 2006;1110:166-174. -march-2013.pdf. 6. Gupta RP, de Wit ML, McKeown D. The 13. Luby JL. Poverty’s most insidious dam- 24. Divisions of Family Practice. Our impact: impact of poverty on the current and fu- age: The developing brain. JAMA Pediatr The poverty intervention tool. Accessed ture health status of children. Paediatr 2015;169:810-811. 28 July 2016. www.divisionsbc.ca/kb/ Child Health 2007;12:667-672. 14. Shonkoff JP, Boyce WT, McEwen BS. povertyintervention. 7. Kuh D, Hardy R, Langenberg C, et al. Mor- Neuroscience, molecular biology, and the tality in adults aged 26-54 years related to childhood roots of health disparities: Build- socioeconomic conditions in childhood ing a new framework for health promotion and adulthood: Post war birth cohort and disease prevention. JAMA 2009; study. BMJ 2002;325:1076-1080. 301:2252-2259. 8. Costello EJ, Angold A, Burns BJ, et al. The 15. Gianaros PJ, Jennings JR, Sheu LK, et al. Great Smoky Mountains study of youth. Prospective reports of chronic life stress Goals, design, methods, and the preva- predict decreased grey matter volume in lence of DSM-III-R disorders. Arch Gen the hippocampus. Neuroimage 2007;35: Psychiatry 1996;53:1129-1136. 795-803. 9. Boyle MH, Lipman EL. Do places matter? 16. Sheline YI. Neuroimaging studies of

460 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Derryck H. Smith, MD, FRCPC, John P. Wade, MD, FRCPC

Chikungunya: A disease risk for Canadians traveling in the tropics

A recent case of chikungunya fever demonstrates why physicians need to make an early diagnosis, provide effective symptomatic treatment of the severe myalgias and arthralgias that can result, and educate patients about preventing mosquito-borne illness.

ABSTRACT: While vacationing in fest as encephalitis, myocarditis, Case data Mexico a 68-year-old man developed hepatitis, arthritis, and multiorgan In November 2015 a previously a generalized rash and low-grade fe- failure. Neurological complications healthy 68-year-old physician vaca- ver and fatigue for 1 week. On re- can include seizures, encephalop- tioning in Mexico developed a gener- turning to Canada he experienced a athy, neuropathy, and Guillain-Barré alized rash and low-grade fever and flare-up of pain in his neck, elbows, syndrome. Patients older than 65 fatigue for 1 week. With the excep- wrists, and knees, and developed and young children, particularly tion of bilateral osteoarthritis of the pain and numbness in both arms. newborns, are at increased risk knees, the patient had no pre-existing The symptoms responded minimally for severe disease. Distinguishing medical concerns. On returning to to naproxen and improved dramat- chikungunya fever from dengue fe- Canada his symptoms abated, but by ically with prednisone. Exposure ver is critical because only the lat- mid-December he had a flare-up of to chikungunya, an RNA alphavirus ter can lead to life-threatening hem- pain in his neck, elbows, wrists, and of the Togaviridae family, was sus- orrhagic disease. Since the spring knees. He developed pain and numb- pected. Subsequently, a reactive IgM of 2014, there have been 320 con- ness in both arms that was intermit- enzyme immunoassay confirmed ex- firmed cases and 159 probable tent and depended upon sleeping pos- posure to chikungunya. The patient cases of chikungunya infection in ition. The pain resulted in significant has now returned to mostly normal Canada. Canadians traveling to trop- sleep disturbance. Arm strength was levels of functioning and has only ical areas should be advised to pro- significantly reduced and he was un- mild residual numbness in his right tect themselves against exposure to able to open twist-top bottles. His per- thumb. With so many Canadians mosquito bites. Precautions include sonal trainer noted a loss of strength traveling to tropical areas, phys- using mosquito repellant at all times, in the upper body of approximately icians must remain aware of the risk sleeping under a mosquito net, and 75%. Lifting cooking pots and tying posed by mosquito-borne illnesses. wearing long-sleeved shirts and long shoelaces was difficult. Severe chikungunya fever can mani- pants. Over the Christmas holidays the patient found he could no longer

Dr Smith is a clinical professor emeritus in the Department of Psychiatry at the Uni- versity of British Columbia. Dr Wade is a clinical associate professor in the Division of Rheumatology at the University of Brit- This article has been peer reviewed. ish Columbia.

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bicycle because of pain in the wrists nisone (5 mg B.I.D.) led to a dramatic A growing body of evidence indi- and weakness in the hands that made and early resolution of symptoms. cates that viruses and other infectious braking impossible. Because of joint Physiotherapy was arranged through agents play a role in chronic, inflam- swelling, rings had to be removed and the local hospital. Laboratory test re- matory arthritides such as rheumatoid a watch strap considerably loosened. sults were unremarkable, with the ex- arthritis.1 More than 30 microorgan- The patient’s family physician ception of a CRP level of 20.6 mg/L isms known to result in significant was concerned about viral infection. (reference range 0.08–3.1 mg/L), joint inflammation have been iden- A referral to neurology and electro- which fell to 0.6 mg/L after treat- tified, including chikungunya virus. myography studies confirmed severe ment with prednisone. Subsequently, Usually viral arthritis is self-limiting and lasts from a few weeks to several months.

Chikungunya Chikungunya is an RNA alphavirus of the Togaviridae family that can cause chronic and incapacitating arthralgia Chikungunya is an RNA alphavirus in humans. CHIKV was first isolated of the Togaviridae family that can in Tanzania in 1952. Since then there has been worldwide spread. Chikun- cause chronic and incapacitating gunya has now been identified in more arthralgia in humans. than 60 countries and is considered an important re-emerging public health problem in both tropical and temper- ate regions. The virus is spread by mosquitoes, typically Aedes aegypti or Aedes albopictus, the same mos- quitoes that spread dengue fever and Zika virus disease.2-4 bilateral carpal tunnel syndrome. a reactive IgM enzyme immunoassay In December 2013 the first local- There was also evidence of a right- confirmed the presence of chikungu- ly acquired CHIKV infections in the sided C7 radiculopathy. No specific nya antibodies. Results from testing Americas were identified in the Ca- cause was identified for the neuropa- for Zika virus were negative. ribbean,5,6 and by May 2014 almost thy. An urgent MRI of the neck was The patient has now returned to 60 000 cases had been reported and ordered, resulting in an appointment mostly normal levels of functioning the outbreak was still spreading.4 In date 9 months later. The patient elect- with mild residual numbness in the Canada, 320 confirmed cases and 159 ed to obtain an MRI privately and the right thumb. The pre-existing osteo- probable cases had been diagnosed as imaging was completed within 48 arthritis in both knees has stabilized of December 2014.7 CHIKV has since hours. The MRI of the neck revealed or improved, likely as a result of been reported in many regions of Afri- degenerative changes and foraminal physiotherapy. ca, the Americas, Asia, and the Pacific narrowing at multiple levels. There islands. The United States had 2320 was mild stenosis in the spinal canal Discussion imported cases as of 8 January 2015, at C4-C5 and severe right and mod- With so many Canadians traveling and in that year chikungunya became erately severe left foraminal stenosis. to tropical areas, physicians must a nationally notifiable condition and In late December the patient began remain aware of the risk posed by jurisdictions are now required to re- taking naproxen (220 mg Q.I.D.) to mosquito-borne illness, which is in- port all cases to the Centers for Dis- minimal effect and was referred to creasing around the world. It is im- ease Control and Prevention. a rheumatologist in early January. portant to educate patients, to make Based on the patient’s history, infec- an early diagnosis, and to provide ef- Diagnosis tion with chikungunya virus (CHIKV) fective symptomatic treatment when The incubation period for CHIKV is was suspected. Treatment with pred- required. 1 to 12 days. The acute phase of the

462 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Chikungunya: A disease risk for Canadians traveling in the tropics

disease is characterized by the rapid Prevention and control of chikun- cate patients about protecting them- onset of fever and intense asthenia, gunya disease involves insecticidal selves from mosquito bites and pro- arthralgia, myalgia, and headache, spraying and management of mosqui- vide effective symptomatic treatment with maculopapular rash occurring in to breeding sites, as well as bite pre- when required. 40% to 50% of cases. Following the vention. Canadians traveling to any rash, severe myalgias and arthralgias tropical area should be informed of Competing interests can be so intense that patients have the significant risk of mosquito-borne None declared. difficulty changing position. The joint illness and advised to take the follow- pain is typically symmetrical and lo- ing precautions: References cated in both the arms and legs. Small • Use mosquito repellant at all times. 1. Mathew AJ, Ravindran V. Infections and joints in the vertebral column can be • Use air conditioning to stay cool arthritis. Best Pract Res Clin Rheumatol involved to a lesser extent. and window or door screens to keep 2014;28:935-959. Severe chikungunya fever can mosquitoes outside. 2. Rougeron V, Sam IC, Caron M, et al. manifest as encephalitis, myocarditis, • Consider sleeping under a mosquito Chikungunya, a paradigm of neglected hepatitis, and multiorgan failure. Neu- net. tropical disease that emerged to be a new rological complications can include • Empty standing water from contain- health global risk. J Clin Virol 2015;64:144- seizures, encephalopathy, neuropathy, ers such as flowerpots and buckets. 152. and Guillain-Barré syndrome. • Wear long-sleeved shirts and long 3. Harwood PF, Buchy P. Chikungunya. Rev Patients older than 65 and young pants. Sci Tech 2015;34:479-489. children, particularly newborns, are at • When using sunscreen and insect 4. Johansson M, Powers AM, Pesik N, et al. increased risk for severe disease. repellant together, apply the sun- Nowcasting the spread of chikungunya Distinguishing chikungunya fe- screen first. virus in the Americas. Plos One ver from dengue fever is critical be- • Treat clothing with permethrin or 2014;9:e104915. cause only the latter can lead to life- purchase permethrin-treated cloth- 5. Halstead SB. Reappearance of chikun- threatening hemorrhagic fever, which ing. gunya, formerly called dengue, in the requires hospitalization of the patient. • Avoid exposure at peak biting times, Americas. Emerg Infect Dis 2015;21:557- Laboratory evidence of recent dawn and dusk (Aedes aegypti is a 561. exposure to chikungunya, dengue, day-biting mosquito species). 6. Weaver SC, Lecuit M. Chikungunya virus or Zika virus is confirmed by testing The Centers for Disease Control and the global spread of a mosquito-borne serum to detect viral nucleic acid or and Prevention website is a good disease. New Engl J Med 2015;372:1231- virus-specific immunoglobulin. source of additional up-to-date infor- 1239. mation: www.cdc.gov/chikungunya. 7. Public Health Agency of Canada. Travel- Treatment related chikungunya cases in Canada, There is no specific antiviral therapy Summary 2014. Canada Communicable Disease for CHIKV infection. Treatment is The case of a 68-year-old patient who Report. Volume 41-01. 8 January 2015. symptomatic and can include rest, recovered after contracting chikun- fluids, and the use of nonsteroidal gunya fever in Mexico shows the anti-inflammatory drugs (NSAIDS) risk posed by mosquito-borne illness. to relieve acute pain and fever. Per- Chikungunya can cause intense as- sistent joint pain may benefit from the thenia, arthralgia, myalgia, headache, use of NSAIDS, corticosteroids, or and maculopapular rash. Patients physiotherapy. older than 65 and young children are at increased risk for severe disease. Dis- Prevention tinguishing chikungunya fever from Currently there are no licensed vac- dengue fever is critical. There are cines for use against CHIKV, although no licensed vaccines for use against numerous candidates are being stud- CHIKV and no medications for treat- ied. Specific medications for treating ing chikungunya disease specifically. CHIKV infection are also not avail- With so many Canadians traveling to able. tropical areas, physicians must edu-

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 463 companion cruises FREE

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464 bc medical journal vol. 58 no. 8, october 2016 bcmj.org worksafebc

Canadian Chiropractic Guideline Initiative for effective knowledge translation espite existing clinical prac- behavior change techniques (from meet with private practitioners on tice guidelines for optimal the literature) were selected to incor- demand.16 management of axial spine porate into a comprehensive knowl- An extension of the initiative is D1-4 13 pain, the degree of adherence across edge translation package. The pro- the Canadian Chiropractic Practice- different health care disciplines var- posed intervention includes (but is Based Research Network, involving ies widely.2,5-7 Known gaps between not limited to) problem-based webi- partnerships between academic insti- guidelines and routine health care nars to promote active learning and tutions, researchers, and community- practice reflect a universal need for enhance knowledge and skills, edu- based practitioners. In BC, chiroprac- more effective knowledge transla- cational videos by respected opinion tors participate in systematic data tion.8,9 Particularly in primary care, leaders to leverage social influence collection while providing evidence- effective knowledge translation strat- and promote modeling of expert be- based education, exercises, and man- egies must consider the constraints havior, and evidence summaries and ual therapy to patients referred by a faced by busy practitioners, including practice tool kits to enhance the en- medical spine physician or surgeon. personal and organizational barriers vironmental context and available re- This participatory research setting to change. Targeted clinicians must sources within private offices. Soon allows investigators to formulate also be convinced that study patients, researchers will undertake a careful- study hypotheses directly informed from whom the data originate, are ly designed cluster randomized trial by experiences of grassroots clini- sufficiently representative of patients to evaluate the effectiveness of their cians while simultaneously engaging in their real-world practices. intervention package.14 and educating clinicians in hypothe- Since knowledge translation of- Knowledge translation is a priori- sis-testing, and knowledge creation ten requires changes in clinicians’ be- ty of chiropractic policymakers and is and implementation activities. liefs and behavior, strategies should supported by every chiropractic regu- By definition practice guidelines be based on explanatory frameworks latory and professional membership and research networks aim to define explicitly recognizing the psycho- organization in Canada. More than credible benchmarks for care based logical determinants of behavior a decade ago the Clinical Practice on the best available scientific evi- change.10 With this in mind, chiro- Guidelines Initiative was launched by dence, broad consensus among stake- practic researchers have used the both the Canadian Chiropractic Asso- holders, and efficient use of health Theoretical Domains Framework ciation and the Canadian Federation of care resources. In chiropractic, uni- (TDF) to inform the design of inter- Chiropractic Regulatory and Educa- versal support of these initiatives is ventions aimed specifically at chang- tional Accrediting Boards.15 Its ongo- a significant achievement and testa- ing practice behavior,11,12 and en- ing mission is to improve chiroprac- ment to the profession’s commitment couraging better adherence to neck tic care delivery in Canada through to the principles and objectives of evi- pain clinical practice guidelines.13 In the development, dissemination, and dence-informed health care. keeping with the TDF approach, chi- effective implementation of clini- —Jeffrey A. Quon, DC, MHSc, ropractors’ beliefs about managing cal practice guidelines. The initiative PhD, FCCSC nonspecific neck pain were evaluated recognizes busy clinicians often find WorkSafeBC Chiropractic and their facilitators and barriers to it challenging to access the latest sci- Consultant implementing guidelines in routine entific evidence, let alone digest and practice were identified. These de- implement it during routine practice. References terminants of behavior change were Therefore, through a dedicated web- 1. Koes BW, van Tulder M, Lin CW, et al. An then mapped to key theoretical do- site, clinicians are now provided with updated overview of clinical guidelines for mains of behavior change. Subse- easy access to information promot- the management of non-specific low back quently, relevant domain-specific ing adherence to evidenced-informed pain in primary care. Eur Spine J 2010; practice, and contact information for 19:2075-2094. This article is the opinion of WorkSafeBC 22 national chiropractic opinion lead- 2. Hurwitz EL, Carragee EJ, van der Velde G, and has not been peer reviewed by the ers and more than 100 best-practices et al. Treatment of neck pain: Noninvasive BCMJ Editorial Board. collaborators who are available to Continued on page 466

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Continued from page 465 Res 2006;6:49. 12. Cane J, O’Connor D, Michie S. Validation interventions: Results of the Bone and 7. Bussières AE, Sales AE, Ramsay T, et al. of the theoretical domains framework for Joint Decade 2000-2010 Task Force on Practice patterns in spine radiograph utili- use in behaviour change and implementa- Neck Pain and Its Associated Disorders. zation among doctors of chiropractic en- tion research. Implement Sci 2012;7:37. Spine 2008;33(suppl 4):S123-152. rolled in a provider network offering com- 13. Bussières AE, Al Zoubi F, Quon JA, et al. 3. Nordin M, Carragee EJ, Hogg-Johnson S, plementary care in the United States. Fast tracking the design of theory-based et al. Assessment of neck pain and its as- J Manipulative Physiol Ther 2013;36: KT interventions through a consensus sociated disorders: Results of the Bone 127-142. process. Implement Sci 2015;10:18. and Joint Decade 2000-2010 Task Force 8. Grol R. Successes and failures in the im- 14. Dhopte P, Ahmed S, Mayo N, et al. Testing on Neck Pain and Its Associated Disor- plementation of evidence-based guide- the feasibility of a knowledge translation ders. Spine 2008;33(suppl 4):S101-122. lines for clinical practice. Med Care 2001; intervention designed to improve chiro- 4. Dagenais S, Tricco AC, Haldeman S. Syn- 39(8 suppl 2):1146-1154. practic care for adults with neck pain dis- thesis of recommendations for the as- 9. Schuster MA, McGlynn EA, Brook RH. orders: Study protocol for a pilot cluster- sessment and management of low back How good is the quality of health care in randomized controlled trial. Pilot and pain from recent clinical practice guide- the United States? Milbank Q 2005;83: Feasibility Stud 2016;2:33. lines. Spine J 2010;10:514-529. 843-895. 15. Bussières A. The Canadian Chiropractic 5. Haldeman S, Dagenais S. A supermarket 10. Grol RP, Bosch MC, Hulscher ME, et al. Guideline Initiative: Progress to date. approach to the evidence-informed man- Planning and studying improvement in pa- J Can Chiropr Assoc 2014;58:215-9. agement of chronic low back pain. Spine tient care: The use of theoretical perspec- 16. Canadian Chiropractic Association. Guide- J 2008;8:1-7. tives. Milbank Q 2007;85:93-138. lines and best practice. Accessed 26 July 6. Hurwitz EL, Chiang LM. A comparative 11. Michie S, Johnston M, Abraham C, et al. 2016. www.chiropractic.ca/guidelines analysis of chiropractic and general practi- Making psychological theory useful for -best-practice/. tioner patients in North America: Findings implementing evidence based practice: from the joint Canada/United States Sur- A consensus approach. Qual Saf Health vey of Health, 2002-03. BMC Health Serv Care 2005;14:26-33. college library

ClinicalKey is mobile

he ClinicalKey mobile app for ClinicalKey subscription focuses on to facilitate retrieval of previous lists iOS and Android and the full-text content in family medicine, of search results, and content can be Tweb-based version are avail- psychiatry, internal medicine, ortho- placed in a saved-content folder to able to all College registrants with pedics, pediatrics, obstetrics and gy- create a personal archive. Library access. ClinicalKey provides necology, and emergency medicine. The app is not technically perfect access to Elsevier’s extensive collec- The ClinicalKey app contains yet; our testing identified some dis- tion of medical journals, books, vid- essentially the same content as the play and search features that do not eos, patient education materials, and web version while offering the con- work consistently. We are in commu- drug monographs. It is coupled with venience of functioning without nication with Elsevier’s technical ser- a Medline search engine and guide- an Internet connection. Users can vices team to improve this resource. line database, making it a powerful browse material or search using the For assistance with the ClinicalKey research tool. The College Library’s simple, intuitive search box. The mobile app, please contact the breadth of results can be filtered Library at either [email protected] or This article is the opinion of the Library of quickly by limiting to formats such as 604 733-6671. the College of Physicians and Surgeons of books, articles, or clinical trials, pro- —Karen MacDonell, PhD, MLIS BC and has not been peer reviewed by the cedural videos, or by specialty. The Director, Library Services BCMJ Editorial Board. app also remembers search activity

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BCMJ survey: Thank you leader who has encouraged the de- dren’s programs and to train orthope- and congratulations velopment of civic, economic, and dic surgeons in developing countries. This past August you may have re- social initiatives in his region. Dr Jeffrey Zorn has been induct- ceived an e-mail request to complete Congratulations to Dr Shaw and ed into the University of Alberta a short survey and to tell us what you Dr Battersby. Sports Wall of Fame for his accom- would like to see in the BCMJ. We plishments as an outstanding student sent the survey to a random sample set Congratulations to all athlete. As a Golden Bears hockey of Doctors of BC members and asked 2016 CMA Honorary player, Dr Zorn was named a Cana- them to provide feedback and be Membership Award winners dian Interuniversity Sport (CIS) All- heard, and gave them the option to en- The list of CMA Honorary Member- Canadian four times and a CIS Aca- ter to win a prize. Thank you to every- ship Award winners included in the demic All-Canadian five times, one who completed the survey—we July/August 2016 issue of the BCMJ among other accolades recognizing had an excellent response rate of 24%, is incomplete. There were 13 recipi- his contributions to sport, academ- spanning family physicians, special- ents of the award in 2016, and 6 names ics, and community involvement. ists, and trainees (students and resi- were omitted from the list. Thank you Dr Zorn is a urologist in Courtenay, dents) of all ages, both community to Dr Beverly Spring for bringing this BC. His interest in surgical volunteer based and hospital based. Your feed- to our attention. Our apologies for the work abroad has recently taken him back helps us shape the journal to be oversight. to Guatemala. relevant for you, and we will be shar- Dr Geoff Appleton ing more information about the survey Dr Jean Carruthers Private wide area network results in upcoming issues. Dr John Fleetham technical support available In appreciation of your feed- Dr Kenneth Fung Doctors who are making changes to back we gave away two iPad Pros. Dr Peter Konkal technology in their offices or access- Congratulations to our two winners, Dr William McDonald ing a new private wide area network Dr Brenda Markland and Dr Karen Dr Ralph Rothstein (the private physician network: PPN) Meathrel, who completed the survey Dr Anthony Salvian are encouraged to contact the Doctors and entered the draw. Dr Evelyn Shukin Technology Office for technical sup- If you did not receive the survey Dr Beverly Spring port focused on understanding the PPN but would like to share your thoughts Dr Paul Thiessen and how to maximize performance about the journal, send us your com- Dr Hugh Tildesley, posthumously issues and reduce security risks. The ments to [email protected]. Dr Kenneth Turnbull PPN is a private wide area network managed by BC Clinical and Support Order of Canada recipients Two BC docs recognized by Services. A private network allows In the September issue of the BCMJ their Alberta alma mater greater control, security, and reliability we neglected to include the following The University of Alberta Alumni than a standard Internet connection. two additional BC physician appoin- Association has recognized two BC Common technical frustrations tees to the Order of Canada. doctors for their contributions to that doctors encounter are often re- • Dr Dorothy Shaw, Officer of the health care and to sport. lated to connectivity issues. For ex- Order of Canada: Dr Shaw, from Dr Norgrove Penny received a ample, setting up a wireless router Vancouver, BC, was recognized Distinguished Alumni Award for his without a complete understanding for her contributions as a doctor contributions to health care, educa- of what the PPN can do will intro- and administrator who has helped tion, and international development. duce performance anomalies such as advance women’s health care in After medical school Dr Penny set up random disconnection to your EMR Canada, and maternal and newborn Vancouver Island’s first sport medi- vendor. Sharing your private network health globally. cine clinic in Victoria in 1978 and is with patients may also expose the net- • Dr Geoffrey Battersby, Member of still a practising orthopedic surgeon work to security issues. For more in- the Order of Canada: Dr Battersby, today, along with contributing his formation about how to optimize PPN from Revelstoke, BC, was acknow­ time to initiatives for children need- performance, visit www.doctorsofbc ledged for his contributions as a phy- ing orthopedic surgery. Dr Penny also .ca/technical-bulletins. sician, politician, and community travels overseas to help establish chil- Pulsimeter continued on page 468

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STI testing and cervical cancer screening: Need for continued STI screening among young people in the era of new cervical cancer screening guidelines

In June 2016 the BC Cancer Agen- mydia, with the latter having its high- cess and uptake of STI screening. cy released updated recommenda- est overall rates in this group.4,5 It is The BCCDC is committed to enhanc- tions for cervical cancer screening.1 critical that health care providers find ing access to sexual health and STI The age to initiate cervical cancer alternative ways to ensure STI screen- screening in the province through screening has increased to 25 years, ing is offered to at-risk women in the low-threshold clinics, anonymized and the routine screening interval has absence of cervical cancer screening. testing, effective use of electronic increased from 2 to 3 years. This is medical records, innovative service consistent with changes being made delivery models such as GetChecked globally in response to clinical evi- Online (https://getcheckedonline dence demonstrating that screening in Primary care .com), text message reminders for younger women is ineffective and is screening, and online tools such an unnecessary burden on health care providers should offer as the SmartSexResource (http:// systems. The updated screening rec- STI risk assessment smartsexresource.com). ommendations are strongly supported and screening to Programs should also consider by provincial leadership; however, sexually active opportunities afforded by innovative these new guidelines may have unin- women under the age and novel interventions that improve tended consequences if they lead to a of 25 at all clinically access to screening, including self- delay in engagement in health care for collection, where participants can appropriate young women under 25 years of age. take their own sample at home using a Screening for sexually transmit- encounters. swab that can be sent by mail for STI ted infection (STI) has traditionally screening. A recent systematic review been offered concurrent with cervical demonstrated that self-collected cancer screening in young women. sampling for chlamydia and gonor- By starting cervical cancer screening Opportunities for STI screening rhea through home-based screening at a later age there would likely be among young people had similar sensitivity and specificity decreased STI screening rates among Primary care providers should offer when compared to clinician-collected young women in BC. This trend was STI risk assessment and screening to samples.7 Self–collection based observed in Ontario by Bogler and sexually active women under the age screening is not intended to replace colleagues,2 where a 60% decrease in of 25 at all clinically appropriate en- routine clinical care; however, it is a Pap testing was seen, along with a 50% counters, consistent with Canadian highly acceptable and effective alter- decrease in screening for chlamydia guidelines,3 and the BC Lifetime native for those who are unable or and gonorrhea, following updated Prevention Schedule.6 Ideal oppor- unwilling to undergo a clinical exam- cervical cancer screening guidelines. tunities to perform an STI risk as- ination. The current Canadian Guidelines on sessment and STI screening are when Though the new recommenda- Sexually Transmitted Infections rec- young women consult health care tions for cervical cancer screening ommend STI screening for any patient providers for contraceptive advice, in BC will allow women to continue who reports risk factors for infection.3 reproductive health, sexual health, receiving optimal, evidence-informed Key components captured in the STI human papillomavirus (HPV) vac- care, it is important to ensure that risk assessment are sexual activity, cination, or family planning. potential gaps in care—such as number of partners, contraception Beyond the need for health care missed opportunities for STI screen- use (including condoms), STI histo- providers to encourage screen- ing—are mitigated. Under the provin- ry, presence of symptoms, pregnancy ing, there are opportunities for pub- cial leadership of the BCCDC and the history, and substance use. Young lic health to promote engagement. BC Cancer Agency’s Cervical Cancer people, particularly women under the The BC Centre for Disease Control Screening Program, primary health age of 25, experience high rates of (BCCDC) provides provincial leader- care providers can be key partners in STIs, especially gonorrhea and chla- ship and guidance around STI clini- ensuring that at-risk women continue cal service delivery. This includes to be screened for STIs. This article is the opinion of the BC Cancer STI treatment guidelines, monitoring —Dirk van Niekerk, MD Agency and has not been peer reviewed disease rates and trends provincially, —Troy Grennan by the BCMJ Editorial Board. as well as ongoing evaluation of ac- —Gina Ogilvie, MD

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STI testing and cervical cancer screening: Need for continued STI screening BC at GC: Home I have seen our young colleagues among young people in the era of new cervical cancer screening guidelines References sweet home and the future is bright. 1. BC Cancer Agency Cervical Cancer Last year I wrote about the ways that Next year will be the 150th Gen- Screening Program. Cervical cancer your colleagues represented you and eral Council of the Canadian Medi- screening policy change: Frequently Doctors of BC at the Canadian Med- cal Association and it will be held asked questions. 2016 reference guide ical Association General Council in in Quebec City. Watch for calls to supporting healthcare professionals in Halifax. This year we had the plea- apply to be part of the Doctors of BC communicating screening information sure of hosting the “Medical Parlia- delegation. Also check your inbox in to patients. Accessed 8 August 2016. ment of Canada” in Vancouver as Dr upcoming months for calls for nomi- www.bccancer.bc.ca/screening/ Granger Avery from Port McNeill nations to recognize colleagues and Documents/CCSP_GuidelinesManual was installed as president of the mentors for national awards. -CervicalCancerScreeningPolicyChange Canadian Medical Association. As always, we welcome your ReferenceGuide.pdf. As usual, Doctors of BC was one input and hope that you continue to 2. Bogler T, Farber A, Stall N, et al. Missed of the most active delegations. Sup- be part of our efforts to promote im- connections: Unintended consequenc- ported by our expert policy team of proved health for all. When it comes es of updated cervical cancer screening Helen Thi and Deborah Viccars, we to improving health policy, we are guidelines on screening rates for sexu- proposed many motions that were better together. ally transmitted infections. Can Fam then voted into national policy on —Eric Cadesky, MD, CM Physician 2015;61:e459-466. important issues such as immuniza- Chair of the General Assembly, 3. Public Health Agency of Canada. Cana- tion, climate change, resident and Doctors of BC dian guidelines on sexually transmitted student health, indigenous health, infections. Accessed 8 August 2016. and health care reform. Videos on Seeking nominations for www.phac-aspc.gc.ca/std-mts/sti-its/ most of these motions can be seen Doctors of BC 2017 awards cgsti-ldcits/index-eng.php. at https://m.youtube.com/user/Cana Doctors of BC is calling for nomina- 4. Public Health Agency of Canada. The dianMedicalAssoc/videos?shelf tions of members in good standing Chief Public Health Officer’s report on _id=14&sort=dd&view=0. for the following 2017 awards. the state of public health in Canada, Your Doctors of BC president, 2013: Infectious disease—the never- Dr Alan Ruddiman, welcomed Gen- Doctors of BC Silver Medal of ending threat. Sexually transmitted in- eral Council and set a tone of unity Service fections—a continued public health and respect by acknowledging the Criteria for nominees include any of concern. Accessed 10 August 2016. difficulties faced by doctors in differ- the following: www.phac-aspc.gc.ca/cphorsphc-resp ent provinces and the need to focus • Long and distinguished service to cacsp/2013/sti-its-eng.php. on the common goal of providing the Doctors of BC. 5. BC Centre for Disease Control. STI in best care. We also heard from Brit- • Outstanding contributions to med­ British Columbia: Annual surveillance re- ish Columbia’s Minister of Health, icine or medical/political involve­ port 2014. Accessed 10 August 2016. the Honourable Dr Terry Lake, and ment in British Columbia or www.bccdc.ca/resource-gallery/ federal Minister of Health, the Hon- Canada. Documents/Statistics%20and%20 ourable Dr Jane Philpott, who both • Outstanding contributions by a Research/Statistics%20and%20 reciprocated Dr Ruddiman’s invita- layperson to medicine or to the Reports/STI/STI_Annual_Report_2014 tion by affirming their willingness to welfare of the people of British -FINAL.pdf. collaborate with doctors. Columbia or Canada. 6. Office of the Provincial Health Officer. Another theme of General Coun- The closing date for nominations Lifetime prevention schedule. Accessed cil was the need to better support is 30 November 2016 at 11:59 p.m. 25 August 2016. www2.gov.bc.ca/gov/ and empower those in the first 15: For more information, visit www content/health/about-bc-s-health-care medical students, residents, and .doctorsofbc.ca/resource-centre/ -system/office-of-the-provincial-health early-career physicians. Indeed, the awards-scholarships. -officer/current-health-topics/lifetime Doctors of BC caucus was one of -prevention. the most diverse in the 149 years of Don B Rix Award for Physician 7. Lunny C, Taylor D, Hoang L, et al. Self- General Council with 10 of the 33 Leadership collected versus clinician-collected sam- delegates coming from the first-15 Candidates for this award may have pling for chlamydia and gonorrhea group. They spoke eloquently and achieved distinction in areas such as: screening: A systemic review and meta- passionately and provided unique • Supporting lifelong learning analysis. PLoS One 2015;10:e0132776. perspectives on important issues. Continued on page 470

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Continued from page 469 to access this resource, contact the cist if they rely on Pharmacare cover- opportunities. Society of General Practitioners at age. • Promoting excellence in medical 604 638-2943 or sgp.office@doctors If you have questions about education. ofbc.ca. changes to the RDP or its impact for a • Providing leadership for new initia- specific patient, call 1 866 905-4912. tives both in business and clinical Transitioning patients Staff are available to answer ques- practice. to the Modernized tions 24 hours a day, 7 days a week. • Providing leadership and service Reference Drug Program to the general community or prov- The Reference Drug Program (RDP) CareCard to be retired ince either by direct support or will be modernized as of 1 Decem- in February 2018 through philanthropy. ber 2016, and associated information The CareCard is being replaced by • Building consensus among physi- packages were mailed to all BC phy- the BC Services Card, a secure cre- cians and physician groups. sicians this summer. If you did not dential with features to protect iden- receive a package call Health Insur- tity, improve patient safety, and help Online resource ance BC (1 866 905-4912) to request avoid fraud and misuse of health care simplifies billing codes a print copy, or access the information services. The Society of General Practitioners online at www.gov.bc.ca/pharmacare/ If a patient presents a CareCard of BC (SGP) has created an online rdp-pro. for health services after February resource to streamline the billing pro- To secure uninterrupted coverage 2018, the patient must also provide cess for physicians. The SGP Simpli- for your patients, Pharmacare encour- one piece of photo ID or two pieces fied Guide to Fees organizes fees into ages physicians to identify patients of ID along with their personal health 20 categories including: who are taking a drug that will not be number. It is the duty of the health • Recently updated fees fully covered by the Modernized RDP care provider to verify Medical Ser- • GPSC fees and, if appropriate, to switch those vices Plan (MSP) coverage prior to • MSP in-office: visits and exams patients to a fully covered reference charging the patient for health care • Procedures, injections, and labs drug before 1 December 2016. benefits. Other Canadian jurisdictions • Obstetrics In September, Pharmacare sent are being directed to not accept the • Mental health letters to all patients who are taking BC CareCard as evidence of enroll- • Residential care drugs that will not be fully covered ment in MSP. • Telehealth as of 1 December 2016 and who have For more information on the BC • WorkSafeBC not yet been switched to a fully cov- Services Card visit www2.gov.bc.ca/ • ICBC and OSMV ered drug. The letters advise patients gov/content/governments/govern For more information about how to contact their physician or pharma- ment-id/bc-services-card. Pulsimeter continued on page 472

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Continued from page 470 disease. McNagny and colleagues A virtual scalpel for UBC Crohn disease discovery are hopeful that their discovery could medical students Scientists from the University of Brit- also be applied to other types of tissue For the first time, first-year medical ish Columbia discovered a mutation that experience fibrosis, potentially students at the University of Brit- that prevented mice from developing blocking complications of age-related ish Columbia will be using a touch- fibrosis after they were infected with fibrotic diseases by dampening these screen table that displays detailed a type of salmonella that mimics the particular inflammatory cell types. images of internal anatomy that can symptoms of Crohn disease. The dis- Liver cirrhosis, chronic kidney dis- be rotated, enlarged, and sliced open. covery could lead to treatments for a ease, scarring from heart attacks, and The anatomy visualization table will debilitating complication of the dis- muscle degeneration all result in tis- be used with traditional anatomical ease. The mutation had switched off sue fibrosis. The researchers’ next dissections to teach first-year medi- a hormone receptor responsible for step will be to test drugs to discover cal students about human anatomy stimulating part of the body’s immune if they can stop or reverse fibrosis in and the medical conditions they are response. mice. likely to encounter as physicians. The Co-author Kelly McNagny, pro- The research, “The orphan nuclear device also will familiarize students fessor of medical genetics and co- receptor ROR alpha and group 3 in- with the radiological images that have director of the UBC Biomedical nate lymphoid cells drive fibrosis in become a core tool in the diagnosis Research Centre, identified that sci- a mouse model of Crohn’s disease,” and treatment of patients. entists found what they think are the is published in the September 2016 The 500-pound, five-foot by inflammatory cells that drive fibrosis, issue of Science Immunology and is three-foot table displays primarily adding that the gene that was defec- available online at http://immunology CT scans of the entire body, including tive in those cells is a hormone recep- .sciencemag.org/content/1/3/ bones, muscles, organs, and connec- tor, and that there are drugs available eaaf8864. tive tissue. Instructors can customize that may block that hormone receptor Watch a video with more informa- the table’s images for the lessons they in normal cells and prevent fibrotic tion about the discovery on bcmj.org. want to convey, showing anonymized patients with diseases and injuries that are deemed particularly relevant to the curriculum and to the practice of medicine. The table will be used in UBC’s gross anatomy lab in conjunction with traditional teaching through dis- section. Groups of students will take turns with the device, moving from their dissection tables to the touch- screen device and back again. Visit bcmj.org to watch a video about how the anatomy visualization table works.

Noninvasive technique to monitor migraines Amplified EEGs can produce diag- nostic results of a brainwave associ- ated with migraines and epilepsy that are comparable to the current, more invasive, standard. The discovery could lead to better treatment and diagnosis of these conditions. The low-frequency brainwave linked to migraines and epilepsy, cor­ tical spreading depression (CSD), is currently best studied by placing elec-

472 bc medical journal vol. 58 no. 8, october 2016 bcmj.org pulsimeter trodes directly on the surface of the logical conditions such as stroke and ferent than living human tissue. The brain. Researchers from UBC, Germa- traumatic brain injury. synthetic material can be created safe- ny, and Iran have found that EEGs— The study is a joint research pro- ly and cheaply, does not decompose, produced by placing electrodes only gram between UBC, the University cannot be contaminated, and feels on the scalp—can produce equally re- of Münster, and Shefa Neuroscience like living human tissue. liable data if a specially designed am- Research Center and Mashhad Uni- The synthetic tissue was invented plifier is used in tandem. The electri- versity of Medical Sciences in Iran. by Professor Hadi Mohammadi and cal signals acquired from the skin of A paper describing the results was Dr Guy Fradet, who are both affili- the scalp were very similar to those published in July 2016 in Neurosci- ated with UBC’s Faculty of Medicine. acquired from the surface of the brain. ence. Contact [email protected] to The invention is currently being An AC/DC amplifier was de- request a copy. used for teaching purposes by a num- signed to acquire electrical signals ber of surgeons and medical residents from scalp electrodes used on anes- Synthetic heart valves to at Kelowna General Hospital to prac- thetized rats in a much broader fre- help improve surgical skills tise bypass surgery on actual hearts quency range than the standard UBC researchers have developed harvested from pigs. The next step clinical EEG system. CSD was then synthetic heart valves, arteries, and will be to create a synthetic heart with induced in the rats, and the record- veins made of polyvinyl alcohol the material. ings from scalp electrodes were hydrogel that resemble human tissue. The research, “Simulation of an­ compared with recordings from elec- The polyvinyl tissue makes it possible astomosis in coronary artery bypass trodes placed on the rats’ brains. for surgeons and medical residents to surgery,” was published in Cardio- Researchers believe the new ana­ practise bypass surgery techniques vascular Engineering and Technol- lysis technique could contribute to using the synthetic material rather ogy and is available online at http:// the development of migraine drugs than arteries and veins from dead pigs link.springer.com/article/10.1007/ that target CSD, and to better under- or human cadavers, which can break s13239-016-0274-x. standing, diagnosing, and treating down quickly if they are not treated Learn more about the synthetic tis- migraines, epilepsy, and other neuro- with preservatives and which feel dif- sue in a video available on bcmj.org. Haughton_SCF_BCMJ_1/2H_Oct2016_Haughton_SCF_BCMJ 1/2.qxd 2016-09-12 12:21 PM Page 1

Join the Section of Clinical Faculty (SCF) of Doctors of BC Your membership in the Section of Clinical Faculty allows us to inform you of progress on issues such as: • How to assure clinicians are supported to provide excellent teaching? • What is the impact of teaching on patient wait-times and physician workload? • Does teaching affect the number of procedures performed in Operating Rooms? • Is teaching required for hospital privileging? • Is teaching required for access to O.R. time? • Does your UBC academic rank determine your clinical income? If so, why? If not so, will it be so in future? 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

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 473 calendar

MEDICAL LEGAL CONF World—Grand Floridian Resort (19– physicians. Accreditation: up to 15 Vancouver, 21 Oct (Fri) 21 Dec); Mexico—Iberostar Mayan Mainpro-M1/MOC Section-3 credits. Examine an eclectic array of medical Riviera (18–20 Jan), Bahamas— Register at ubccpd.ca/course/SEMP and legal issues! Attend the confer- Atlantis Resort (9–11 Feb 2017); Las -Oct27-2016. Tel 604 875-5101, ence at the Pan Pacific Hotel or via live Vegas—Aria Resort (15–17 Feb); e-mail [email protected]. webinar. Examine an eclectic array of Whistler—Delta Whistler Village current and ongoing medical and legal Suites (20–22 Mar); Maui—Shera- UGEMP COURSE issues for lawyers, legal support staff, ton Ka’anapali (27–29 Mar); Kauai— Vancouver, 28 Oct (Fri), 18 Nov (Fri) doctors, and nurses. On the legal side, Grand Hyatt (10–12 Apr 2017); South The use of bedside ultrasound by cli- the medical dimension arises when Pacific cruise—Paul Gauguin (15–29 nicians to guide invasive emergency there are injured parties and claims in Apr 2017); Mediterranean cruise— and critical care procedures improves the context of accidents, occupational Celebrity Reflection (9–20 Oct 2017). success and reduces complications, health, and medical care. At this course CBT Canada, now 20 years old, is a and is rapidly becoming established you will learn about the current state national winner of the CFPC’s CME as the standard of care. The Ultra- of the law with medical assistance Program Award and was the first orga- sound Guided Emergency Medicine in dying, how to effectively prepare nization authorized to provide 3-cred- Procedures course will be held at the expert evidence in litigation, the com- it-per-hour CME. Lead faculty Greg Centre of Excellence for Surgical plex issues around the prescription Dubord, MD, has given over 300 CBT Education & Innovation, Vancouver of opioids, how to manage medical workshops and is a recent University General Hospital, 3602–910 W. 10 legal matters in litigation, medical and of Toronto CME Teacher of the Year. Ave. Pre-course work includes web- legal causation, and much more. Who For details and to register visit www. based learning modules to complete should attend: lawyers, personal injury cbt.ca or call 1 877 466-8228. Look the self-directed learning. Human litigators, litigation legal support staff, for early-bird deadlines. models will allow for demonstra- doctors, and nurses. Course chairs: tion of human surface landmarks, Dr Garry Feinstadt, physician and SEMP COURSE and ultrasoundable task-trainers that surgeon, Vancouver, and Mr Paul T. Vancouver, 27 Oct (Thu) simulate the tactile feel of human tis- McGivern, Pacific Medical Law, Van- The Simulation Assisted Emergency sue will allow for the repeated prac- couver. Early bird pricing (until 23 Sep Medicine Procedures course allows tice of invasive procedures without 16): Live webinar: $485; live course: physicians to acquire, review, and harming the human models. Forma- $575. Further information and regis- practise their skills in essential life- tive evaluation in the form of immedi- tration at www.cle.bc.ca/onlinestore/ saving emergency procedures. Before ate feedback provided by the instruc- productdetails.aspx?cid=1306&utm_ the course, students will have access tor will help the students to monitor source=CLEBC+Staff+Members to web-based learning modules to their progress and guide their learn- &utm_campaign=fe0cb6e5af-Med complete the self-directed learning. ing. Maximum course capacity: 24 icalLegalConf_Aug5%2F16&utm_ The hands-on portion of the course participants. Target audience: Emer- medium=email&utm_term= at the Centre of Excellence for Sur- gency, rural, intensive care, and 0_5923440f7a-fe0cb6e5af. gical Education & Innovation, Van- family physicians, pediatricians, couver General Hospital, 3602–910 anesthetists, trauma physicians, resi- MEDICAL CBT W.10 Ave., will have experienced dents, IMGs. Accreditation: up to 15 Various locations and dates instructors demonstrating the proce- Mainpro-M1/MOC Section-3 credits. When you learn medical cognitive dures and supervising the students as Register for 28 Oct at http://ubccpd behavior therapy’s ultra-brief tech- they practise on animal and realistic .ca/course/UGEMP-Oct28-2016 and niques, you’ll feel much more com- plastic models. Students will have the for 18 Nov at http://ubccpd.ca/course/ fortable handling the many “supraten- opportunity to integrate performance UGEMP-Nov18-2016. Tel 604 875- torial issues” in your practice. Choose of these procedures into the real-time 5101, e-mail [email protected]. from the following workshops, each resuscitation of a critically ill patient “3.1” accredited for at least 36.0 using the latest human patient simu- FALL/WINTER CME CRUISES Mainpro+ credits by the CFPC: Scott- lator technology to create realistic FROM SEA COURSES sdale—Fairmont Scottsdale Princess scenarios. Maximum course capac- November 2016–March 2017 (24–26 Nov); Caribbean cruise—Dis- ity: 24 participants. Target audience: Travel with the CME cruise experts. ney Fantasy (10–17 Dec); Disney Emergency physicians and rural Discover new destinations. Return

474 bc medical journal vol. 58 no. 8, october 2016 bcmj.org calendar to favorite ports. Costa Rica (Nov), BLEEDING AND THROMBOSIS Canada and the BC Chapter for up to Tahiti & Marquesas (Nov), Caribbe- Vancouver, 17 Nov (Thu) 6.5 Mainpro+ credits. Attendees will an (Dec, Mar & Apr), South America The Centre for Blood Research at gain up-to-date oncology knowledge (Jan), Australia / New Zealand (Feb), the University of British Columbia is and build useful cancer care connec- Mexico (Feb), Bali–Singapore (Feb). hosting the 10th annual Earl W. Davie tions. The session will take place at the Trips planned by physicians for phy- Symposium at the Segal Building, Child & Family Research Institute at sicians. Sea Courses has provided 500 Granville St. This 1-day event in BC Children’s Hospital in Vancouver almost 300 unique CME conferences honor of the discoverer of the coagula- and provides an effective way to learn onboard cruise ships over the past 20 tion cascade, features presentations by about new oncology resources and years. Programs are accredited for experts in vascular biology, hemosta- support in BC. Register now at www specialists and FPs, have no pharma- sis-thrombosis, inflammation, cardio- .fpon.ca. For more information con- sponsorship and include a compli- vascular and neurovascular disease, tact Jennifer Wolfe, jennifer.wolfe@ mentary enrichment program for trav- and facilitates knowledge exchange bccancer.bc.ca or 604 219-9579. elling companions. All Sea Courses between researchers and physicians. trips offer group pricing, special air- This symposium will focus on cutting ESSENTIAL MEDICAL-LEGAL fares, and free cruising for compan- edge advances in the understanding TOOLKIT ions. Contact Sea Courses Cruises for and treatment of hemophilia, throm- Vancouver, Various dates more information and details of cur- bosis, and bleeding disorders. High- This program is suitable for family rent promotions. Phone 604 684-7327 lights of the symposium include key- physicians and specialists and will be or toll free 1 800 647-7327; e-mail note presentations by Drs Nigel S. held at UBC Robson Square. Medical [email protected]. Visit www Key and John W. Wiesel, a lineup of Legal Reports: The Essentials, will be .seacourses.com for a complete list of leading local and international speak- held 9 a.m. to 4 p.m., 26 Nov (Sat), CME cruises and tours. ers, talks by patients, and selected oral and 25 Feb (Sat). If writing medical and poster presentations by students legal reports causes you stress, if you LIVE WELL WITH DIABETES at all levels of training. Accreditation: are not sure what to write when asked Richmond, 4–6 Nov (Thu–Sun) RCPSC MOC Section 1 credits (pend- about prognosis, unsure of what to do Come check out the conference for ing). Fees: $99 (professionals); $49 about patients’ subjective complaints, health care professionals at the Radis- (students). Registration: http://cbr.ubc or how much you should be billing for son Hotel, our new venue in Rich- .ca/events/earl-w-davie-symposium. your reports, then this is the course mond, close to the Canada Line sta- you want to attend. Medical Legal tion! Building on the success of our FP ONCOLOGY CME DAY Reports Advanced and Testifying in new 3-day format, this year’s agen- Vancouver, 19 Nov (Sat) Court: Becoming a Great Expert, will da includes presentations designed The BC Cancer Agency’s Family Prac- be held 9 a.m. to 4 p.m. on 4 Mar (Sat) for family physicians, allied health tice Oncology Network invites family and will provide advanced training on professionals, podiatrists, and other physicians and primary care profes- writing more complex medical legal health care professionals who have an sionals to attend its annual Family reports and provide tips on how to interest in recent advances in diabe- Practice Oncology CME Day certified reduce stress while testifying in court. tes. Featured topics: Diabetes and the by the College of Family Physicians of Continued on page 476 elderly; Ambulatory glucose moni- toring/CGMS; Combination therapy: Does 1 + 1 equal 3; Economics of dia- betic foot complications: Importance of risk reduction; How to discuss obesity—A family physician’s per- spective. A public health fair has been scheduled for Sunday, 6 November, at the same venue. Conference regis- tration, information, program details, and online registration are available at www.ubccpd.ca. Tel 604 875-5101, fax 604 875-5078, e-mail cpd.info@ ubc.ca.

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Continued from page 475 that they may provide enhanced care (Hawaii’s longest), crescent-shaped These courses will be taught by medi- for local cancer patients and their Hanalei Bay, and Hawaii’s only navi- cal legal professionals with extensive families. Following the introductory gable river, the Wailua. See www.cbt experience—faculty who have busy session, participants complete a fur- .ca for details about both the Maui and personal injury practices and know ther 6 weeks of customized clinic Kauai workshops. Warning: Our sig- exactly what they want from medi- experience at the cancer centre where nificantly discounted guestrooms for cal legal reports and expert testimo- their patients are referred. These can these two workshops will sell out far ny in court. Fees: $480/course. For be scheduled flexibly over 6 months. in advance. registration and further information Participants who complete the pro- call 604 525-8604, e-mail manager@ gram are eligible for credits from the SOUTH PACIFIC CRUISE coremedicalcentre.com, or visit www College of Family Physicians of Can- 15–29 Apr 2017 (Sat–Sat) .medlegaltoolkit.com. ada. Those who are REAP-eligible Join us for a 13-night cruise exploring receive a stipend and expense cover- exotic Tahiti (where Captain Bligh’s MINDFULNESS IN age through UBC’s Enhanced Skills men mutinied to stay put), Mo’orea MEDICINE—FOUNDATIONS Program. For more information or to (Arthur Frommer’s vote for “the most OF THEORY AND PRACTICE apply, visit www.fpon.ca, or contact beautiful island on earth”), Taha’a Brentwood Bay Resort, 2–4 Dec Jennifer Wolfe at 604 219-9579. (French Polynesia’s vanilla-scented As chronic stress and its associated isle), Bora Bora (celebrities’ exclusive mental and physical health challenges HAWAIIAN CME: MAUI/KAUAI hideaway), the Cook Islands (New continue to rise in epidemic propor- Maui, 27–29 Mar 2017 (Mon–Wed), Zealand’s private paradise), the King- tions, the application of mindfulness Kauai, 10–12 Apr 2017 (Mon–Wed) dom of Tonga (proudly never colo- in clinical practice settings has gained Aloha! Please join us in the happi- nized), and three idyllic islands of Fiji prominence both in terms of evidence- est American state next spring for (Viti Levu, Vanua Levu, and postcard- based research and in the popularity of award-winning CME in medical cog- perfect Beqa). You’ll be enchanted by its use. Join us for this 3-day experi- nitive behavior therapy—Medical the South Pacific’s craggy volcanic ential workshop on mindfulness and CBT: Ultra-brief techniques for real peaks, sugary beaches, warm lagoons meditation as it relates to the unique doctors. The Maui workshop (CBT teaming with fish, glistening black challenges and blessings of our work for Depression/Happiness) will be pearls, and Tamure dancing sugges- as physicians. Learn about the latest held at the idyllic Sheraton Maui on tive enough to make you blush. The clinical evidence and neuroscience Ka’anapali Beach. With 23 acres of CME provides a rock-solid founda- on mindfulness in medicine, find out lush Hawaiian grounds, you’ll never tion in medical CBT for depression, about programs offered throughout feel crowded! Maui has been voted reviewing a plethora of ultra-brief BC and Canada, and explore practical best island by the readers of Condé office techniques to defeat depression meditation tools for yourself and for Nast Traveler for more than a dozen and be happy. CBT Canada, now 20 your patients. Accrediation: 32 cert + years. Attractions include 10 000 foot years old, is a national winner of the group learning credits. Visit drmark Hale’akala (Hawaiian for house of the CFPC’s CME Program Award, and sherman.ca for more info or contact sun), 14 golf courses (including some was the first organization authorized [email protected] to register. of the world’s top-rated), the scenic to provide 3-credit-per-hour CME. road to Hana, the Seven Sacred Pools Lead instructor Greg Dubord, MD, is GP IN ONCOLOGY TRAINING of Oheo, and over 500 restaurants. The a University of Toronto CME Teacher Vancouver, 20 Feb–3 Mar (Mon– Kauai workshop—CBT Tools, will be of the Year. Assistant faculty includes Fri), and 11 Sep–22 Sep 2017 held at the spectacular Grand Hyatt on the inimitable Fijian psychiatrist Ben- (Mon–Fri) sunny Poipu Beach. The Grand Hyatt jamin Prasad, MD, FRCPC, from the The BC Cancer Agency’s Family Kauai is ranked among the world’s University of Manitoba. Super early Practice Oncology Network offers an top resorts by both the Condé Nast bird rates for ocean-view staterooms 8-week General Practitioner in Oncol- Traveler and Travel+Leisure. Kauai aboard the spectacular m/s Paul ogy training program beginning with is the most tranquil and pristine of the Gauguin start at $12 850 (includes a 2-week introductory session every main Hawaiian Islands, with beach- all beverages, all taxes, all gratuities, spring and fall at the Vancouver Cen- es fringing nearly 50% of its tropi- return airfares, and companion cruis- tre. This program provides an oppor- cal coastline. Attractions include the es free). Book with Canada’s largest tunity for rural family physicians, world-famous Kalaulua Trail on the cruise agency, CruiseShipCenters. with the support of their community, Napali Coast, red-rocked Waimea See CBT Canada at www.cbt.ca or to strengthen their oncology skills so Canyon, 17-mile Polihale Beach call 1 888 739-3117.

476 bc medical journal vol. 58 no. 8, october 2016 bcmj.org council on health promotion

Driving stoned: Marijuana legalization and drug-impaired driving

fter alcohol, marijuana is and cerebellum of the brain. Mari- 5 ng/mL, but legal levels vary sig- the most frequently detected juana has been shown to negatively nificantly between American states. A drug in crash-involved driv- impact peripheral vision, awareness Marijuana’s main psychoactive ingre- ers. The Canadian government has of the passage of time, motor control, dient, THC, is fat soluble, making it indicated its intention to legalize and balance. Marijuana also affects difficult to connect a person’s current marijuana for recreational use in the prefrontal cortex, the home for state of impairment to a blood level. 2017, and while many Canadians executive function. Driving is an Blood levels will vary depending on a support this initiative some American exercise in timing, multitasking, and number of factors, including whether studies indicate that marijuana legal- situational awareness, all functions the individual is a chronic or occa- ization may adversely impact road adversely impacted by marijuana. It sional user. Similar to alcohol levels, safety. Since 2012 a growing number should be noted that unlike drivers Washington State’s decision to use 5 of American states have legalized the under the influence of alcohol, mari- ng/ml to define impairment is more of use of marijuana for recreational or juana users tend to be aware of their an administrative standard than a sci- medical and therapeutic use. impairment, exhibit greater caution, entific one. Canadian discussions around and drive more slowly, although this To date there is limited evidence the legalization of marijuana must may not adequately compensate for supporting the 5 ng/mL standard. include a clear-headed assessment the impairments discussed above. First, research from Australia demon- regarding the impact of legalization The most common standard used strates that chronic users of cannabis on road safety. We must create a sci- to define marijuana-impairment is Continued on page 478 entifically sound and fair approach toward drug-impaired driving, and develop appropriate standards and penalties to enforce any new laws. So far, postlegalization, motor vehicle fatality statistics in the US are sobering. In Washington State, fatal companion crashes among drivers who tested cruises positive for marijuana doubled from FREE 8% in 2013 to 17% in 2014.1 In Col- orado the number of drivers in fatal crashes who tested positive for mari- juana without other drugs in their sys- tem tripled between 2005 and 2014 from 3.4% to 12.1%.2 BC Medical Journal “What better way to get those CME Driver impairment from marijua- credits and see the world indeed!” na use may be different than alcohol CME Cruise —Romy Anastasio MD, use. Detrimental effects of marijuana Hamilton ON Canada vary in a dose-related fashion and 12-Night Quintessential Mexican are more pronounced in affecting the highly automatic functions of driving Family Practice Refresher rather than complex tasks that require February 09–21, 2017 conscious control, as is the case for San Diego, CA, USA • Roundtrip alcohol.3 Cannaboid receptors are found in the amygdala, basal ganglia, For more information: 1-888-647-7327 [email protected] • www.seacourses.com This article is the opinion of the Council on Health Promotion and has not been peer reviewed by the BCMJ Editorial Board.

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 477 cohp

Continued from page 477 Robust scientific evidence and References are unlikely to register higher than practical roadside testing tools to pre- 1. Tefft BC, Arnold LS, Grabowski JG, AAA 5 ng/mL 24 hours following inges- cisely measure marijuana impairment Foundation for Traffic Safety. Prevalence tion.4 This diminishes the chance that for drivers are not yet available. Until of marijuana involvement in fatal crashes: unfair convictions would occur for these are available, road-side sobri- Washington, 2010–2014. Accessed 16 those who have consumed cannabis ety testing by properly trained offi- August 2016. www.aaafoundation.org/ more than a day before. Second, this cers will continue to be the method prevalence-marijuana-use-among-drivers research suggests that drivers below by which marijuana-impaired drivers -fatal-crashes-washington-2010-2014. 5 ng/mL have twice the incidence are removed from our roads. Police 2. Colorado Department of Transportation. of fatal accident involvement while officers in some American states may Drugged driving statistics. Accessed 9 drivers above the 5 ng/mL threshold order drivers to undergo blood test- August 2016. www.codot.gov/safety/ have more than 6 times the incidence ing at a hospital to measure blood alcohol-and-impaired-driving/drugged of fatal accident involvement. levels; however, the practicality of driving/drugged-driving. Roadside breath testing for mari- such tests is questionable due to the 3. Sewell RA, Poling J, Sofuoglu M. The juana may become a reality for law cost and time required for them. As effect of cannabis compared with alcohol enforcement but further testing for we proceed to legalize marijuana, it on driving. Am J Addict 2009;18:185-193. such devices is required. Through will be imperative for federal and pro- 4. Drummer OH, Gerostamoulos J, Batziris analysis of active THC, testing devic- vincial governments to fully consider H, et al. The involvement of drugs in driv- es may be able to detect recent canna- and appropriately mitigate the risks of ers of motor vehicles killed in Australian bis ingestion. This could assist a zero- marijuana-impaired driving. road traffic crashes. Accid Anal Prev tolerance enforcement program but —Chris Rumball, MD 2004;36:239-248. would still lack the ability to define Chair, Emergency Medical degrees of impairment. Services Committee

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FILENAME 2016-08-2331-MB-Aug-E-Class-Print_Ad-BCMJ.indd INTERNAL REVISION 3 C M Y K BC Medical Journal CLIENT TRIM CLIENT REVISION -- 6.625” x 4.2” 2 Material: Aug 15, 2016 bc medical journal vol. 58 no. 8, october 2016 bcmj.org 478 CREATION DATE 05/06/16 BLEED -- OPERATOR RP Insertion: REVISION DATE August 15, 2016 10:26 AM FOLD -.--" x -.--" T: 604.417.7865

OUTPUT DATE 08/15/16 LIVE -.--" x -.--" E: [email protected] TRAP AT FINAL OUTPUT SAFE -.--" x -.--" APPROVALS SEEN APPROVED RESOLUTION 300dpi CREATIVE/DESIGNER -- FONTS -- COPYWRITER --

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dics, psychiatry, radiology, urology, and oncol- ver Island. Well-established, very busy clinic practices available ogy. Income of $244 200 supported through a with 26 general practitioners and 2 specialists. LAKE COUNTRY, BC—FOUR service contract with on-call stipend and no Two locations in Nanaimo; after-hours walk-in PHYSICIANS NEEDED overhead costs. For more information e-mail clinic in the evening and on weekends. Com- Lake Country Family Practice is expanding! [email protected] or puterized medical records, lab, and pharmacy Lake Country is a fast-growing community of visit www.betterhere.ca. on site. Contact Ammy Pitt at 250 390-5228 or 19 000, 15 km north of Kelowna. We are look- e-mail [email protected]. Visit ing for four physicians to join our established LILLOOET—FP our website at www.caledonianclinic.ca. group of four practices to allow very flexible Five-physician, unopposed fee-for-service working hours and a minimum of 8 weeks of practice seeks sixth family physician with ER NEW WEST—FAMILY PHYSICIAN vacation per year, yet maintain low overhead skills. Clinic group focus is on balancing work New Westminster: Columbia Square Medical and full coverage without the need for locums. and lifestyle. Easy access to Lower Mainland, Clinic is looking for a family physician for a No government bureaucrats dictating your Whistler, and Interior of the province. Call is full- or part-time position. Partnership and style of care and no business corporation prof- currently 1 in 5. Regular schedule includes 1 options to buy are available. Flexible hours, iting off of your hard work. For more informa- week off every fifth week. Full rural physician competitive split. The clinic is newly renovat- tion visit our website lakecountryfamilyprac recruitment and retention benefit eligibility, ed with bright rooms, Oscar EMR, excellent tice.com, or e-mail Bonnie at [email protected]. including 38 days of rural locum coverage for friendly and efficient staff, 20 minutes from holidays. World-class wilderness at your door- downtown Vancouver. We have 800 families VANCOUVER—PEDIATRICS step for skiing, hiking, fishing, white-water waiting for a family doctor who wants to es- Busy pediatric practice available. Solid referral kayaking, and mountain biking. Full-service tablish a permanent practice or work part-time. base. Recently renovated 1000 sq. ft. office, in- rural hospital with GP surgeon and anesthe- Considering a change of location or practice cluding four exam rooms and two MD rooms. tist on staff. For more information e-mail style? Call Irina at 778 886-6511 or e-mail irina EMR in place. Conveniently located near BC [email protected] or [email protected]. Children’s Hospital. Options to buy or rent com- visit www.betterhere.ca. mercial unit. E-mail [email protected] NORTH DELTA—GENERAL or call 778 233-6543 for more information. MERRITT—FP PRACTITIONER Rolling hills, sparkling lakes, and over 2030 Very busy, established family practice located hours of sunshine every year make Merritt a on Scott Road. The practice consists mainly employment haven for four-season outdoor recreation. We of Punjabi-speaking patients. Two spacious have a need for family physicians in their exam rooms plus a private office available for ABBOTSFORD—LOCUMS choice of clinic. Nicola Valley Hospital and the physician. Underground parking. No set- Full-service East Abbotsford walk-in clinic re- Health Centre is a 24-hour level-1 community up fees or equipment required. Everything is quires locum physicians for a variety of shifts hospital with a 24-hour emergency room. Roy- included in the billing split (80/20). Potential including weekends and evenings. Generous al Inland Hospital in Kamloops is a tertiary- to earn 400K per year. Physician may decide split: pleasant office staff and patient popula- level hospital located only 86 km away. Re- their own schedule. Each exam room is fully tion. Please contact Cindy at 604 504-7145 if muneration is fee-for-service ($250 000 to equipped with everything required. EMR: Med you are interested in obtaining more info. $450 000-plus per year), rural retention incen- Access. Very friendly medical office assistant tives and on-call availability payment. For and office manager. For more information con- KAMLOOPS—HOSPITALISTS more information e-mail physicianrecruitment tact Dr Jagtar Rai at raimedicalclinic@gmail Royal Inland Hospital, a 246-bed tertiary @interiorhealth.ca or view online at www .com. hospital and referral centre, is seeking perma- .betterhere.ca. nent full-time physicians to join our collegial hospitalist service. You will provide general NORTH VAN (LYNN VALLEY)—FAMILY N VANCOUVER—FAMILY PHYSICIANS medical care of hospitalized adult patients and PRACTICE LOCUM WELCOME co-management of surgical and psychiatric pa- Regular and occasional shifts available in a Family practice/walk-in seeking F/T or P/T tients. The hospitalist service is supported by busy walk-in. We are on Oscar EMR and have physicians. Spacious, Oscar EMR, Wi-Fi. Lo- a complement of specialty services including experienced staff to assist you. There is also an cated near SeaBus. Convenient to downtown anesthesia, general internal medicine, general opportunity to share a family practice 1 to 2 surgery, orthopedics, psychiatry, radiology, Vancouver. Offering highest splits on North days per week with additional walk-in shifts. and urology. Opportunity to teach. Income of Shore (up to 72.5%). No OB or ED mandatory. For more information contact Carla Orsmond $244 200 supported through a service contract Flexible hours. Great staff. Contact Francis: at [email protected] or call 604 988-5389. with on-call stipend and no overhead. For more e-mail [email protected]. information e-mail physicianrecruitment@ PENTICTON—OB/GYN LOCUM interiorhealth.ca or visit www.betterhere.ca. N VANCOUVER—FP LOCUM Locum needed to cover mat. leave, Dec 2016– Physician required for the busiest clinic/family Feb 2016, or part thereof. 1:4 call and office KELOWNA—HOSPITALISTS practice on the North Shore! Our MOAs are practice. New office with EMR, good MOA. Kelowna General Hospital, a tertiary hospital known to be the best, helping your day run Fee for service, MOCAP. Great skiing nearby! and referral centre with 400 beds, is seeking smoothly. Lucrative 6-hour shifts and no head- E-mail [email protected] for more permanent full-time and part-time physicians aches! For more information, or to book shifts info. to join our progressive hospitalist service. You online, please contact Kim Graffi at kimgraffi will provide general medical care of hospital- @hotmail.com or by phone at 604 987-0918. POWELL RIVER—PERMANENT FPs & ized adult patients, and co-management of sur- LOCUMs gical and psychiatric patients. The hospitalist NANAIMO—GP Powell River is a rural community of 20 000 service is supported by a complement of spe- General practitioner required for locum or people on the Sunshine Coast of British Co- cialty services including anesthesia, general permanent positions. The Caledonian Clinic lumbia, a 25-minute flight from Vancouver. internal medicine, general surgery, orthope- is located in Nanaimo on beautiful Vancou- Continued on page 480

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 479 classifieds

Continued from page 479 the staff. Vacation is shared locum between It’s known for its waterfront location, outdoor physicians. A full-time employee may expect beauty, urban culture, and international music approximately $300 000 annually for a 40-hour festivals. Supported by a 33-bed general hospi- work week. Please contact Granger Medical at tal, the close-knit medical community consists [email protected]. We look forward to hearing of 26 general practitioners, 4 ER and anesthe- from you. sia physicians, 2 NPs, and 7 specialists. We are looking for permanent general practitioners VANCOUVER/RICHMOND—FP/ and locums. Please visit divisionsbc.ca/powell SPECIALIST river/opportunities for details. We welcome all physicians, from new gradu- ates to semiretired, either part-time or full- RICHMOND—FP time. Walk-in or full-service family medicine Best clinic to work at in Richmond! Full- or and all specialties. Excellent split at the busy part-time physician needed for busy, mod- South Vancouver and Richmond Superstore ern walk-in/family medicine clinic. We are a medical clinics. Efficient and customizable team of caring physicians and staff looking for Oscar EMR. Well-organized clinics. Please a like-minded addition to our team. Central contact Lisa at [email protected]. Richmond, OSCAR EMR, large rooms, on-site pharmacy. E-mail: [email protected]; VANCOUVER—FP Website: www.livewellmedicalcentre.com. Mainland Medical Clinic is seeking a family doctor for our modern, multidisciplinary street- Family Practice Group RICHMOND—FP & LOCUMs level clinic in Yaletown, downtown Vancouver. in Kerrisdale Seeking Opportunities for physicians looking to do We have been operating for over 13 years in walk-in shifts, build a practice, or relocate in a comfortable setting shared with a chiroprac- our busy modern clinic. EMR OSCAR. Great tor, massage therapists, and a nutritionist to location next to a 24-hr Shoppers Drug Mart. complement our three family doctors. Ideally Family No hospital work, no call, 70/30 split—walk-in seeking someone with an existing practice— shifts at $100 per hour minimum—and bonus perhaps relocating or cutting back. We serve Physician available. Contact us at healthvuemedical@ a broad spectrum of patients, both walk-ins gmail.com, 604 270-9833/604 285-9888. and appointments. Excellent revenue split. The clinic offers a pleasant work environment in an upbeat, fun neighborhood. Contact Dr Brian • Brand new clinic SURREY (WHALLEY)—METHADONE- LICENSED GP Montgomery at [email protected] or located in the heart of Methadone-licensed GP needed to joint an ad- 604 240-1462, or just drop by. Vancouver’s Kerrisdale diction clinic. No overhead if available week- neighborhood days other than Tuesday and Thursday. Patient VANCOUVER—FP/BREASTFEEDING loads guaranteed. Staffed with MOA and coun- MED • Part time and Locum selor. MSP billing available. Please apply by Vancouver Breastfeeding Centre is looking for opportunities available e-mail to [email protected] a permanent, part-time family physician with or contact 604 715-6011 for more info. a special interest in breastfeeding medicine to • Competitive join our group. Maternal and child health ex- compensation SURREY/DELTA/ABBOTSFORD—GPs/ perience and IBCLC qualification preferred. Supervised clinical training is available. Visit • Fully integrated EMR SPECIALISTS Considering a change of practice style or loca- www.breastfeedingclinic.com and contact tion? Or selling your practice? Group of seven [email protected] for more info. locations has opportunities for family, walk-in, Highroads Medical Clinic is or specialists. Full-time, part-time, or locum VANCOUVER—LOCUM inviting a family physician to doctors guaranteed to be busy. We provide Busy walk-in shifts in Kitsilano at Khatsahlano join our existing group of administrative support. Paul Foster, 604 572- Medical Clinic, three-time winner of Georgia 4 GP’s at our brand new clinic in 4558 or [email protected]. Straight reader’s poll for Best Independent the Vancouver neighborhood Medical Clinic in Vancouver. Split is 65%; of Kerrisdale. Come experience VANCOUVER (KERRISDALE)—FP PT 70% on evenings/weekends. Contact Dr Chris our collaborative culture and Watt at [email protected]. innovative approach to Highroads Medical Clinic is seeking a PT fam- family practice. ily physician to join our existing group of four MDs at our brand new clinic in the Vancouver VANCOUVER—PRIVATE PRACTICE/ To learn more about joining our neighborhood of Kerrisdale. Our ideal can- WALK-IN dedicated and enthusiastic team, didate would either have an existing practice Our clinic is located in the heart of Vancouver please email or be willing to build a new practice with us. in the Cambie Village/Broadway corridor and [email protected] Walk-in shifts optional, 70% + split. E-mail right beside the Canada Line SkyTrain (Broad- [email protected]. way–City Hall Station). This is a large 1890 sq. ft. facility with large windows. The front staff VANCOUVER (KITSILANO)—GP will consist of an office manager and multiple Granger Medical has an opening for a physi- full-time medical office assistants. The clinic cian looking to work within a semi-private will be looking for walk-in physicians, locum multidisciplinary clinic in Vancouver. Ideally physicians, family physicians, and specialists. highroadsmedical.com we are looking for someone who currently has Full-time and part-time positions are available. or wants to build a patient roaster. The office Standard 30%/70% for remuneration. Please runs on Osler EMR; billing can be managed by contact [email protected] to e-mail your

480 bc medical journal vol. 58 no. 8, october 2016 bcmj.org classifieds resume and cover letter. Three months’ free airport). Contact 1 877 522-9722 or physician start a practice. Lease and operating costs sub- rent. [email protected]. sidized by pharmacy operating beside clinic. Contact Rob at 778 235-8137 or e-mail robd@ VERNON—AESTHETICS/VEIN/LASER claytonwellness.com. Outstanding opportunity to join a well- medical office space established and thriving GP derm/aesthetics/ VAN (VGH AREA)—MED OFFICE vein/laser practice in one of the best places ABBOTSFORD—OFFICE SPACE SUBLEASE to live in Canada. We are looking for an as- Fully furnished, ready-to-go medical office Office space for psychiatrists, psychologists, or sociate/equity partners. The office has all the available for lease in heart of Abbotsford. any other specialist MD. No secretary or other latest technology and an excellent, congenial Rent-free for 6 months! Clinic includes four additional overhead expenses. Top floor. Great staff. Training provided but a special interest large exam rooms, reception area, large wait- view. Two offices for sublease. One office is in dermatology a definite asset. The Okanagan ing room with TV, two washrooms, large pri- bigger and has a sink and space for an exami- has some of the best weather, lakes, wineries, vate office, on-site free parking. Located in nation table. E-mail [email protected]. golf courses, ski hills, and overall lifestyle any- a professional building at a busy intersection where in Canada, if not the world. Contact Dr with lots of walk-in traffic. Great opportunity VANCOUVER (DWTN)—MED OFFICE William Sanders: 250 558-9606, w.sanders@ for someone looking for an existing space with SPACE shaw.ca. the flexibility to design their own practice and Two established psychiatrists seeking a third hours of operation. Please contact Frank Dyks- psychiatrist to share office space in the Rob- tra at 604 835-6300 or [email protected]. VICTORIA (OAK BAY)—MD PARTNER son Professional Building located on Robson Derma Spa is a well-established medical/cos- Street. The space features two bright offices; metic practice located in the charming seaside PORT COQUITLAM—HIGH-TRAFFIC reception/waiting room area; kitchen with sink, neighborhood of Oak Bay, Victoria. Our busi- MED OFFICE SPACE fridge, and microwave. Includes full secre- ness is growing and we have an experienced Approximately 1500 sq. ft. space in a high- tarial services (reception, typing, and billing). medical, financial, and marketing team in place traffic strip mall available. You will have a den- Opportunity for mentoring in assessment and to support you. Please contact Alex at 250 580- tist office, massage therapist, physio, and much treatment of ADHD and comorbidities avail- 9428 or [email protected]. more available as your neighbors. Building is able. Very reasonable rent. Available: January 16 years young. End unit. The neighborhood 2017. Call 604 687-0654 or e-mail inquiries to would love a doctor’s office. Available for im- [email protected]. VICTORIA—GP/WALK-IN mediate possession. Call for details: 403 828- Shifts available at three beautiful, busy clinics: 9596/604 941-7025. VANCOUVER—WEST BROADWAY Burnside (www.burnsideclinic.ca), Tillicum Fully furnished space for one or multiple doc- (www.tillicummedicalclinic.ca), and Uptown tors. Space can be used part-time or full-time (www.uptownmedicalclinic.ca). Regular and RICHMOND—MED OFFICE SPACE with short- or long-term arrangement possible. occasional walk-in shifts available. FT/PT GP New modern EMR clinic in Steveston Village looking for physicians to join our team. Oppor- Use some or all of the large space. MOA pro- post also available. Contact drianbridger@ tunities to start a practice or relocate existing vided if needed. Extraordinary views. Con- gmail.com. practice without worrying about administra- crete professional building with elevators, tive headaches. We offer base 70/30 split and underground parking, and three restaurants. VICTORIA—SHARED PRACTICE higher for complex care and forms. Visit www. Available immediately. Please call Neil at 604 Ideal opportunity for Mandarin/Cantonese- HealthVue.ca or contact healthvuemedical@ 644-5775. speaking physician to join a turnkey, EMR gmail.com, 604 285-9888. practice with a view to building the practice. WEST VAN—MED OFFICE SPACE Escape the high-cost accommodation in Van- RICHMOND—PSYCHIATRIST or Medical office space available for part-time couver and relocate to Victoria, known for its THERAPIST use on weekdays and weekends. Two rooms. breathtaking natural beauty and enviable qual- Psychiatrist (and owner) wishes to share fully Great view, lots of natural light, ideal location ity of life. Combine a rewarding career with a furnished esthetic office; 200 sq. ft. suitable for in Ambleside. Located in medical building satisfying lifestyle. E-mail [email protected]. group or individual counseling. Wheelchair with pharmacy, lab, X-ray, etc. Please e-mail accessible, ground floor, in-office sink. One [email protected] or call 778 919- VICTORIA—WALK-IN parking spot. Quiet setting, trees and pond 0585 or 604 356-3282. Walk-in clinic shifts available in the heart of nearby. Available immediately weekdays lovely Cook St. Village in Victoria, steps from and weekends from $95 per half-day. E-mail the ocean, Beacon Hill Park, and Starbucks. [email protected] or call 604 616-3250. miscellaneous For more information contact Dr Chris Watt at [email protected]. CANADA-WIDE—E TRANSCRIPTION SOUTH SURREY/WR (NEAR US SVCS BORDER) E Transcription Services allows hospitals, WILLIAMS LAKE—FP EMERGENCY No existing GPs within a 5 km radius. New fur- clinics, and specialists to outsource a critical Seeking CCFP-EM or CCFP with ER experi- nished medical clinic on Highway 15. Six exam business process, reduce costs, and improve ence. Cariboo Memorial Hospital services rooms, one washroom, one staff room, wait- the quality of medical documentation. By out- a population of approximately 26 000 with ing room and reception area, and free on-site sourcing transcription work you will be able to 20 000 visits to the ER annually. ER is staffed parking. Air conditioned and wheelchair ac- increase the focus on core business activities by six full-time ER physicians and a variety cessible. Located in new building within phar- and patient care. Our goal is to exceed your ex- of part-time ER physicians (staffed 24/7). We macy. Contact Tazim Mohammed at pharma pectations. Call for free trial 1 877 887-3186. have a 28-bed hospital with 3-bed ICU. Ex- [email protected] or 604 345-7075. www.etranscription.ca. cellent collegial specialist support including general surgery, OB/GYN, pediatrics, internal SURREY (CLAYTON HEIGHTS)—NEW CANADA-WIDE—MED med, radiology, anesthesia, and psychiatry. CLINIC, RENT FREE TRANSCRIPTION Further specialist support available at our re- Brand-new furnished medical clinic opening in Medical transcription specialists since 2002, ferral centre in Kamloops. Williams Lake is Surrey (Clayton Heights). An opportunity for Canada wide. Excellent quality and turnaround. known for its outdoor opportunities and full a group of family physicians looking to lower range of amenities (including local college and existing overhead or new physicians looking to Continued on page 482

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 481 classifieds in memoriam Continued from page 481 All specialties, family practice, and IME re- ports. Telephone or digital recorder. Fully confidential, PIPEDA compliant. Dictation Dr D’Arcy D. Lawrence was recruited to practise radiology in tips at www.2ascribe.com/tips. Contact us at www.2ascribe.com, [email protected], or 1941–2016 Victoria, where he stayed until 2014. toll free at 866 503-4003. He was the chief of medical imaging from 1990–2004. FREE MEDICAL RECORD STORAGE Dr Lawrence was well respected Retiring, moving, or closing your family practice? RSRS is Canada’s #1 and only by the medical staff, fellow radiolo- physician-managed paper and EMR medi- gists, technologists, clerical/support cal records storage company. Since 1997. staff, and the administration. Dur- No hidden costs. Call for your free prac- tice closure package: everything you need ing his tenure he was instrumental in to plan your practice closure. Phone 1 866 completing the amalgamation of the 348-8308 (ext. 2), e-mail [email protected], or two radiological groups (RJH and visit www.RSRS.com. VGH) into one harmonious group. PATIENT RECORD STORAGE—FREE Because Dr Lawrence was pre- Retiring, moving, or closing your fam- maturely grey he was affectionately ily or general practice, physician’s estate? called the Grey Fox, and his good DOCUdavit Medical Solutions provides free storage for your active paper or elec- looks even got him cast as a radiolo- tronic patient records with no hidden Dr Lawrence was born in Toronto and gist in the movie Intersection with costs, including a patient mailing and received his MD from the University Richard Gere and Sharon Stone. doctor’s web page. Contact Sid Soil at DOCUdavit Solutions today at 1 888 781- of Toronto in 1965. He met his wife, Dr Lawrence is survived by his 9083, ext. 105 or e-mail ssoil@docudavit Lynn, who was a gynecological nurse wife, Lynn; son, Douglas (Gloria); .com. We also provide great rates for closing at Royal Victoria Hospital, while he daughter, Kerrilee (Gary); and 10 specialists. was interning there, and they married grandchildren and step grandchildren. VANCOUVER—TAX & ACCOUNTING in 1967. January 2017 would have Dr Lawrence was an only child, and SVCS been their golden anniversary. this large crew of grandchildren over- Rod McNeil, CPA, CGA: Tax, account- Dr Lawrence started a pathol- whelmed him but also fulfilled him. ing, and business solutions for medical and health professionals (corporate and person- ogy residency at Vancouver General He was also very proud of his daugh- al). Specializing in health professionals for Hospital but changed his mind after ter Kerrillee’s police career, and the the past 11 years, and the tax and financial 1 year and moved to Montreal Gen- pride was evident when she arranged issues facing them at various career and professional stages. The tax area is complex eral Hospital to study radiology. He a ride-a-long for D’Arcy with her and practitioners are often not aware of so- obtained his FRCP in 1970 and fol- sergeant. With joy and happiness, Dr lutions available to them and which avenues lowed it with a fellowship in neurora- Lawrence was able to proudly dance to take. My goal is to help you navigate and keep more of what you earn by minimizing diology at the Montreal Neurological with Danielle, his granddaughter, at overall tax burdens where possible, while Institute. Dr Lawrence then accepted her wedding this summer. It was a at the same time providing you with per- a job as a neuroradiologist at Foothills very special moment. sonalized service. Website: www.rwmcga .com, e-mail: [email protected], phone: Hospital in Calgary and he practised —Richard Mark, MD 778 552-0229. there until 1979, following which he Victoria

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YOUR PROFESSIONAL PRACTICE LIFECYCLE Professional Cycle Getting Started DELIVERING MORE AT EVERY STAGE. Don Murdoch, CPA, CA

Congratulations to all of the physicians who have recently 3. You will likely start planning to purchase a home. completed their residency and are now embarking on the This is the next most common financial objective after your student next stage of their medical careers. You may not have heard debt repayment plan. You should consider using your existing Registered this before but most of you are now small business owners in Retirement Savings Plan (RRSP) room to make a contribution to your RRSP that would enable you to access the RRSP Home Buyers Plan, if you addition to being medical professionals. qualify. The rules for qualifying as well as the rules for contributions and The purpose of this article is to provide you with a basic withdrawals are complicated and professional assistance is recommended. outline of the issues you will likely need to consider in the Planning for the balance of your home purchase down payment will require Getting Started Stage of your Practice Lifecycle. discussions with your lender and a savings plan from your practice cash flow.

4. Other considerations. 1. Your practice structure will determine your requirements for income The above comments are generally applicable to all physicians as you are tax planning. getting started, but throughout your practice lifecycle, there will be issues For most of you, when you left your residency program, you ceased to be to consider that are uniquely related to you and your individual goals and an employee. The work you are doing as a locum or a member of a clinic circumstances. Choosing a team of professional advisors who will take will be taxed as self-employment income. Income tax and Canada Pension the time to get to know you and understand your goals throughout your Plan contributions on self-employment income are not deducted “at practice lifecycle will ensure that you are getting thorough and timely source” and will be payable upon filing your 2016 T1 Personal Income Tax planning assistance. Return in the late spring of 2017. You will need to develop a savings plan for this. With 20 locations throughout British Columbia, MNP provides You might decide to move quickly to Incorporate your medical practice, support to medical professionals at all stages of their careers. which will introduce a new corporate taxpayer into your world. You Contact Don Murdoch, B.C. Leader, Professional Services at should ensure that you have adequately reviewed the benefits and costs 1.877.766.9735 or [email protected] of operating your medical practice as a corporation before doing this and understand the expanded tax responsibilities. For more information about MNP’s Professional Services, 2. You will need to include a plan to repay any outstanding visit our website at student debt. www.mnp.ca/en/professionals There are minimum levels of interest / principal payments that will require cash flow from your practice and you may decide you want to increase the rate of principal payments to eliminate your student debt faster. Your debt repayment decisions need to be part of your cash flow planning.

bc medical journal vol. 58 no. 8, october 2016 bcmj.org 483 billing tips advertiser index

Advice about a patient in community Thanks to the following advertis- ers for their support of this issue care (fee item 13005) of the BC Medical Journal.

ee item 13005 (advice about are employed by or who are under Cambie Surgery Centre/ a patient in community care) contract to a facility and whose du- Specialist Referral Clinic ..... 470 F applies to residential, interme- ties would otherwise include provi- High Roads Medical Clinic .... 480 diate, and extended care patients and sion of this care. also includes patients receiving home • Advice provided by physicians MD Financial Management nursing care, home support, or pal- working under salary, service con- Fossil Fuel Free Funds ...... 487 liative care at home. It is defined in tract, or sessional arrangements Medray Imaging ...... 441 the Doctors of BC Guide to Fees as whose duties would otherwise in- Mercedes-Benz ...... 478 advice given by telephone, fax, or in clude provision of this care. written form about a patient in com- • Advice provided by physicians who MNP ...... 483 munity care in response to an enqui- are on site, on duty in an emergency Pacific Centre for ry initiated by an allied health care department, who are being paid at the Reproductive Medicine ...... 436 worker* specifically assigned to the time on a sessional basis, or who are working at the time as hospitalists. Pollock Clinics ...... 438 Medical inspectors look for prop- QHR Technologies er documentation in the patient’s Accuro Medeo ...... 471 Medical inspectors record to support the criteria to bill look for proper fee item 13005. There must be docu- Record Storage and documentation in the mentation in the medical record of the Retrieval Service ...... 472 date of service, name and position of patient’s record to RX Security ...... 482 support the criteria to the enquiring health care worker, and the advice given. Alternatively, the Sea Courses Cruises ...... 475 bill fee item 13005. original of a fax or a copy of written Section of Clinical Faculty ..... 473 advice will suffice to document these services. To simply state “no advice Speakeasy Solutions ...... 437 care of the patient (including comple- given” in the patient’s chart or “thank UBC Robson Square tion of faxed medication review with you” on the fax sheet or a simple refill Essential Medical orders, up to twice per calendar year). order with no documentation that the Legal Toolkit ...... 488 Audits reveal that physicians fre- medications were reviewed would not quently bill fee item 13005 incorrect- qualify you to bill for these services. ly. Services that do not qualify for this Always refer to the Doctors of BC fee include: Guide to Fees and its preamble for • Prescription renewals or pharma- interpretation of all fees.

cist’s adaptations. —Keith J. White, MD • Booking for appointments. Chair, Patterns of Practice • Advice given in response to enqui- Committee ries from a patient or their family.

• Advice provided by physicians who * Allied health care workers are defined

as home care coordinators, nurses This article is the opinion of the Patterns of (registered, licensed practical, pub- Practice Committee and has not been peer lic health, psychiatric), psychologists, reviewed by the BCMJ Editorial Board. For mental health workers, physiothera- further information contact Juanita Grant, pists, occupational therapists, respira- audit and billing advisor, Physician and Ex- tory therapists, social workers, ambu- ternal Affairs, at 604 638-2829 or jgrant@ lance paramedics, and pharmacists. doctorsofbc.ca.

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bc medical journal vol. 58 no. 8, october 2016 bcmj.org 485 INV-16-00151 MD_SmallChanges_PrintAd-BCMJ E-P.pdf 1 2016-09-16 2:33 PM back page

Proust questionnaire: Small change, big difference. David Patrick, MD

What is your greatest fear? sonalized prevention has even more White people playing bongos. potential than personalized diagnosis and treatment. What is the trait you most deplore in yourself? Which living physician do you I concern myself too much with being most admire? What profession might you have conciliatory. Everyone who had the guts to go to pursued, if not medicine? West Africa and help out during the Music. I play jazz and rhythm and What characteristic do your Ebola crisis. blues, and it might have been fun to favorite patients share? focus on that for a while. Interesting world travel and experi- What is your most marked ences. characteristic? Which talent would you most I can find the humor in almost any- like to have? What is your favorite activity? thing, and this can really be annoying I wish I were more handy. I like doing Spending quality time with my wife, to some people. small projects but it takes me a while followed by making music. to get them right. What do you most value in your On what occasion do you lie? colleagues? What do you consider your I never lie, or just did. You tell me. Compassion. greatest achievement? Sharing a life with Patricia, raising Which words or phrases do you Who are your favorite writers? kids, and keeping it real. most overuse? Kurt Vonnegut and Richard Dawkins. “That’s right.” Who are your heroes? What is your greatest regret? Those Battle of Britain Spitfire and Where would you most like to Attempting to microwave a roast. Hurricane pilots. They gave us a practise? much brighter future. Oh, and Louis I’m here in Vancouver by choice. What is your motto? Pasteur. Onward and upward. What medical advance do you What is your idea of perfect most anticipate? How would you like to die? happiness? submit-proust-box.qxp:LayoutPeople finally figuring out1 that10/9/13 per- I’m8:46 not surePM thatPage should1 be printed. Satisfying work or play in the absence of negative energy.

Submit a Proust Questionnaire—your colleagues will appreciate it. Dr Patrick is an infectious disease physician Sometimes the impact of a small environmental change is easy to see. Other times, not so much. But all and epidemiologist, serves as professor Online E-mail www.bcmj.org/content/contribute [email protected] environmentally friendly changes matter, no matter how small. If everyone made just one, it could lead to a and director at UBC’s School of Population Click on the Proust tab, then com- E-mail and we’ll send you a big dierence in climate change. Consider making a small change by including MD Fossil Fuel Free Funds™ and Public Health, and provides service as a plete and submit online. Word document to complete and e-mail back to us. in your portfolio. Together we can help make a brighter future for both you and the planet. medical epidemiologist at the BCCDC. His primary focus is the control and study of Print Mail www.bcmj.org/content/contribute 604 638-2858 To learn more about MD Fossil Fuel Free Funds, speak to your MD Advisor or visit md.cma.ca/fff. emerging infectious diseases with a strong Click on the Proust tab, click on Call and we’ll send you a blank emphasis on the problem of antibiotic re- “Print a PDF copy,” then complete questionnaire to complete and and submit by fax or mail. return to us by mail. Commissions, trailing commissions, management fees and expenses all may be associated with mutual fund investments. Please read the prospectus before investing. sistance at the population level. Mutual funds are not guaranteed. Their values change frequently and past performance may not be repeated. To obtain a copy of the prospectus, please call your MD Advisor, or the MD Trade Centre at 1 800 267-2332. The MD Family of Funds is managed by MD Financial Management Inc., a CMA company. • ™ Trademark of the Canadian Medical Association, used under licence. • MD Financial Management provides †nancial products and services, the MD Family of Funds and investment 486 bc medical journal vol. 58 no. 8, october 2016 bcmj.org counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca. INV-16-00151 MD_SmallChanges_PrintAd-BCMJ E-P.pdf 1 2016-09-16 2:33 PM

Small change, big difference.

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To learn more about MD Fossil Fuel Free Funds, speak to your MD Advisor or visit md.cma.ca/fff.

Commissions, trailing commissions, management fees and expenses all may be associated with mutual fund investments. Please read the prospectus before investing. Mutual funds are not guaranteed. Their values change frequently and past performance may not be repeated. To obtain a copy of the prospectus, please call your MD Advisor, or the MD Trade Centre at 1 800 267-2332. The MD Family of Funds is managed by MD Financial Management Inc., a CMA company. • ™ Trademark of the Canadian Medical Association, used under licence. • MD Financial Management provides †nancial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca. bc medical journal vol. 58 no. 8, october 2016 bcmj.org 487 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 Presented by CORE Occupational Health Care Centre professionals and lawyers. The legal teaching faculty have busy personal injury practices and UBC Robson Square know exactly what they want from 800 Robson Street medical legal reports and expert Vancouver, BC V6Z 3B7 488Dr Gurdeepbc medical Parhar journal testimonyvol. 58 no. 8, octoberin court. 2016 bcmj.org