The Economic Burden of Injuries in British Columbia: Applying Evidence to Practice

September 2018; 60:7 Pages 337–380

The economic burden of injuries in British Columbia: Applying evidence to practice

Also in this issue Early surgical management of acute cholecystitis Weighing the options: Two shingles vaccines available Building interprofessional maternity care in BC Helping patients and families navigate dementia Pseudoscience, anti-science, and woo www.bcmj.org PARTICIPANT FEEDBACK:

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Register at www.medlegaltoolkit.com Cost: $490/course Presented by CORE UBC Robson 338Morebc medicalinformation: journal vol. 60 604-525-8604 no. 7, september 2018 orbcmj.org Occupational Health 800 Robson St. email [email protected] Care Centre Vancouver, BC September 2018 Volume 60 • Number 7 Pages 337–380 contents

341 Editorials Spot-on studies, David R. Richardson, MD (341) “I have to post this!” Yvonne Sin, MD (342)

343 President’s Comment Pseudoscience, anti-science, and woo: This time it’s personal Eric Cadesky, MD

344 Letters to the Editor Re: Water, water everywhere but not a drop to drink, H.C. George Wong, MD (344); Re: Best practices in treating chronic noncancer pain, Romayne Gallagher, MD (344); Sale of MD Financial Management, Ken On the cover Markel, MD (345); Re: Sale of MD Financial Management; CMA Board Physicians and policymakers can Chair replies, Brian Brodie, MD (345); Re: Nonrecognized qualifications, support broader prevention initia- Chris Sladden, FRCPC (346); Re: Nonrecognized qualifications; College tives for falls, transport incidents, Heidi M. Oetter, MD (346) unintentional poisoning, and self- responds, harm by making use of data from a study quantifying injury costs. 347 Article begins on page 358. News BC Children’s Hospital furthering development of immunotherapy treatment for kids (347); Immune-resistant HIV mutations in Saskatchewan (347); “Smart stent” detects narrowing of arteries (347); Matchmaking service combats antibiotic-resistant infections (347); Novel therapy offers hope for social anxiety (348); Anger overlooked as feature of postnatal mood disorders (348); Fifteen minutes of exercise creates optimal brain state for mastering new motor skills (348); Breakthrough discovery will change treatment for COPD patients The BCMJ is published by (349); Doctors of BC. The journal BCEHS Action Plan transforming emergency health services in provides peer-reviewed clinical BC (349); Medication use in Indigenous communities (350); University and review articles written of Winnipeg research aims to identify resistance to breast cancer primarily by BC physicians, (350); for BC physicians, along with treatment The Vancouver Medical Staff Hall of Honour (VCH): debate on medicine and medical Remember the heroes of the past (369) politics in editorials, letters, and essays; BC medical news; career and CME listings; physician 351 College Library profiles; and regular columns. Clinical Handbook of Psychotropic Drugs—Clinically relevant drug Print: The BCMJ is distributed information at your fingertips monthly, other than in January Paula Osachoff and August. Web: Each issue is available at www.bcmj.org. Subscribe to print: Email Clinical Articles [email protected]. Single issue: $8.00 Canada per year: $60.00 352 Early surgical management of acute Foreign (surface mail): $75.00 cholecystitis: A quality improvement initiative Subscribe to the TOC: To receive the table of contents Carla Pajak, MD, Sharmen Vigouret Lee, MHA, Dave Konkin, MD, Sue Sidhu, by email, visit www.bcmj.org and MD, Scott Cowie, MD click on free e-subscription. Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org for submission requirements.

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 339 contents

BC Medical Journal Vancouver, Canada 604 638-2815 358 the economic burden of injuries in British [email protected] Columbia: Applying evidence to practice www.bcmj.org Fahra Rajabali, MSc, Emilie Beaulieu, MD, Jennifer Smith, BFA, Ian Pike, PhD

Editor 365 WorkSafeBC David R. Richardson, MD Lower-extremity radiographs: Weight-bearing, please Editorial Board Dereck Smith, MD Jeevyn Chahal, MD David B. Chapman, MBChB Brian Day, MB 366 Council on Health Promotion David Esler, MD Timothy C. Rowe, MB Increasing physical activity in patients: By asking the questions, we Yvonne Sin, MD can make a difference Cynthia Verchere, MD Tommy Gerschman, MD Managing Editor Jay Draper

Senior Editorial and 368 General Practice Services Committee Production Coordinator Kashmira Suraliwalla Helping patients and families navigate dementia: The Kootenay Boundary Dementia Roadmaps Associate Editor Afsaneh Moradi Joanne Jablkowski

Copy Editor Barbara Tomlin 370 Shared Care Proofreader Ruth Wilson Building interprofessional maternity care in BC Nancy Falconer, Lee Yeates, RM Design and Production Scout Creative

Cover Concept 371 Obituaries & Art Direction Annie Davidson (371) Jerry Wong Dr Andrew Burger Murray, Peaceful Warrior Arts Dr Murray Allen Peglar, Murray Peglar (371) Printing Mitchell Press 372 BC Centre for Disease Control Advertising Kashmira Suraliwalla Weighing the options: Two shingles vaccines available for older adults 604 638-2815 Monika Naus, MD [email protected]

ISSN: 0007-0556 374 CME Calendar Established 1959

376 Classifieds

379 Club MD

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

340 bc medical journal vol. 60 no. 7, september 2018 bcmj.org editorials

Spot-on studies

“ ey DRR, we did a study and rates of less than 20% from which no thors also include a discussion in their the conclusion is that you are meaningful information can be ob- paper of the limits of their survey Hincompetent.” tained. The assumption that the great- study. Here at the BCMJ we don’t re- “While this may be true, can I en- er than 80% of people who didn’t ally look at a survey study unless the quire as to your study design?” respond would have completed the response rate is well over 50%. “We did a survey study and 67% survey the same way as the respon- Now, I don’t want to discourage of respondents agree that you aren’t dents is just that—an assumption. prospective authors, only to give ad- fit to be the editor of a journal. We vice on how to increase the chance did all the statistics and the P value is of publication. Handing out program < 0.001.” The assumption that evaluation surveys in a haphazard “I’m curious how you decided fashion without regard to random the greater than 80% who to survey?” sampling techniques or total number “Well, Bob and I don’t like you of people who didn’t of potential respondents is really a and my wife thinks you are okay, respond would have waste of everyone’s time and doesn’t mostly because she doesn’t really completed the survey lead to conclusions that can be acted know you.” the same way as the upon. At the BCMJ we review all sorts respondents is just Okay, I’ve said my piece and have of submissions for publication and ranted enough. that—an assumption. we appreciate all the work that goes —DRR into the process of designing and car- rying out a scientific study. That being said, one thing that drives us a What if that 80% couldn’t be both- little crazy (particularly the editor) is ered to complete the survey because Is the BCMJ low-response survey studies. Surveys they really disliked something about good value? are handed out, collected, tabulated, it? Good survey studies are easy to and subjected to rigorous statistical spot. The target population is clearly In 2017 the BCMJ cost analysis including P values, which all defined and follow-up contact is done each member $24, or looks very impressive. The problem: on numerous occasions in an attempt about $2.40 per issue. many of these surveys have response to increase the response rate. The au-

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 341 editorials

“I have to post this!”

hile on social media one medicine? I was confused, curious, of the original author, and the patient night, I was scrolling and intrigued. were to make a complaint and bring W through photos of food I decided to look into the policies forward legal action, the author who adventurers, fashion bloggers, and ex- regarding medicine and social media, originally posted the photos may be otic travelers, when suddenly a photo and found an article published in 2017 liable despite doing their part to main- of a surgeon holding up a large mass by the Canadian Medical Protective tain patient confidentiality.1 in the OR showed up on my feed. Association (CMPA) that addressed There are myriad online com- The photo included blood, IV lines, ments to the interesting clinical cases, the intubated patient, and all. I took with physicians and patients sharing a second look and of course could not similar experiences or acknowledg- resist clicking into the comments. The What happens when a ing the wonders of the human body. 25 kg ovarian mass had been removed stranger halfway around I wonder what a patient thinks if their from a patient who had suffered from the world decides to diagnosis or treatment plan differed abdominal pain for years. What was distribute the photo and from those suggested by anonymous more shocking is that the photo got comments. Would their faith in their claim it as their own, 14 000 likes in 1 day. doctor waiver? Or maybe they would Were the likes for the surgeon who perhaps even posting add to the conversation to try and gar- operated on the patient? Or for the their own opinion and ner support? patient, who had suffered for years diagnoses of the case? As social media becomes more and now been cured? Or because the prominent, many physicians and pa- photo contained graphic content that tients find it to be a useful tool for satisfied the public’s curiosity about sharing information and experiences. this issue.1 The CMPA suggests that It can even act as a support group. As “physicians who share information the online community grows, there Dragon® Medical about their existing patients on so- are also many positive opportuni- cial networks are obligated to protect ties for professional education and Practice Edition 4 patient confidentiality . . . by ensur- networking, promotion, and public (it’s the version you have been ing that the posted information is health awareness. waiting for) properly de-identified.” The article Next time you come across a also mentioned that physicians may photo of an interesting clinical case share identifiable personal health in- on social media, allow your curiosity formation if the patient’s consent is to see what the photo is about; may- obtained and documented consent be even learn something from it. But is signed. The College of Physicians don’t forget to look at it objectively and Surgeons of BC adopted similar and consider how social media has professional guidelines last year.2 become intertwined not only into our I know of physicians who will personal lives, but also our profes- ask for their patients’ permission to sional ones. —YS take photos of an interesting clinical case for teaching purposes, or for use References on their own blogs and social media 1. CMPA. Social networks in healthcare: Op- Dragon Software platforms. If a patient’s consent and portunities and challenges for a connect- Installation & Support agreement were obtained, then it is ed future. Accessed 24 July 2018. www. EMR Integration & Training unlikely any legal action would arise. cmpa-acpm.ca/en/advice-publications/ But what happens when a stranger browse-articles/2017/social-networks-in CONTACT US TODAY! halfway around the world decides -healthcare-opportunities-and-challeng speakeasysolutions.com to distribute the photo and claim it es-for-a-connected-future. 1-888-964-9109 as their own, perhaps even posting 2. College of Physicians and Surgeons of speech technology specialists their own opinion and diagnoses of BC. Professional guideline: Social media. for 18 years the case? If online photos were to be Accessed 24 July 2018. https://www redistributed without the knowledge .cpsbc.ca/files/pdf/PSG-Social-Media.pdf.

342 bc medical journal vol. 60 no. 7, september 2018 bcmj.org president’s comment

Pseudoscience, anti-science, and woo: This time it’s personal

e all have memories of thyroid tests, ignore fatigued adre- hold ourselves childhood rituals that nals, and let yeast run amok in inno- to the highest W seemed normal at the cent intestines. Coincidentally, these standard and time, but feel more suspect upon adult promoters not only know the secrets, abide by the reflection. For me, Saturday morn- they sell the solutions as well (and for scientific pro- ings were spent gorging on enormous a great price if you act now!). cess. We need bowls of sugary cereal while a boxy to continue television framed large men in color- Let’s use science and stories working with ful costumes pretending to hurt one to appeal to people’s hearts our patients, another. Yes, my father was a wres- as well as their heads. complementing tling fan, and whether he believed their values with our scientific infor- it was real or theatrical, he wasn’t Such attacks on science are found mation and making the best decisions saying. everywhere. Although we take into together. But in our advocacy efforts Looking back on that passive ex- account how a study is funded, there we must also engage more by using posure to spandex and violence, I now are those who reject work supported the power of stories to support what realize that there were morals implicit by industry as proof that doctors are science is telling us. in the story arc of every episode. For in the pocket of Big Pharma. (I sup- Evolution has wired our brains for example, there were two sets of rules. pose the often useless and potentially stories. Stories help us organize infor- On one hand, the villains were able harmful products that make up the mation and tie content together, and to use any means they desired in the $6 billion supplement industry are help us provide the meaning behind attempt for victory. They could claw grown organically in orchards where the science. They connect us to each and scratch, kick below the belt, or willing workers harvest them for eq- other through shared experiences and hit their opponents with hefty for- uitable use.) common values, and they are how eign objects hidden perilously in Millions of lives around the globe we explain the past and predict the their microscopic trunks. The heroes, have been saved through mass vacci- future. It is fair play to mention our on the other hand, had to play by the nation, yet the antivaccine movement wheelchair-bound patients who have rules. The message was clear: it’s not counters with tales of profits-over- polio to vaccine-hesitant parents or enough to win, it must be done the people, conspiracies to control indi- to show pictures of lethargic chil- right way. vidual freedoms, and children afflict- dren covered in the red spotted rash But when it comes to talking ed by autism, autoimmune disease, of measles. We can talk about how about health, it feels like we are back and other injury blamed on vaccina- Steve Jobs regretted delaying treat- in the squared circle. In one corner, tion. These antivaccine campaigns ment for his cancer to pursue “alter- we have the scientific community that have taken on political weight as a natives.” We can still be measured in promotes the best information as we symbol of anti-establishment, result- what we say, but we must do a better know it and speaks often with reser- ing in outbreaks of mumps, measles, job of showing what we mean. vation, knowing that theories are by polio, and other preventable—and So let’s continue to promote the definition limited—ideas waiting for eradicable—diseases. best health practices that we know. a challenge, able to be disproven. We Clearly our efforts have not been Let’s leave behind our notions of what are naturally cautious and restrained. as effective as they could be. To tru- constitutes a fair battle. Let’s use sci- We listen to patients and scrutinize ly go to the mat for our patients, our ence in our content and stories in our studies. We are a storied profession neighbors, and our communities, we style to build bridges and appeal to seemingly reticent to tell stories. need to reassess our self-imposed people’s hearts as well as their heads. This is problematic, because in the rules. The old adage “Don’t bring sto- And if using our stories helps other corner confident promoters of ries to an evidence fight” misses the people make better-informed deci- immunity boosters, cancer-preventing point: to achieve the goals of healthier sions, then that’s a worthwhile fight supplements, superfoods, and weight people and societies, stories are ex- for us all. loss miracles aim to inform the pub- actly what we need. —Eric Cadesky, MD lic on how doctors order the wrong Certainly we must continue to Doctors of BC President

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 343 letters to the editor

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

Re: Water, water everywhere 2. Wong HCG. Mercury poisoning in the 30% of the deaths, and that 25% of but not a drop to drink Grassy Narrows First Nation: History not the deaths involved codeine. In 97% Dr Maheswaran raised the concern completed. CMAJ 2017;189:E784. of these deaths, multiple other pre- of clean-water insecurity for the In- scribed and nonprescribed substances digenous peoples of Canada (BCMJ Re: Best practices were involved. 2018;60:195). The effects include in- in treating chronic Any death that implicates a pre- fections, mental and physical stress, noncancer pain scribed drug should be investigated diabetes, and dental caries. I was disheartened to see that Dr Peter in order to prevent further harm, and Mr Mosa and Ms Duffin outlined Rothfels, in his article “Best practices physicians should be made aware of the history of mercury poisoning in treating noncancer pain”1 chose the outcomes of these investigations. of the Grassy Narrows First Nation to use United States data and an On- The narrative that implies that along the English–Wabigoon river tario study about emergency phys- BC physicians have been prescrib- system in Ontario compared to an ician prescribing to back up his claim ing more opioids and in greater dos- industrial incident in Minamata, Ja- that, “since the mid-1990s, physicians es leading to increased harm is not pan. The poisoning in Ontario was have been increasingly prescribing accurate. due to mercury contamination from higher doses and stronger opioids for —Romayne Gallagher, MD, a pulp and paper mill some 50 years their patients, particularly those with CCFP(PC), FCFP ago.1 The mercury levels downstream chronic noncancer pain.” Being the Vancouver of the plant should have returned to chief medical officer for WorkSafe- normal by now; however, recent tests BC, I would presume this article is References revealed much higher mercury levels addressed to BC physicians and their 1. Rothfels P. Best practices in treating downstream compared with upstream prescribing. chronic noncancer pain. BCMJ 2018;60: locations, from unknown sources.2 Prescribing of opioids varies 244,269. The mercury poisoning continues to dramatically across Canada.2 BC’s 2. Canadian Institute for Health Information. affect the health, economy, and cul- mortality rate of 3.9 pharmaceutical Amount of opioids prescribed dropping in ture of this Indigenous community. opioid-associated deaths per 100 000 Canada; prescriptions on the rise. Ac- Federal and provincial govern- population has remained stable from cessed 19 July 2018. www.cihi.ca/en/ ments should act urgently to ensure 2004 to 2013.3 This rate includes all amount-of-opioids-prescribed-dropping Indigenous peoples have access to pharmaceutical opioid deaths (in- -in-canada-prescriptions-on-the-rise. clean, safe drinking water wherever cluding methadone for maintenance), 3. Gladstone E, Smolina K, Morgan SG. they live in Canada. intentional and unintentional, pre- Trends and sex differences in prescription —H.C. George Wong, MD, scribed, and diverted. This pattern is opioid deaths in British Columbia, Canada. FRCPC strikingly different from the pattern Inj Prev 2016;22:288-290. in Ontario and the United States. The 4. BC Coroner’s Service & BC Ministry of References BC coroner, in reviewing prescrip- Health. Preventing pharmaceutical opioid- 1. Mosa A, Duffin J. The interwoven history tion opioid deaths in BC from 2009 to associated mortality in British Columbia: of mercury poisoning in Ontario and Ja- 2013,4 found that methadone, used as A review of prescribed opioid overdose pan. CMAJ 2017;189:E213-215. opioid agonist therapy, accounted for deaths, 2009-2013. Accessed 19 July

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2018. https://www2.gov.bc.ca/assets/ bership. Why would the CMA even not an easy decision to make, nor was gov/public-safety-and-emergency-services/ consider selling this trusted institu- it a process our members were used death-investigation/statistical/pharma- tion that dealt with the financial se- to. At the CMA, we’re known for our ceutical-opioid-mortality.pdf curity of its members? consultations with members and we Questions to the CMA: pride ourselves on it. Understand- WorkSafeBC declined to respond. —Ed 1. Why was this done? ably, not being able to participate in 2. Why was the membership not this process was upsetting for some Sale of MD Financial consulted? Why didn’t the CMA members and seen as a break from Management float the idea to the membership our usual consultative approach. Let The sale of MD Financial Manage- long before entering negotiations? me say that we would have much pre- ment to Scotiabank has been very (They may talk about financial ferred to be able to discuss the sale unsettling to me and to many of my confidentiality, but that is disin- with members ahead of time, but it colleagues. This subsidiary of the genuous. Confidentiality does not simply wasn’t possible for the protec- CMA has been an integral part of the apply to a theoretical discussion tion of clients and staff and because of financial planning and retirement se- that the CMA should have had with the nature of this type of transaction. curity for Canadian physicians for their colleagues prior to embarking I can assure you that we’ve landed the past 50 years. An overwhelming on the strategy.) with an organization that can help us number of the physicians I know sup- 3. What happened to the $2 billion? serve our clients even better. In fact, ported MD Management because it What were the commissions paid? a key principle of our agreement is felt safe. The physicians owned the Who received them? to offer services that are the “same or company. The financial agents did not The CMA may wish to change its better.” And so, our current products work on commission. They worked mission statement, as posted on the and people are not changing, they’re solely for us. The fees were the lowest MD Financial Management website, only going to be expanded upon. in the investment community. It will as it is no longer valid: “MD Financial I know this is a bold step, but it’s be hard to convince us that this will Management supports the CMA and also a necessary one. At the end of the not change. No company spends $2 enhances the CMA-PTMA member- day, it would have been very difficult billion without a plan for a significant ship experience by helping members for MD to remain relevant and stay return on their capital investment. achieve financial well-being from competitive given the way the finan- The following excerpt from the medical school through retirement.” cial industry is changing. With a new MD Financial Management website The CMA abdicated this respon- owner, MD will be able to expand its demonstrates the special relationship sibility and it was done in a secretive, products and services and technology it has had with Canadian physicians: noninclusive manner. It may have platforms while still providing the Owned by the Canadian Me- been legal, but it was also shameful. objective advice that it’s known for. dical Association, MD Finan- I encourage the physicians of BC MD’s advisors will remain salaried cial Management has the only who share these concerns to commu- and noncommissioned. MD’s main business imperative of enhan- nicate with the BCMJ, Doctors of BC, goal remains: to help Canada’s physi- cing physicians’ financial out- and the CMA. If you would like to be cians and their families achieve finan- comes by focusing on their added to an email distribution group cial well-being. distinctive needs and opera- on this subject, please contact me at Over the coming weeks, the CMA ting in their best interests . . . [email protected]. will be creating an investment board MD’s Advisors work on sala- —Ken Markel, MD to be the steward of the proceeds of ry, not commission. Without Richmond the sale. We’ll be working closely incentives to sell any parti- with members to map out the best cular product, our Advisors Re: Sale of MD Financial areas where we can effect impact- provide objective advice that Management; CMA ful change and create programs to is in our clients’ best interests Board Chair replies support physicians and better health . . . Our priority is for clients to Thank you for taking the time to share in support of the CMA’s vision and meet their financial goals, not your thoughts on our decision to sell mission. for us to maximize corporate MD Financial Management. I appre- I believe, more than ever, that profits. ciate this opportunity to provide some there’s a need for a strong, nation- We were all blindsided by this further details and hopefully answer al association to act on the issues event. There was no debate, no pro- some of the questions you raised. that matter to all of us—physician posals, and no inclusion of the mem- First, I want to say that this was Continued on page 346

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 345 letters

Continued from page 345 Re: Nonrecognized through either of the two national cer- burnout, support for medical students qualifications; College tifying colleges. The College recog- and residents, and improved health responds nizes that there are many diploma and care. The CMA is now better posi- While the College does not collect certification-granting organizations tioned than ever to be that leader and information from physicians about that sound more impressive than can to be a strong voice for medicine for whether they perform a particular be verified through independent ac- decades to come. procedure or have a specific expertise creditation of the training program. I do hope I’ve addressed some of or special interest beyond their formal Physicians who have obtained your concerns, but please feel free training and academic credentials, it membership or certification from a to contact me at [email protected] does have an expectation as outlined nonrecognized society, or partici- with any further questions. in the bylaws under the Health Pro- pated in specialized training in a par- —Brian Brodie, MD fessions Act, and as clearly stated in ticular treatment or procedure, should Chair, CMA Board of Directors a practice standard (Advertising and be extra vigilant in ensuring that they Communication with the Public), that are not misrepresenting themselves. Re: Nonrecognized registrants represent themselves and For example, a family physician who qualifications their credentials accurately and truth- has obtained additional training in Evert Tuyp raises some interest- fully, and that they avoid misleading treating sport injuries must clearly ing points in his letter about non- the public through false or exagger- indicate on any advertising or promo- recognized qualifications (BCMJ ated claims. tional material that they are a “fam- 2018;60:240). I appreciated the frank Part 7, Section 7-4(3) of the by- ily physician with a special interest in and honest editorial comment at- laws states: “A registrant must not sports medicine.” testing that the BCMJ doesn’t have a identify himself or herself as a spe- The legislation is clear. Physi- robust policy on the topic. I wonder cialist unless he or she has certifica- cians can advertise their professional whether the College of Physicians tion from the RCPSC or equivalent services provided the content isn’t and Surgeons of BC, or for that matter accrediting body approved by the inflated and that it genuinely assists governing bodies such as the College board.” patients in making informed choices of Family Physicians of Canada, have Part 7, Section 7-4(4) of the by- about their health and well-being. robust policies either. As this issue laws states: “No one other than a reg- —Heidi M. Oetter, MD clearly affects patient safety, public istrant who is a certificant or fellow Registrar and CEO, trust, and physician accountability, of the RCPSC or who has completed College of Physicians and one would expect them to. postgraduate training in his or her spe- Surgeons of British Columbia Any policy should provide evi- cialty satisfactory to the registration dence that nonrecognized training committee, may indicate on his or her being used in Canada is validated, letterhead or office door or otherwise ethical, and indeed appropriate for represent himself or herself as hold- 60 volumes patient needs. I have seen many pa- ing such specialist qualifications.” strong tients who tell me that they have Only those registrants who have “already seen the specialist” in a par- obtained certification with the RCP- ticular town, while I am aware that SC in a surgical field can refer to there is no such specialist there. What themselves as “surgeon.” they had actually seen were proudly The College encourages addi- displayed certificates of training that tional training and recognized certi- is not recognized in Canada, and pa- fication through reputable societies tients are often completely unaware and organizations such as the Cana- that this is the case. Perhaps part of dian Society of Addiction Medicine any College policy should be a re- (CSAM) and the American Society of quirement for such physicians to ob- Addiction Medicine (ASAM). Physi- The BCMJ is publishing its tain informed written consent from cians who provide addiction medicine 60th volume this year! patients acknowledging that they un- services come from a variety of pro- derstand when a certificate and train- fessional backgrounds (e.g., family ing is not recognized in Canada. medicine, psychiatry, internal medi- —Chris Sladden, FRCPC cine) and, at this time, an established Kamloops route to certification does not exist

346 bc medical journal vol. 60 no. 7, september 2018 bcmj.org news

BC Children’s Hospital The study, presented at the 2018 persons self-identify as having Indig- furthering development AIDS Conference in Amsterdam and enous ancestry. of immunotherapy published in the scientific journal treatments for kids AIDS, shows that HIV strains circu- “Smart stent” detects BC Children’s Hospital has joined lating in Saskatchewan have adapt- narrowing of arteries CureWorks, an international collabor- ed to evade host immune responses. For every three individuals who have ative of leading academic children’s These HIV strains are being com- had a stent implanted to keep clogged hospitals focused on improving care monly transmitted and, if the result- arteries open and prevent a heart at- for children with hard-to-treat cancers ing HIV infections are left untreated, tack, at least one will experience rest- by expanding clinical trials and accel- rapid progress to AIDS-related ill- enosis—the renewed narrowing of erating the development of leading- nesses may happen. the artery due to plaque buildup or edge immunotherapy treatments. Researchers on the study—from scarring—which can lead to addition- Every year in BC, approximately the BC-CfE, SFU, and the Public al complications. 150 kids are diagnosed with cancer. Health Agency of Canada, in partner- A team led by UBC electrical Thanks to rapid and significant ad- ship with Saskatchewan physician- and computer engineering profes- vances in cancer treatments, 80% of researchers and with funding from sor Kenichi Takahata has developed kids are now expected to survive. For the Canadian Institutes of Health a “smart stent” that monitors even the remaining 20%, who have cancers Research—were startled at the prev- subtle changes in the flow of blood that are difficult to treat with tradi- alence of immune resistance muta- through the artery, detecting the nar- tional therapies, immunotherapy pro- tions. One key mutation was found in rowing in its earliest stages and mak- vides new hope. more than 80% of Saskatchewan HIV ing early diagnosis and treatment Working with the newly formed strains, compared with only about possible. The device uses medical- Seattle Children’s Hospital–based 25% of HIV strains found elsewhere grade stainless steel and looks similar CureWorks, researchers at BC Chil- in North America. The pervasiveness to most commercial stents. Research- dren’s will further the science of a of such mutations is increasing over ers say it’s the first angioplasty-ready promising type of immunotherapy time. More than 98% of the HIV se- smart stent. called “chimeric antigen receptor quences collected in Saskatchewan Research collaborator Dr York (CAR) T-cell therapy,” add to the most recently (2015 and 2016) har- Hsiang, a UBC professor of surgery body of knowledge around this inno- bored at least one major immune re- and a vascular surgeon at Vancouver vative treatment, and develop exper- sistance mutation. HIV antiretroviral General Hospital, noted that monitor- tise within the research institute and treatment, however, works equally ing for restenosis is critical in manag- the hospital. effectively against immune-resistant ing heart disease. The first CAR T-cell clinical trials HIV strains. The device prototype was suc- will launch this fall at BC Children’s The multi-year analysis compared cessfully tested in the lab and in a and will initially be available to chil- more than 2300 anonymized HIV swine model. The research team is dren with certain types of leukemia sequences from Saskatchewan with planning to establish industry partner- who are no longer responding to con- data sets from sites across the United ships to further refine the device, put ventional treatment. States and Canada. Genetic analy- it through clinical trials, and eventu- ses of HIV strains in Saskatchewan ally commercialize it. Immune-resistant HIV showed high levels of clustering— The research is described in the mutations in Saskatchewan indicating that viruses with similar May issue of Advanced Science. The BC Centre for Excellence in mutations are being frequently and HIV/AIDS (BC-CfE) and Simon Fra- widely transmitted. Matchmaking service combats ser University conducted research in This study is significant as HIV antibiotic-resistant infections response to reports in Saskatchewan incidence rates in Saskatchewan are UBC researchers have matched pep- of unusually rapid progression of HIV among the highest in North America, tides with antibiotics so they can to AIDS-defining illnesses in the ab- with 2016 rates in some regions more work together to combat hard-to-treat sence of treatment—revealing gen- than 10 times the national average. infections that don’t respond well to etic mutations in HIV strains in that Saskatchewan’s HIV epidemic is also drugs on their own. The study builds province. unique in that nearly 80% of infected Continued on page 348

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Continued from page 347 who often deal with dense, chronic The study suggests that this new on previous research that showed that infections in the lungs. The disease group therapy may work as well as the peptides are key to making harm- causes mucus to build up around tis- individual therapy, but at half the cost ful bacteria more responsive to drugs. sues, creating an ideal environment for per patient. The study aimed to find new bacteria to form biofilms and thrive. The study, “Transportability of treatments for infections caused by Researchers are hoping to com- imagery-enhanced CBT for social antimicrobial-resistant bacteria in- mercialize this treatment and have anxiety disorder,” appears in Behav- cluding Escherichia coli and the so- licensed the peptides to ABT Innova- iour Research and Therapy. called ESKAPE pathogens, a group tions, a UBC spinoff company owned named from the first-letter of six bac- by Dr Bob Hancock. Anger overlooked as feature teria species: Enterococcus faecium, The research was funded by Cys- of postnatal mood disorders Staphylococcus aureus, Klebsiella tic Fibrosis Canada, a Canadian Insti- Women in the postpartum period pneumonia, Acinetobacter bauman- tutes of Health Research Foundation should be screened for anger in addi- nii, Pseudomonas aeruginosa and grant, the Canada Research Chair tion to depression and anxiety, new Enterobacter. These infections col- program, and the Alexander von research from the University of Brit- lectively account for more than 60% Humboldt Foundation. The study was ish Columbia suggests. of all hospital infections, manifesting published in PLOS Pathogens. Although anger has been recog- as abscesses in the skin or infections nized as an element of postpartum in internal tissues like the lungs or uri- Novel therapy offers mood problems for some women, it nary tract. hope for social anxiety has not been well studied and is not Most antibiotics are designed to People with social anxiety disorder included in the Edinburgh Postnatal work on bacteria that are swimming benefit from group therapy that targets Depression Scale screening tool. In freely in the body. However, in the the negative mental images they have a review of existing research, UBC majority of infections, bacteria grow of themselves and others, according nursing PhD student Christine Ou together on body surfaces in mas- to a study at the University of Wat- found anger to be a significant feature sive communities known as biofilms, erloo. Called “imagery-enhanced” in postpartum mood disturbances. shielded by a protective structure. To- cognitive behavioral therapy (CBT), Ou’s analysis, recently published gether, biofilm bacteria adapt to stress the new group treatment helps relieve in Birth, also found that feelings of by learning to resist the immune sys- symptoms including social perform- powerlessness, a mismatch between tem and chemicals, making them ex- ance and interaction anxiety, depres- reality and expectations of mother- tremely resistant to antibiotics and sion, and stress. hood, and unmet expectations of difficult to treat. More than 4 million Canadians support contributed to anger in the The peptides help several antibiot- will develop social anxiety disorder context of postpartum depression. ics to work by removing the bacteria’s at some point in their lives. Without ability to respond to stress and form treatment, the disorder can impair Fifteen minutes of these resistant communities. To find people’s functioning at school, work, exercise creates optimal the best combination of peptide and and relationships. brain state for mastering drug, the researchers tested different The 13-session treatment used new motor skills options in a laboratory setting. Once specialized exercises including video A recent study in NeuroImage dem- they identified possible mixtures, they feedback and imagery rescripting, onstrates that exercise performed tested them in mice with abscesses on where patients are guided to reimag- immediately after practising a new their skin. In total, they found seven ine the outcomes of past negative ex- motor skill improves its long-term combinations that worked better than periences and to challenge distorted retention. The research shows, for antibiotics on their own. images of themselves and others. the first time, that as little as a single When the peptides worked in The goal was to see if the success- 15-minute bout of cardiovascular ex- combination with the drugs, the re- es achieved in a pilot and open trial ercise increases brain connectivity searchers observed a reduction in the could be replicated in a different set- and efficiency. It’s a discovery that size of the abscess in mice and the ting, without input from the treatment could accelerate recovery of motor number of bacteria in the infection developers. The results were striking- skills in patients who have suffered a area. The combinations offered up to ly similar in treatment retention and stroke or who face mobility problems 100-fold improvement. symptom improvement, strongly sug- following an injury. The results are particularly impor- gesting that imagery-enhanced group To find out what was going on in tant for patients with cystic fibrosis CBT is effective. the brain as the mind and the muscles

348 bc medical journal vol. 60 no. 7, september 2018 bcmj.org news interacted, the research team asked cifically at what was going on, the tion of their small airways (more than study participants to perform two researchers discovered that, after ex- 40%) on average. different tasks. The first, known as ercise, there was less brain activity, Currently, patients with mild a pinch task, consists of gripping an most likely because the neural con- COPD, as determined by a lung func- object akin to a gamer’s joystick (and nections both between and within the tion test, are given minimal or no known as a “dynamometer”) and us- brain hemispheres had become more treatment. ing varying degrees of force to move efficient. The new findings also suggest pre- a cursor up and down to connect red What researchers found espe- vious large clinical trials testing new rectangles on a computer screen as cially intriguing was that when they COPD treatments may have failed be- quickly as possible. The task was cho- tested participants at the 8-hour mark, cause patients already had substantial sen because it involved participants there was little difference between lung damage. in motor learning as they sought to groups in skill retention. Both groups Lung samples from 34 patients modulate the force with which they were less able to retain the skills they were analyzed using an ultra-high res- gripped the dynamometer to move had newly acquired than they were olution microCT scanner, one of three the cursor around the screen. This was at the 24-hour mark, when the dif- scanners of this kind in the country. then followed by 15 minutes of exer- ference between the two groups was Though the HLI Lung Tissue Reg- cise or rest. once more apparent. istry Biobank at St. Paul’s has been Participants were then asked to re- This suggests that sleep can inter- collecting specimens for more than peat an abridged version of this task, act with exercise to optimize the con- 30 years, the recent addition of the known as a handgrip task, at intervals solidation of motor memories. microCT scanner made it possible to of 30, 60, and 90 minutes, after ex- To learn more about the research, image samples that are embedded in ercise or rest, while the researchers read “Acute cardiovascular exer- paraffin in extreme detail. assessed their level of brain activ- cise promotes functional changes in It is estimated approximately 1 ity. This task involved participants cortico-motor networks during the in 10 people over the age of 40 may simply repeatedly gripping the dy- early stages of motor memory con- suffer from COPD. Dr Don Sin, the namometer for a few seconds with a solidation” by Fabien Dal Maso and Canada Research Chair in COPD similar degree of force to what they colleagues in the 1 July 2018 issue of and a St. Paul’s respirologist, said used to reach some of the target rect- NeuroImage. the findings have significant impli- angles in the pinch task. The final step cations. By 2020, COPD is expected in the study involved participants in Breakthrough discovery to be the third leading cause of death both groups repeating the pinch task will change treatment worldwide. 8 and then 24 hours after initially per- for COPD patients forming it, allowing the researchers Permanent lung damage caused by BCEHS Action Plan to capture and compare brain activity chronic obstructive pulmonary dis- transforming emergency and connectivity as the motor memo- ease (COPD) starts much earlier than health services in BC ries were consolidated. previously thought, even before pa- BC Emergency Health Services Researchers discovered that those tients are showing symptoms. (BCEHS) has made significant who had exercised were consistently These are the findings of a study progress in the first year of imple- able to repeat the pinch task, con- published in The Lancet Respiratory menting the 3-year BCEHS Action necting different areas of the brain Medicine. The discovery, led by Dr Plan. more efficiently and with less brain Tillie-Louise Hackett, associate pro- The bold plan focuses on im- activity than those who hadn’t exer- fessor in the University of British Co- proving ambulance response times cised. The reduction of brain activ- lumbia’s Faculty of Medicine, will for life-threatening and time-critical ity in the exercise group was also dramatically change how patients are 9-1-1 calls, and enhancing services correlated with a better retention of treated for COPD, the leading cause for patients who don’t require ambu- the motor skill 24 hours after mo- of hospital admissions in BC and lance transport to hospital. tor practice. This suggests that even Canada. A newly released progress re- a short bout of intense exercise can Hackett, who is also a principal in- port on the BCEHS Action Plan de- create an optimal brain state during vestigator at St. Paul’s Hospital Cen- scribes many of the changes that have the consolidation of motor memory, tre for Heart Lung Innovation (HLI), already taken place in year 1 of the which improves the retention of mo- and her research team found that even 3-year plan. Progress includes adding tor skills. patients diagnosed with mild COPD 127 paramedic positions, 20 dispatch When they looked more spe- have already lost a significant por- Continued on page 350

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Continued from page 349 cial Health Services Authority. For cases, and is characterized by estro- positions, and 45 ambulance vehicles, more information, visit www.bcehs.ca. gen binding to an abnormal number of as well as other investments to ensure receptors. Doctors typically prescribe high-quality, sustainable services. University of Winnipeg Tamoxifen at the start of any ER+ BCEHS has also introduced inno- research aims to identify treatment, thanks to its success rate in vations in its dispatch centres to im- resistance to breast patients who are responsive to it. prove clinical oversight and enhance cancer treatment Key to solving the issue is a protein the patient experience for those who A simple test could improve the treat- within cancer cells known as N-My- have nonurgent medical issues. ment odds of patients diagnosed with ristoyltransferase (NMT), which the The first year of implementation breast cancer, thanks to new research lab has already discovered activates of the BCEHS Action Plan lays the at the University of Winnipeg. with increased estrogen receptor ac- groundwork for more service improve- The drug Tamoxifen, used to treat tivity. Since last September, Reddick ments in years 2 and 3. As part of year 2, the majority of breast cancer cases, is has produced 14 different variants of BCEHS has implemented a new clini- ineffective in approximately half of breast cancer cells, each with different cal response model and will introduce all patients who receive it. Dean Red- localizations of the protein. The plan more pathways for patients to be treat- dick, a graduate student in the Master is now to treat each one and monitor ed in their homes and communities. of Science in Bioscience, Technol- their responses. Although the lab still BCEHS is responsible for the ogy and Public Policy program, is has further testing to do, Reddick be- delivery and governance of prehos- researching a way to identify these lieves the protein is an indicator of re- pital emergency medical care and patients before treatment starts. sponsive cells. Once the indicators are interfacility patient transfer services The research impacts the treatment identified, Reddick says within 3 to 4 through the BC Ambulance Service of estrogen receptor positive (ER+) years a biopsy could be used to deter- and the BC Patient Transfer Network. breast cancer, which accounts for ap- mine a patient’s resistance level and BCEHS is supported by the Provin- proximately 70% of all breast cancer prescribe appropriate treatment.

Medication use in Indigenous communities An Indigenous storytelling project called Coyote’s Food Medicines was launched in front of an audience of 4000 Elders at the BC Elders Gathering in July to encourage conversations about wellness and how to manage medications for a healthy life. Secwepemc Elders created the Coyote’s Food Medicines story using a traditional approach to share knowledge and humor to raise awareness of the issue of multiple medications and their potential impact on health. Shared Care’s Polypharmacy Risk Reduction Initiative (a partnership of Doc- tors of BC and the BC government), the First Nations Health Authority, and Interior Elders of Northern Secwepemc: Health worked with Elders, initiating conversations that led to the creation of the Clara Camille, Jean William, and Coyote story. In describing the challenges concerning medication use in First Na- Cecelia de Rose tions communities, Elder Jean William said, “In the past, our Elders didn’t take lots of medication, mostly just Aspirin. But now, cupboards look like pharmacy shelves.” The Coyote’s Food Medicines project promotes healthy conversations between patients and providers, such as doctors, nurses, and pharmacists, in an effort to prevent side effects and adverse events, such as falls and injuries, from polypharmacy. Dr Keith White, physician lead for the Polypharmacy Risk Reduction Initia- tive, says, “We feel this story can provide a platform for discussions among First Nations families and their health care providers, to help initiate regular medication reviews and find options that optimize health and minimize risks of multiple medications.” Copies of the book are available online at www.coyotestory.ca, along with materials to help track medications, and tips on how to talk about medications with health providers.

News continued on page 369

350 bc medical journal vol. 60 no. 7, september 2018 bcmj.org college library

Clinical Handbook of Psychotropic Drugs—Clinically relevant drug information at your fingertips

he College Library offers the Each section in the handbook ad- mation in the CHPD is particularly Clinical Handbook of Psycho- dresses a drug class (e.g., SSRIs), pre- valuable given that most psychophar- T tropic Drugs (CHPD) in two senting information on drugs within macology publications assume an online volumes—one pertaining to that class at a glance; a variety of treat- American readership. adults, and another for children and ment options can be quickly scanned Both volumes of the Clinical adolescents. The CHPD contains au to select the best course of action for Handbook of Psychotropic Drugs are thor itative drug information based on the patient. The volume devoted to available online on the College Li- the latest evidence, gathered from large children and adolescents addresses brary’s website, on the Point of Care clinical trials to case reports discussing the dosage needs and unique effects and Drug Tools page: www.cpsbc rare adverse effects. The information is that drugs have on that age group. .ca/library/search-materials/point-of presented in concise reviews and color- The CHPD is searchable for spe- -care-drug-tools (login required: cur- coded tables for ease of use at the point cific drugs, and both volumes contain rent CPSID and password). of care. A range of clinicians from psy- off-label uses for each drug, interac- Contact the College Library if you chiatrists to family practitioners can tions, nondrug treatments such as require further assistance. Phone: 604 benefit from the CHPD. bright-light therapy, and printable pa- 733-6671, email: [email protected], tient information. online request form: www.cpsbc.ca/ This article is the opinion of the Library of The CHPD is edited by a Cana- library-requests. the College of Physicians and Surgeons of dian team of clinical pharmacists, —Paula Osachoff BC and has not been peer reviewed by the pharmacologists, and physicians. Librarian BCMJ Editorial Board. Canadian-specific prescribing infor-

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bc medical journal vol. 60 no. 7, september 2018 bcmj.org 351 Carla Pajak, MD, FRCSC, Sharmen Vigouret Lee, MHA, Dave Konkin, MD, FRCSC, FACS, Sue Sidhu, MD, FRCSC, Scott Cowie, MD, FRCSC

Early surgical management of acute cholecystitis: A quality improvement initiative

A modest educational intervention at a community hospital resulted in an 85% increase in early laparoscopic cholecystectomy rates and a 47% reduction in time from admission to surgery.

ABSTRACT Background Background: Significant research of operations, rates for conversion Acute cholecystitis is seen commonly has shown convincingly that man- to open surgery, and length of stay. in the emergency room and is a lead- aging acute cholecystitis with early ing cause of gastrointestinal-related laparoscopic cholecystectomy rath- Results: The retrospective audit hospital admissions.1 Cholecystec- er than delayed cholecystectomy is found that more than half of health tomy is the accepted standard of care safe and is associated with improved authority patients (54%) did not re- to manage cholecystitis; however, outcomes and lower costs. However, ceive early access to surgery, de- the timing of surgery has been the early laparoscopic surgery is not spite this approach being preferred subject of debate. In the past, con- routine, suggesting barriers to uni- by most surgeons. The comparison servative management with a course form adoption of this practice. of management approaches before of antibiotics was thought to reduce and after the educational interven- inflammation and facilitate definitive Methods: An online survey of prac- tion at Langley Memorial Hospital tising general surgeons in the Fra- showed an 85% increase in early Dr Pajak is a physician in the Division of ser Health Authority was followed laparoscopic cholecystectomy rates General Surgery at the University of Brit- by a retrospective audit of all pa- and a 47% reduction in time from ad- ish Columbia. Ms Vigouret Lee is president tients presenting to health authority mission to surgery. and CEO of Strategyst Healthcare and dean sites with acute cholecystitis from of the School of Health Sciences at the April 2012 to June 2013. A modest Conclusions: Improving access to British Columbia Institute of Technology. educational intervention was then timely surgery is possible and re- Dr Konkin is a general surgeon at Royal implemented at Langley Memor- quires engagement of key stake- Columbian Hospital and a clinical assistant ial Hospital to facilitate adoption holders. Policies aimed at increasing professor in the Department of Surgery at of early laparoscopic cholecystec- rates of early laparoscopic chole- the University of British Columbia. Dr Sidhu tomy. Data were compared from cystectomy for treatment of acute is a general surgeon at Royal Columbian before and after implementation of cholecystitis must focus on im- Hospital and a clinical instructor in the De- the educational intervention. Some proving surgeon access to surgical partment of Surgery at the University of outcomes considered were times resources. British Columbia. Dr Cowie is head of the from admission to surgery, duration Division of General Surgery at Langley Me- morial Hospital and a clinical instructor in the Department of Surgery at the Univer- This article has been peer reviewed. sity of British Columbia.

352 bc medical journal vol. 60 no. 7, september 2018 bcmj.org Early surgical management of acute cholecystitis: A quality improvement initiative

surgical management at a later date, Table 1. Severity grading for acute cholecystitis. usually 6 weeks after the initial presentation. This approach was felt to Grade Conditions reduce operative risks and was en- III (severe) Associated with any one of the following: dorsed as recently as 2013 for grade 1. Cardiovascular dysfunction: hypotension requiring vasopressors II (moderate) and grade III (severe) 2. Neurological dysfunction: decreased level of consciousness cholecystitis as outlined in the Tokyo 3. Respiratory dysfunction: PaO2/FiO2 ratio < 300 guidelines ( Table 1 ).2 However, re- 4. Renal dysfunction: oliguria, creatinine > 2.0 mg/dl search has shown convincingly that 5. Hepatic dysfunction: PT-INR > 1.5 3 early laparoscopic cholecystectomy 6. Hematological dysfunction: platelet count < 100 000/mm (ELC), defined as occurring 24 to II (moderate) Associated with any one of the following: 72 hours from time of admission, 1. Elevated white blood cell count (> 18 000/mm3) is preferred for treatment of acute 2. Palpable tender mass in the right upper abdominal quadrant cholecystitis in the modern laparo- 3. Duration of complaints > 72 hours scopic era.3 Surgery within 72 hours 4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, peritonitis, emphysematous cholecystitis) has become a benchmark after being associated with lower costs and I (mild) Does not meet criteria of grade III or grade II acute cholecystitis better outcomes, namely reduced 1. Healthy patient with no organ dysfunction and mild inflammatory changes complication and mortality rates.4,5 Adapated from Tokyo guidelines.2 When compared with delayed laparoscopic cholecystectomy (DLC), early scopic cholecystectomy was offered Methods laparoscopic cholecystectomy has to patients with symptom duration In 2014 all practising general sur- been shown to be safe, to have simi- greater than 72 hours.14 Furthermore, geons in the Fraser Health Author- lar or better rates of conversion to an delaying cholecystectomy is associat- ity were approached to complete an open procedure, and to reduce dur- ed with a higher risk of complications online survey about surgeon atti- ation of hospital stay.5-11 Looking at and costs.5,9,12 Patients with acute cho- tudes, preferences, and practice pat- data from 77 case-control studies, lecystitis who are discharged without terns regarding management of acute early laparoscopic cholecystectomy surgery have a 19% risk of a gallstone- cholecystitis. This was followed by was also found to be associated with related emergency room visit or hos- a retrospective database audit of re- statistically significant reductions in pital admission.15 In addition, among cords for all patients presenting with mortality, total complication rate, bile patients with recurrent symptoms, acute cholecystitis in Fraser Health duct leaks, bile duct injuries, wound approximately 30% will progress between April 2012 and June 2013 infections, conversion rates, length to a more morbid gallstone-related who underwent a surgical interven- of hospital stay, and blood loss.3 In a complication such as biliary tract tion from April 2012 to December Canadian model, performing surgery obstruction or pancreatitis.15 Despite 2013. Baseline data were collected for early was also estimated to save ap- the significant body of literature sup- the entire health authority as well as proximately $2129 per patient.12 The porting early access to surgery, there for each individual hospital within the most recent consensus statement in continues to be variation in practice authority. Regional analysts collected the 2018 Tokyo guidelines reflects seen even within a single regional data as part of an approved quality this by extending adoption of early health care system, suggesting the audit using ICD and Canadian Classi- laparoscopic cholecystectomy for presence of institutional barriers im- fication of Health Intervention codes. both grade II and grade III severity as peding uniform adoption of ELC.16 Our educational intervention the ideal preferred approach.13 We sought to investigate further by took place at Langley Memorial The benefits of early cholecyst- assessing surgeon attitudes toward Hospital, a 166-bed facility serv- ectomy may extend to patients with early laparoscopic cholecystectomy ing a population of approximately symptoms lasting more than 72 hours: and current practice patterns, and to 130 000 in Langley, British Colum- a recent randomized controlled trial determine the impact of an education- bia. The intervention began in May demonstrated a reduction in length of al intervention at a single site on the 2015 with the distribution of infor- stay, duration of antibiotic use, and rates of early surgery. mation by email to emergency room costs when same-admission laparo- physicians and with educational

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 353 Early surgical management of acute cholecystitis: A quality improvement initiative

rounds for operating room nurses. A practice algorithm for acute chole- 10 9 Number of patients cystitis was then developed and dis- 9 tributed to staff in the emergency 8 7 room and operating rooms. The al- 7 6 gorithm included a recommendation 6 for early surgical consultation for all 5 4 confirmed or suspected cases of acute 3 3 cholecystitis. After the educational 2 2 2 2 intervention, data were collected from 1 1 1 1 0 0 electronic and paper charts from July 0 2015 to June 2016. Outcomes includ- 4–6 7–9 10–19 20–29 1–2 2–3 3–4 4–5 5–7 7–8 8–9 9–10 days days days days months months months months months months months months ed times from admission to surgery and from booking to surgery, as well Figure 1. Wait times for 34 patients undergoing delayed cholecystectomy at Langley as preoperative American Society of Memorial Hospital before implementation of educational intervention supporting early Anesthesiologists (ASA) scores and cholecystectomy. duration of operations, conversion to open surgery rates, length of stay, and readmission rates. FHA, all sites Langley Memorial Hospital 100 93 97 Results 80 Survey respondents included 26 % 60 54 55 general surgeons (48% of active/ 46 45 50 40 provisional regional members) repre- 25 senting all Fraser Health sites. When 20 7 3 surgeons were asked how they would 0 manage acute uncomplicated chole- Intervention at ELC Drainage No initial DLC during study admission procedure intervention period cystitis in a medically fit patient, 73% chose early laparoscopic cholecystec- ELC = early laparoscopic cholecystectomy, DLC = delayed laparoscopic cholecystectomy tomy and 27% chose a trial of conservative management with delayed Figure 2. Management of acute cholecystitis at all Fraser Health Authority (FHA) sites and at Langley Memorial Hospital before implementation of educational intervention supporting early cholecystectomy. Of those who opted cholecystectomy. for delayed surgery, 75% cited limited access to the operating room as their main reason for choosing this itial admission. Of these, 569 (93%) ley Memorial Hospital with acute strategy. Among those who opted for had laparoscopic cholecystectomies cholecystitis over 13 months, and 61 early laparoscopic cholecystectomy, and the remaining 48 (7%) had drain- (45%) had an intervention on their 84% would book the case as needing age procedures (either operative or initial admission. Of these, 59 (97%) to be done within 24 hours, although radiologic). This left 718 patients underwent cholecystectomies and 2 only 23% said they felt surgery was (54%) who had no intervention for (3%) had drainage procedures. This “usually” or “always” completed cholecystitis on their initial admission. left 74 patients (55%) who had no in- within this time frame. The majority Among these patients, 359 (50%) went tervention for acute cholecystitis on of respondents (88%) supported an on to have a delayed cholecystectomy their initial admission. Among these, institutional policy allowing for early during the study period. Average hos- 34 patients (25%) went on to have a laparoscopic cholecystectomy. pital length of stay in the ELC group delayed procedure during the study Between April 2012 and Decem- receiving early treatment was 5.8 days period ( Figure 1 ). Overall, manage- ber 2013, a total of 1329 patients were compared with 6.4 days for the DLC ment of acute cholecystitis at Langley admitted to Fraser Health sites with group receiving delayed treatment. Memorial Hospital before the educa- a diagnosis of cholecystitis, and 611 Before the educational interven- tional intervention was comparable to (46%) had an intervention on their in- tion, 135 patients presented to Lang- that seen at other Fraser Health sites

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( Figure 2 ). Table 2. Reasons for nonoperative Table 3. Reasons for laparoscopic After the educational intervention, management in 20 cases of acute cholecystectomy in 29 cases not involving 129 patients presented to Langley cholecysitis at Langley Memorial Hospital acute cholecystitis at Langley Memorial Memorial Hospital with acute chole- after educational intervention. Hospital after educational intervention. cystitis over 12 months. Of these, Number of Number of Reason Reason 109 (84%) had an early cholecystec- cases cases tomy and 20 (16%) had nonoperative Medically unfit* 10 (50%) Gallstone pancreatitis 15 management for a variety of reasons Biliary colic (symptoms Common bile duct stone 4 (20%) ( Table 2 ). Of the138 cholecystec- resolved) requiring endoscopic 9 retrograde tomies performed during the entire Refused surgery/left against 3 (15%) cholangiopancreatography study period, 29 (21%) were per- medical advice Delayed diagnosis/referral 2 formed for reasons other than acute Incidental gallstones 2 (10%) Admitted from same-day cholecystitis ( Table 3 ). Initially managed with 2 1 (5%) surgery The impact of the educational percutaneous drain intervention on surgical access was Percutaneous *Including 2 cases addressed with conservative cholecystostomy tube 1 management alone and 8 cases addressed with positive ( Table 4 ), with reductions in inserted time from admission to surgery and percutaneous drain insertion from booking to surgery ( Table 5 ). Table 4. Impact of educational intervention on surgical access for cases of acute The average OR time was 62.32 min- cholecystitis managed with early laparoscopic cholecystectomy. utes (OR times for the period prior to the educational intervention are Before After Percentage not known). Of the early cholecyst- intervention intervention change ectomy patients, 3 were readmitted, Number of cases 59 109 85% increase with 2 requiring endoscopic retro- Total time from admission to 2808.00 2461.50 12% reduction grade cholangiopancreatography and surgery (hours) Average time from admission 1 with abdominal pain requiring no 43.20 22.92 47% reduction intervention. Conversion to open pro- to booking for surgery (hours) cedures was required in only 3 (2.9%) Average length of stay (days) 4.60 2.57 44% reduction of all the cholecystectomies. The preoperative status of most patients who Table 5. Time from admission to underwent early cholecystectomy booking and from booking to surgery after 7% was ASA 2 (45%) or ASA 3 (34%) educational intervention. 14% ( Figure 3 ). The ASA status of all pa- Admission to Booking to surgery tients’ pre-educational intervention is booking start not available. 22.92 hours 7.38 hours 34% Conclusions With a modest educational interven- preciably shorter (2.57 days) than for 45% tion we were able to achieve signifi- patients in the Fraser Health early cant clinical impact: an 85% increase cholecystectomy group (5.1 days). in early cholecystectomy rates and a Interestingly, the hospital stay after 47% reduction in time from admis- the educational intervention was 1 sion to surgery for patients with acute also shorter than the 5.1 days seen in 2 cholecystitis. In addition to providing pooled data for patients undergoing 3 better patient care, increasing patient early cholecystectomy.3 One pos- 4 access to early cholecystectomy re- sible explanation for this substantial sulted in a 44% reduction in hospital reduction in length of stay is that our Figure 3. ASA status of early cholecystectomy patients at Langley length of stay. The length of stay for intervention focused on education Memorial Hospital after implementation of early cholecystectomy patients after for both emergency room physicians educational intervention supporting early the educational intervention was ap- and perioperative staff, which may cholecystectomy.

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have facilitated more streamlined early laparoscopic cholecystectomy, that not all cases of acute cholecysti- care for patients with acute chole- some degree of caution must be exer- tis present an equal surgical challenge cystitis and expedited their access to cised before instituting a strict policy and risk to the patient, and that other surgery. This outcome is significant of ELC with rigid scheduling bench- options such as percutaneous drain- from both a system and a patient per- marks, since such a policy could lead age may be preferred.19 However, a spective. Reducing hospital length of to markedly increased after-hours recent retrospective review found that stay will reduce the costs associated surgery. Data regarding the safety a majority (90.7%) of patients with with cholecystitis for an already over- of nighttime laparoscopic cholecyst- moderate to severe acute cholecystitis burdened system. Less time in hospi- ectomy are somewhat conflicting; who received early laparoscopic cholecystectomy had a subsequent open conversion rate of only 9.2% and an overall mortality rate of 1.5%.13 Per- haps the most prudent surgical approach would be one that estimates The need for early access to surgery the difficulty of surgery to determine for acute cholecystitis is clear which patients are ineligible for after- hours surgery rather than ineligible and the benefits of it have been for early cholecystectomy altogeth- well defined in the literature. er. For example, male gender, previous episodes of cholecystitis, serum fibrinogen, neutrophil count, and al- kaline phosphatase levels can be used preoperatively to calculate a score of operative difficulty in laparoscopic tal also reduces the impact of acute a retrospective review at two large cholecystectomies.20 Patients with cholecystitis on patients by facilitat- urban centres found an increased risk high scores could then be prioritized ing a faster return to baseline function of conversion to an open procedure for daytime operations. A “working and work. for patients receiving laparoscopic smarter, not harder” approach is like- Part of the success of our interven- cholecystectomies between 7 p.m. ly to be the most sensible way to man- tion resulted from surgeon buy-in, al- and 7 a.m.17 Another slightly larger age this common disease. though this is not the only factor that and more recent retrospective re- determines patient access to timely view found no increased risk of com- Study limitations surgery for cholecystitis. In a large plications for patients undergoing The main limitation of this study is review of patients with acute chole- laparoscopic cholecystectomies after the retrospective design, which ex- cystitis across Ontario, similar pa- 5 p.m., and statistically significant poses it to selection bias. As well, data tients at different hospitals did not reduced length of stay among the for the educational intervention were receive comparable care, likely re- nighttime laparoscopic cholecyst- obtained from a single site, which flecting local institutional barriers ectomy group.18 While performing limits generalizability. Despite these to the provision of early surgery.16 after-hours surgery may be safe, the limitations, our results are concord- Providing all patients with access to long-term impacts on the surgeon ant with previous findings that sup- early laparoscopic cholecystectomy and operating room staff, which can port the safety and feasibility of early requires more than surgeon buy-in; it include burnout, exhaustion, and job laparoscopic cholecystectomy. also requires administrative support dissatisfaction, must be considered. that allocates the appropriate amount It is important to note that we were Summary of institutional resources to make this able to achieve our increased rates The need for early access to surgery delivery of timely care possible. of early cholecystectomy while ad- for acute cholecystitis is clear and the hering to a policy of operating after benefits of it have been well defined Management approaches 11 p.m. only if conditions were life- in the literature. Achieving higher While our results suggest it would or limb-threatening. rates of early laparoscopic chole- be worthwhile to increase access to Finally, it is worth emphasizing cystectomy is possible but requires

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the engagement of the entire health al. Comparative operative outcomes of 2013;74:26-30. care team, from front-line emergency early and delayed cholecystectomy for 16. de Mestral C, Laupacis A, Rotstein OD, et room staff to medical and nursing acute cholecystitis: A population-based al. Early cholecystectomy for acute chole- staff in the operating room. Policies propensity score analysis. Ann Surg 2014; cystitis: A population-based retrospective aimed at increasing the rates of early 259:10-15. cohort study of variation in practice. laparoscopic cholecystectomy will 10. Society of American Gastrointestinal and CMAJ Open 2013;1:E62-67. provide greater access to surgical re- Endoscopic Surgeons. Guidelines for the 17. Wu JX, Nguyen AT, de Virgilio C, et al. Can sources, and ideally this access will clinical application of laparoscopic biliary it wait until morning? A comparison of be in the daytime. tract surgery. Los Angeles: SAGES; 2010. nighttime versus daytime cholecystecto-

Competing interests None declared.

References 1. Russo MW, Wei JT, Thiny MT, et al. Diges- Policies aimed at increasing tive and liver diseases statistics, 2004. the rates of early laparoscopic Gastroenterology 2004;126:1448-1453. 2. Miura F, Takada T, Strasberg SM, et al. cholecystectomy will provide greater TG13 flowchart for the management of access to surgical resources. acute cholangitis and cholecystitis. J Hep- atobiliary Pancreat Sci 2013;20:47-54. 3. Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: A metaanalysis of case-control studies. Surg En- Accessed 31 May 2018. www.sages.org/ my for acute cholecystitis. Am J Surg dosc 2016;30:1172-1182. publications/guidelines/guidelines-for 2014;208:911-918; discussion 917-918. 4. Zafar SN, Obirieze A, Adesibikan B, et al. -the-clinical-application-of-laparoscopic 18. Siada SS, Schaetzel SS, Chen AK, et al. Optimal time for early laparoscopic chole- -biliary-tract-surgery. Day versus night laparoscopic cholecys- cystectomy for acute cholecystitis. JAMA 11. Polo M, Duclos A, Polazzi S, et al. Acute tectomy for acute cholecystitis: A com- Surg 2015;150:129-136. cholecystitis-optimal timing for early cho- parison of outcomes and cost. Am J Surg 5. Gutt CN, Encke J, Köninger J, et al. Acute lecystectomy: A French nationwide study. 2017;214:1024-1027. cholecystitis: Early versus delayed chole- J Gastrointest Surg 2015;19:2003-2010. 19. Melloul E, Denys A, Demartines N, et al. cystectomy, a multicenter randomized 12. Johner A, Raymakers A, Wiseman SM. Percutaneous drainage versus emergen- trial. Ann Surg 2013;258:385-393. Cost utility of early versus delayed laparo- cy cholecystectomy for the treatment of 6. Gurusamy KS, Samraj K. Early versus de- scopic cholecystectomy for acute chole- acute cholecystitis in critically ill patients: layed laparoscopic cholecystectomy for cystitis. Surg Endosc 2013;27:256-262. Does it matter? World J Surg 2011;35: acute cholecystitis. Cochrane Database 13. Okamoto K, Suzuki K, Takada T, et al. 826-833. Syst Rev 2006;(4):CD005440. Tokyo Guidelines 2018: Flowchart for the 20. Bourgouin S, Mancini J, Monchal T, et al. 7. Gurusamy KS, Samraj K, Gluud C, et al. management of acute cholecystitis. J How to predict difficult laparoscopic cho- Meta-analysis of randomized controlled Hepatobiliary Pancreat Sci 2018;25:55-72. lecystectomy? Proposal for a simple pre- trials on the safety and effectiveness of 14. Roulin D, Saadi A, Di Mare L, et al. Early operative scoring system. Am J Surg early versus delayed laparoscopic chole- versus delayed cholecystectomy for 2016;212:873-881. cystectomy for acute cholecystitis. Br J acute cholecystitis, are the 72 hours still Surg 2009;97:141-150. the rule? A randomized trial. Ann Surg 8. Lau H, Lo CY, Patil NG, Yuen WK. Early 2016;264:717-722. versus delayed-interval laparoscopic cho- 15. de Mestral C, Rotstein OD, Laupacis A, et lecystectomy for acute cholecystitis: A al. A population-based analysis of the clin- metaanalysis. Surg Endosc 2006;20: ical course of 10 304 patients with acute 82-87. cholecystitis, discharged without chole- 9. de Mestral C, Rotstein OD, Laupacis A, et cystectomy. J Trauma Acute Care Surg

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 357 Fahra Rajabali, MSc, Emilie Beaulieu, MD, Jennifer Smith, BFA, Ian Pike, PhD

The economic burden of injuries in British Columbia: Applying evidence to practice

Physicians and policymakers can support broader prevention initiatives for falls, transport incidents, unintentional poisoning, and self-harm by making use of data from a study quantifying injury costs.

ABSTRACT Background Background: Approximately 2000 Results: Unintentional poisoning Injuries are the leading cause of death deaths and 8000 cases of permanent and self-harm resulted in the high- among British Columbians age 1 disability result from injury every est number of years of life lost and to 44, and the fifth leading cause of year in BC. Quantifying the eco- gross cost, while falls and transport death among Canadians of all ages.1,2 nomic and societal burden of injury incidents resulted in the greatest Every year in BC approximately 2000 can provide physicians and policy- number of years lived with disabil- deaths and 8000 cases of permanent makers with comprehensive data to ity. In 2013 the gross cost for the disability result from injury.2 Be- support the development and imple- leading causes of injury ranged from yond the injured person, there are far- mentation of broader injury preven- $547 million to $922 million. The to- reaching consequences for families, tion initiatives. tal cost of injury increased between communities, the health care sys- 2004 and 2013. tem, and society at large. This public Methods: Disability-adjusted life health issue directly affects the prac- years and total costs were calcu- Conclusions: Health professionals tice of physicians who must care for lated using an incidence costing, are ideally positioned to support in- these people. human capital, societal perspective jury prevention initiatives and pro- In the past decade, efforts have approach. Data were collected and vide appropriate patient counseling. been made to consider the economic analyzed for the four leading causes Physicians and policymakers can cost of injury and the related societal of injury: falls, transport incidents, help combat rising injury rates and unintentional poisoning, and self- related costs by applying evidence Ms Rajabali is a researcher with the BC harm. The Burden Calculator and from the study of injuries in BC. In- Injury Research and Prevention Unit. Dr Electronic Resource Allocation Tool creased effort should be made to Beaulieu is a pediatrician at BC Children’s were used to establish direct and in- prevent injuries caused by falls, Hospital and a postdoctoral trainee at the direct costs of injury using data from transport incidents, unintentional BC Injury Research and Prevention Unit. a number of sources, including hos- poisoning, and self-harm. Ms Smith is a research coordinator at the pitals and emergency rooms. BC Injury Research and Prevention Unit. Dr Pike is a professor in the Department of Pe- diatrics at the University of British Colum- bia and director of the BC Injury Research This article has been peer reviewed. and Prevention Unit.

358 bc medical journal vol. 60 no. 7, september 2018 bcmj.org The economic burden of injuries in British Columbia: Applying evidence to practice

burden of death and disability, and to perspective, the disability-adjusted the relevant period within the work- enlighten decision-makers regarding life year offers a comprehensive mea- ing life of an individual age 15 to 64. the extent of the injury issue.2 Inju- sure of the relative magnitude of the Other economic factors consider ry costs in BC in 2010 amounted to injury issue and provides physicians ed included wage rates, participation $3.7 billion in both direct and indirect and policymakers with reliable and rates, unemployment rates, income costs.2 To reduce the burden on the practical information for advising pa- loss due to disability, and real wage health care system and society, phy- tients and developing effective injury growth rates, which were all dis- sicians and policymakers must be in- prevention initiatives. counted at a rate of 3%. formed of the economic cost of injury A study was proposed to calculate so they can support cost-effective pri- the cost of treating injuries in BC, the Calculation mary and secondary injury prevention impact of years of life lost to death or The Burden Calculator,8 an open- initiatives.3 disability, and the economic loss of source analytic tool, was used to es- There are several approaches to diminished labor market productivity timate disability-adjusted life years measuring economic burden of ill- and earnings. Such findings are need- for the leading causes of injury: falls, ness or injury, but a simple way is to ed to raise awareness about the bu- transport incidents, unintentional measure the direct costs. The cost-of- rden of injury, to provide physicians poisoning, and self-harm.2 The cal- illness approach generally follows with comprehensive information for culation applied disability weights,9 one of two methods: incidence cost- discussions with patients, and to as- which reflected the severity of the ing or prevalence costing. Both ap- sist policymakers in the development health decrement on a scale from 0 proaches produce the same results for and implementation of broader injury (perfect health) to 1 (dead). The dis- steady-state chronic health problems prevention initiatives. ability-adjusted life years were then and conditions that are short-term translated into 2013 dollars using the in nature. However, if policymakers Methods gross national income per capita. 6 want to assess the benefits of reduc- The economic and societal burden The Electronic Resource Alloca- ing the incidence of injuries, the in- of injury over time in BC was quan- tion Tool,2 developed by Parachute cidence method is more useful and tified using an incidence costing,5 Canada, was used to calculate both accurate. Incidence costing estimates human capital, societal perspective direct and indirect costs. The tool the lifetime direct and indirect costs approach.4,6 The total economic im- combines existing data with variables of new cases of injury that have their pact of injury was assessed by in- from the literature in order to model onset in a given year.2 Combined with cluding costs borne by the health care the full costs of unintentional and in- a societal perspective, it provides a system as well as productivity lost to tentional injuries.2 Direct and indirect useful starting point when illustrat- death or disability over the course of costs were calculated for the most ing the full burden of injury for phys- an individual’s life. Injury and pre- recent year of data available (2013), icians and policymakers. mature injury-related deaths were with results from previous injury cost The disability-adjusted life year is translated into direct and indirect studies used for comparison.10 Direct a common measure of disease or inju- costs to estimate what the societal mortality costs were also estimat- ry burden, based on the core principle gain would have been if these injured on a complete episode of events that everyone should live a long life ies and deaths had been prevented.5,7 due to an injury-related death. Costs in full health.4,5 Disability-adjusted Direct costs were defined as all health from previous years (2004 and 2010) life years are calculated as the sum care costs, including expenditures for were converted to 2013 dollars using of years of life lost due to premature hospitalization, physician and health the consumer price index to account death and years lived with disability professional services, pharmaceutical for inflation and to allow for direct to provide a single measure describ- drugs, and rehabilitation treatment. comparison. ing the total health loss at the popu- Indirect costs were defined as the total To capture the effects of variations lation level.4 The disability-adjusted productivity loss to society due to in- in direct and indirect costs of injuries, life year permits comparisons with juries that prevented individuals from sensitivity analyses were conducted previous years or between communi- performing their normal activities. using variations in the discount rate of ties, and can be used to monitor the ef- These costs were calculated by con- 1%, 3%, and 5%, unemployment rate, fectiveness of new injury prevention sidering mean individual earnings in and average weekly earnings. programs or laws.6 From a clinical relation to time loss from work over

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 359 The economic burden of injuries in British Columbia: Applying evidence to practice

Data Table 1. Data sources for study of economic burden of injuries in BC. Data used for this study were collected Type of data Estimate calculated Data source from a number of sources, including hospitals and emergency rooms Mortality data Death costs BC Vital Statistics ( Table 1 ). To allow for comprehen- Hospitalization data Hospital costs and Discharge Abstract Database, BC sive documentation of all costs asso- length of stay Ministry of Health ciated with injuries, proxy measures Emergency room data Emergency room visits Extrapolated data from National were also developed using the meth- Ambulatory Care Reporting System, odology of Miller and colleagues.11 Canadian Institute for Health Information Direct morbidity costs for out-of- hospital injury treatment were calcu- Disability data (unemployment, Cost of productivity Statistics Canada lated using ratios of episodes and re- labor force participation, losses from morbidity average wage rates) and premature death lated costs of emergency room visits Life expectancy year tables to hospitalized cases. The incidence of BC population data Injury rates and per BC Statistics both permanent partial and total dis- capita costs ability were estimated using coeffi- cients that relate these episodes and costs to the incidence of hospitalized Table 2. Number of injury-related events and incidence rates in BC by cause of injury, 2013. and emergency room injury cases. Emergency room Permanent Deaths Hospitalizations Cause visits disability (rate per 100 000) (rate per 100 000) Results (rate per 100 000) (rate per 100 000) Injuries in BC resulted in 2110 deaths, 37 207 hospitalizations, 482 687 emer- Falls 635 (13.8) 20 902 (455.5) 146 170 (3185.2) 3731 (81.3) gency room visits, and 8911 perma- Transport 275 (6.0) 4527 (98.6) 39 336 (857.2) 1227 (26.7) nent disabilities in 2013 ( Table 2 ). incidents The leading cause of death was falls, Unintentional 420 (9.2) 1657 (36.1) 7369 (160.6) 352 (7.7) which accounted for 30% of all injury- poisoning related deaths. The second leading Suicide/ cause of death was unintentional poi- self-harm 127 (2.8) 2561 (55.8) 3272 (71.3) 568 (12.4) soning, followed by suicide/self-harm (poisoning) (other) and transport incidents. Suicide/ Looking at the four leading causes self-harm 364 (7.9) 344 (7.5) 924 (20.1) 59 (1.3) of injury, unintentional poisoning and (other) self-harm resulted in the highest num- Violence 45 (1.0) 1130 (24.6) 13 651 (297.5) 298 (6.5) ber of years of life lost and gross cost, Other injuries 244 (5.3) 6086 (132.6) 271 966 (5926.4) 2676 (58.3) while falls and transport incidents resulted in the highest number of years Total 2110 (46.0) 37 207 (810.8) 482 687 (10 518.3) 8911 (194.2) lived with disability. The gross cost for the leading causes of injury in the years studied ranged from $547 mil- Table 3. Impact of disability-adjusted life years in BC by four leading causes of injury, 2013. lion to $922 million ( Table 3 ). Disability- Gross cost per Years of Years lived Cause of injury adjusted disability-adjusted life lost with disability Economic burden life years life year* (millions) Injuries cost British Columbians $4.1 Transport incidents 9993 1406 11 399 $569 billion in 2013, with 64% of this in direct cost ($2.62 billion) and 36% in Falls 8549 2396 10 945 $547 indirect cost ($1.48 billion). Perma- Unintentional poisoning 18 384 66 18 450 $922 nent disability was responsible for Self-harm 18 280 152 18 432 $921 the greatest economic burden of injury at $1891 million, followed by *Based on 2013 per capita income of Can$49 965 (US$39 601)

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outpatient treatment costs of $805 million ( Table 4 ). 1400 Falls resulted in the highest costs 1300 for inpatient treatment ($498 mil- 1200 lion), outpatient treatment ($232 mil- 1100 lion), and permanent disability ($635 1000 million). Unintentional poisoning re- 900 sulted in the highest total death cost 800 ($201 million) and highest cost per 700 600 patient death ($47 414). Suicide/self- Cost in million $ 500 harm (other) was the second highest 400 for total death cost ($150 million). 300 200 Sensitivity analysis 100 2004 2010 2013 Analyses using discounted rates of 1%, 3%, and 5% revealed high sensi- Falls Transport Self-harm Unintentional poisoning tivities to these variations and resulted in significant differences in Figure. Total cost of injuries in BC by four leading causes, 2004 to 2013. total, direct, and indirect costs of injuries. Lowering the discount rate to 1% increased total costs by 21.2%, Costs over time cost of injury increased by an average direct costs by 18.6%, and indirect From 2004 to 2013, the total cost of of 2.6% per year, and then from 2010 costs by 25.4%. Conversely, raising injury in BC increased from $3.3 bil- to 2013 increased by a lesser aver- the discount rate to 5% decreased lion to $4.1 billion, a 24.4% increase age of 1.3% per year. From 2004 to total costs by 15.1%, direct costs by over 9 years. While the cost of trans- 2010, increases in the average cost 11.7%, and indirect costs by 21.1%. port-related injuries decreased by per year were seen for falls (3.4%), The analyses for unemployment rate 7.1%, increases in cost were seen for unintentional poisoning (6.3%), self- and average weekly earnings varia- falls (35.5%), unintentional poison- harm (1.5%), and transport incidents tions indicated minimal sensitivities ing (75.6%), and self-harm (6.0%) (0.5%). From 2010 to 2013, increas- and minimal effect. ( Figure ). From 2004 to 2010, the total es continued for the average cost per

Table 4. Cost in dollars for injuries in BC by cause and injury outcome, 2013.

Cause Death Inpatient treatment Outpatient treatment Permanent disability Overall costs Total Per Total Per Total Per Total Per Per Total cost cost* death cost treatment cost treatment costs injury person (millions) (millions) cost (millions) cost (millions) cost (millions) cost cost Falls 42 65 908 498 23 808 232 1586 635 170 148 1406 136 Transport incidents 118 427 759 109 24 096 77 1965 320 261 192 624 306 Unintentional 201 479 414 22 13 053 8 1141 84 239 048 316 69 poisoning Suicide/self-harm 45 356 966 32 12 328 4 1132 170 299 397 251 55 (poisoning) Suicide/self-harm 150 412 718 8 24 328 2 2015 19 327 259 180 39 (other) Violence 21 474 626 19 17 070 20 1449 92 307 618 152 152 Other injuries 90 369 866 118 19 315 393 1443 570 213 160 1171 255 Overall $668 $316 592 $805 $21 639 $735 $1524 $1891 $212 198 $4100 $893

*Due to rounding, numbers do not add up precisely to totals shown.

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year for falls (2.3%) and unintention- tion efforts and patient counseling. In- nuances of the injury burden gained al poisoning (5.5%), while decreases vesting time and effort in counseling from studying costs can apply this were seen for self-harm (1.0%) and and injury prevention saves lives and evidence in their own practices using transport incidents (2.5%). health care resources and reduces dis- the many resources and tools avail- abilities. Previous studies have shown able ( Table 5 ). They can address the Conclusions that every dollar spent on zero alcohol burden of self-harm by connecting This study quantifies the economic tolerance for drivers under 21 years youth to mental health services such and societal burden of injury in BC. of age produces savings of $25,12 as Foundry. They can use resources At the time of writing, it was the first and that injury prevention counseling such as Parachute Canada to edu- review of costs using 2013 data, the from health care providers to parents cate parents of toddlers about risks most recent available. is positively associated with safety in the home associated with improp- The economic analyses reveal behaviors.14 erly stored cleaners and medications. that the burden is equivalent to one The results of this study indicate They can also address unintentional injury-related death every 4.2 hours that unintentional poisoning, self- poisoning associated with drugs and and an expenditure of $467 980 every harm, transport incidents, and falls alcohol by discussing social support hour.12 The significance of this bu- require attention, as they represent the programs with patients, and address rden is such that preventing injury is highest disability-adjusted life year disability from falls by discussing fall a top priority of the Provincial Health costs. As children and youth have the prevention using resources such as Services Authority.13 Physicians are most potential life remaining, they are Finding Balance BC. ideally positioned to provide guid- a priority population for primary pre- ance to health authority operational vention efforts and provide a mean- Injury prevention leaders regarding effective strategies ingful opportunity to reverse this While the results of this study indicate and top injury issues, as well as to societal and economic loss. that falls and unintentional poisoning engage in community-based preven- Physicians who understand the have contributed to increased injury

Table 5. Injury prevention resources and tools.

Injury type Resource Link Description Falls Health Link BC www.healthlinkbc.ca/health-topics/ • Fall prevention suggestions for seniors ug2329spec#tp21184 Finding Balance BC https://findingbalancebc.ca • Risk assessment tools and fall prevention courses for practitioners • Multilingual educational resources for seniors • Fall prevention campaign toolkit Transport incidents Screening and Brief http://vghtrauma.vch.ca/injury-prevention/sbirt • Videos about the SBIRT program Intervention Training for http://vghtrauma.vch.ca/new-sbirt-clinical-tools/ (Screening, Brief Intervention, and Trauma Care Providers Referral to Treatment) • Patient pamphlets • Screening tools for practitioners • Clinical tools Unintentional poisoning Parachute Canada www.parachutecanada.org • Information for parents and others regarding many injury topics pertinent to children Self-harm Crisis Intervention and https://crisiscentre.bc.ca • Training in suicide prevention and skillful Suicide Prevention responding for service providers Centre of British • Crisis chat services Columbia • Mindfulness training • Support for families Foundry https://foundrybc.ca • Support and services for youth and their families

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costs over time, the overall annual in- tional poisoning might be explained suffering, economic dependence, and crease has slowed from 2.6% (2004 in part by the opioid crisis in BC and social isolation that have a profound to 2010) to 1.3% (2010 to 2013), sug- the rising number of drug overdoses impact on affected individuals, fam- gesting that injury prevention inter- and deaths since 2006. Following the ilies, and communities. ventions are having an effect. After public health emergency declared in publication of the Economic Burden BC in April 2016,21 many programs Summary of Injury in Canada report,10 policy- were developed to prevent drug The purpose of this study was to quan- makers in BC acknowledged the ne- overdoses and provide emergency tify the economic and societal burden cessity of investment in prevention to response to victims, including the of injury in BC and provide compre- reduce the impact of injury. Follow- Overdose Prevention Outreach Team hensive data to support physician dis- ing several years of concerted effort of the Vancouver Area Network Drug cussions with patients and encourage and planning, a public health report was published15 and programs were launched, including Preventable, a province-wide injury prevention social marketing campaign.16 One program that may have con- While a wide range of recent and tributed to the decrease in self-harm ongoing efforts have addressed injury costs from 2010 to 2013 is the Crisis Intervention and Suicide Preven- prevention in BC, rising costs indicate tion Centre of British Columbia.17 that strategic action is required. The centre provides emotional support to youth, adults, and seniors in distress and offers immediate access to websites and chat lines—an early intervention approach designed to prevent a crisis from escalating and Users that facilitates access to life- engagement with injury prevention turning into a tragedy. Another exam- saving naloxone kits.22 These actions initiatives. Investing in primary pre- ple of early intervention is the SBIRT have slowed the rate of unintentional vention has the greatest potential to (Screening, Brief Intervention, and poisoning from opioids21 and contrib- reduce the incidence and severity of Referral to Treatment) program18 im- uted to greater awareness of risks. injuries, including premature death, plemented at the Vancouver General The increase in costs for falls and produce significant savings in Hospital Trauma Centre in 2014.19 might be explained in part by the health care costs.25-27 The program addresses alcohol as a aging population in BC.23 The need While a wide range of recent and risk factor, identifies those at risk, and to reduce falls is recognized on the ongoing efforts have addressed injury connects them with appropriate ser- Health Link BC website, where fall prevention in BC, rising costs indi- vices in an effort to reduce alcohol- prevention resources are available in cate that strategic action is required to related injuries ranging from motor eight languages.24 achieve further reductions in uninten- vehicle crashes and pedestrian injur- tional poisoning, self-harm, transport ies to falls and assaults. Despite these Limitations of study incidents, and falls, as injuries from achievements, the cost of transport- The human capital approach used to these produce most of the economic related and self-inflicted injuries re- measure indirect costs in this study and societal burden. Physicians and mains high, indicating that continued produced a conservative estimate be- other health care professionals are focus and efforts to improve preven- cause costs were assigned only for ideally positioned to participate in tion are needed to achieve further re- injured people age 15 to 64 and not implementing the provincial action ductions. This is especially the case for those who leave the workforce to plan for injury prevention and to sup- with unintentional poisoning hospi- provide care for injured family mem- port priority prevention initiatives in talizations and deaths, the majority of bers. Furthermore, we were not able their own communities and provide which are caused by drugs.20 to quantify and include costs associ- appropriate patient counseling during The increase in costs for uninten- ated with injuries such as pain and office visits.

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9. Peden M, Oyegbite K, Ozanne-Smith J, et ferral to treatment (SBIRT) into clinical Competing interests al. (eds).World report on child injury pre- practice settings: A brief review. J Psycho- None declared. vention. Geneva: World Heal Organiza- active Drugs 2012;44:307-317. tion; 2008. Accessed 6 June 2018. http:// 19. Vancouver Coastal Health. VGH Trauma References apps.who.int/iris/bitstream/10665/ Services. SBIRT. Accessed 6 June 2018. 1. Statistics Canada. Leading causes of 43851/1/9789241563574_eng.pdf. http://vghtrauma.vch.ca/injury-preven death, total population, by age group. Ac- 10. SMARTRISK. The Economic Burden of tion/sbirt. cessed 6 June 2018. www.statcan.gc.ca/ Injury in Canada. Toronto: SMARTRISK; 20. BC Injury Research and Prevention Unit. tables-tableaux/sum-som/l01/cst01/ 2009. Accessed 5 January 2018. www Poisoning. Accessed 6 June 2018. www hlth36a-eng.htm. .parachutecanada.org/downloads/ .injuryresearch.bc.ca/quick-facts/ 2. Belton K, Pike I, Heatley J, et al. The cost research/reports/EBI2009-Eng-Final.pdf. poisoning/#info. of injury in Canada. 2015. Accessed 6 11. Miller TR, Pindus NM, Douglass JB, Ross- 21. BC Centre for Disease Control. The BC June 2018. www.parachutecanada.org/ man SB. The databook on nonfatal injury: public health opioid overdose emergency. downloads/research/Cost_of_Injury Incidence, costs, and consequences. March 2017. Accessed 6 June 2018. -2015.pdf. Washington DC: The Urban Institute; www.bccdc.ca/resource-gallery/Docu 3. Hodgson TA, Meiners MR. Cost-of-illness 1995. Accessed 6 June 2018. http:// ments/Educational Materials/Epid/Other/ methodology: A guide to current practices webarchive.urban.org/publications/ Public Surveillance Report_2017_03_17 and procedures. Milbank Mem Fund 105980.html. .pdf. QHeal Soc 1982;60:429-462. 12. Piedt S, Rajabali F, Turcotte K, et al. The 22. Vancouver Coastal Health. New programs 4. BC Injury Research and Prevention Unit. British Columbia casebook for injury pre- to combat overdose crisis. Accessed 6 Economic burden of injury in British Co- vention. August 2015. Accessed 6 June June 2018. www.vch.ca/about-us/news/ lumbia. August 2015. Accessed 6 June 2018. www.injuryresearch.bc.ca/wp news-releases/new-programs-to-com 2018. www.injuryresearch.bc.ca/wp -content/uploads/2015/08/BCIRPU bat-overdose-crisis. -content/uploads/2015/08/BCIRPU -Casebook-2015.pdf. 23. BC Stats, Ministry of Technology, Innova- -EB-2015.pdf. 13. Provincial Health Services Authority. Man- tion and Citizens’ Services. Population 5. Gabbe BJ, Lyons RA, Fitzgerald MC, et al. date letter 2017-2018. Accessed 6 June projection. Accessed 6 June 2018. Reduced population burden of road trans- 2018. www.phsa.ca/about-site/Docu file:///C:/Users/User/Downloads/ port-related major trauma after introduc- ments/2017 PHSA mandate letter.pdf. BCProj1705.pdf. tion of an inclusive trauma system. Ann 14. Gielen AC, McDonald EM, Wilson ME, et 24. Province of British Columbia. Resources Surg 2015;261:565-572. al. Effects of improved access to safety to learn more. Accessed 6 June 2018. 6. Cameron J, Hunter P, Jagals P, Pond K counseling, products, and home visits on www2.gov.bc.ca/gov/content/family (eds). Valuing water, valuing livelihoods: parents’ safety practices: Results of a ran- -social-supports/seniors/health-safety/ Guidance on social cost-benefit analysis domized trial. Arch Pediatri Adolesc Med disease-and-injury-care-and-prevention/ of drinking-water interventions, with spe- 2002;156:33-40. fall-prevention/resources-to-learn-more. cial reference to small community water 15. Kendall PRW. Investing in prevention: Im- 25. Gyllensvärd H. Cost-effectiveness of in- supplies. London: World Health Organiza- proving health and creating sustainability. jury prevention—a systematic review of tion and IWA Publishing; 2011. Accessed The Provincial Health Officer’s special re- municipality based interventions. Cost Eff 6 June 2018. http://apps.who.int/iris/ port. August 2010. Accessed 6 June Resour Alloc 2010;8:17. bitstream/handle/10665/44635/ 2018. www.health.gov.bc.ca/library/pub 26. Bergen G, Pitan A, Qu S, et al. Publicized 9781843393108_eng.pdf?sequence=1. lications/year/2010/Investing_in_preven sobriety checkpoint programs. Am J Prev 7. Rehm J, Mathers C, Popova S, et al. Glob- tion_improving_health_and_creating Med 2014;46:529-539. al burden of disease and injury and eco- _sustainability.pdf. 27. Naumann RB, Dellinger AM, Zaloshnja E, nomic cost attributable to alcohol use and 16. Pike I, Scime G, Lafreniere K. Preventable: et al. Incidence and total lifetime costs of alcohol-use disorders. Lancet 2009; A social marketing campaign to prevent motor vehicle-related fatal and nonfatal 373(9682):2223-2233. injuries in British Columbia, Canada. Inj injury by road user type, United States, 8. Bhalla K, Harrison JE. Burden calculator: Prev 2012;18(suppl 1):A176.1-A176. 2005. Traffic Inj Prev 2010;11:353-360. A simple and open analytical tool for esti- 17. About us. Crisis Centre. Accessed 6 June mating the population burden of injuries. 2018. https://crisiscentre.bc.ca/about-us. Inj Prev 2016;22(suppl 1):i23-6. 18. Agerwala SM, McCance-Katz EF. Integrat- ing screening, brief intervention, and re-

364 bc medical journal vol. 60 no. 7, september 2018 bcmj.org worksafebc

Lower-extremity radiographs: Weight-bearing, please

njured workers often require im- used to assess patients for subtle liga- mains is, is it weightbearing, weight- aging for joint-related trauma or mentous disruptions, such as Lisfranc bearing, or weight bearing? Maybe Ipain. After a history and examina- injuries not seen on initial films.10 just write “WB” or “standing,” and tion, plain radiographs are often the The standard radiographic for OA avoid the conundrum. next step in investigating a patient’s of the knee includes weight-bearing —Derek Smith, MD, FRCSC musculoskeletal complaints. Patients AP, lateral, skyline views.11 A weight- WorkSafeBC Orthopaedic with possible surgical pathology, such bearing tunnel (Rosenberg) view may Specialist Advisor as osteoarthritis, may be referred to increase detection.11 Weight-bearing an orthopaedic surgeon, who often References repeats the initial films. While there 1. Phillipon MJ, Briggs KK, Goljan P, et al. may be other reasons for requesting Comparison of radiographic hip joint Patients with any new X-rays, such as time elapsed space in weight bearing and supine X-rays hip dysplasia have been since first films, specific views, or in patients with hip pathology. Osteo accessibility, a very common reason shown to be more arthritis Cartilage 2013;21:S204. is that the original films were not or- accurately assessed for 2. Courtney PM, Melnic CM, Howard M, et dered weight-bearing. OA with standing films. al. A systematic approach to evaluating So why weight-bearing X-rays? hip radiographs – A focus on osteoarthri- For the hip, there are some authors tis. J Orthopedics Rheumatol 2014;1:1-7. who feel supine radiographs are views have been shown to more ac- 3. Fuchs-Winkelmann S, Peterlein CD, sufficient,1 but many consider a curately assess JSN than supine films. Tibesku CO, Weinstein SL. Comparison of weight-bearing AP pelvis film to be They can also better demonstrate pelvic radiographs in weightbearing and standard.2,3 Although osteophytes malalignment, such as varus or val- supine positions. Clin Orthop Relat Res can be seen on both, the discussion is gus. For patients > 40 years old with 2008;466:809-812. on the best evaluation of joint space > 50% JSN on weight-bearing films 4. Gold GE, Cicuttini F, Crema MD, et al. narrowing (JSN). The Osteoarthritis referred with only an MRI, the latter OARSI clinical trials recommendations: (OA) Research Society International is found not useful in the majority of Hip imaging in clinical trials in osteoarthri- noted that while standing films have cases.12 tis. Osteoarthritis and Cartilage 2015; a theoretical advantage of evaluat- All this highlights some of the im- 23:716-731. ing JSN, they can be assessed accu- portance of obtaining weight-bearing 5. Younger AS, Sawatzky B, Dryden P, et al. rately supine as well for normal hip X-rays. But the issue is hardly lim- Radiographic assessment of adult flat- morphology. Patients with any hip ited to Canada. A 2012 British study foot. Foot Ankle Int 2005;26:820-825. dysplasia have been shown to be found no patients with knee issues 6. Lever CJ, Hennessy MS. Adult flat foot more accurately assessed for OA with referred from a GP’s office to an deformity. Orthopaedics Trauma 2016; standing films.4 orthopaedic clinic had had weight- 30:41-50. Standing foot and ankle X-rays bearing films. Another 2014 British 7. Hayes BJ, Gonzales T, Smith JT, et al. are the standard for assessing condi- study found 98% of nontraumatic Ankle arthritis: You can’t always replace it. tions such as flat foot, ankle arthri- knee radiographs requested by GPs J Am Acad Orthop Surg 2016;24:e29-e38. tis, and hallux valgus as well as other were non-weight-bearing.13 The for- 8. Wagner P, Wagner E. Is the rotational de- conditions.5-9 Non-weight-bearing mer recommended all requests to the formity important in our decision-making images are often felt to be misleading, Radiology Department for knee ra- process for correction of Hallux Valgus while standing films allow better stan- diographs from GPs to be standard- Deformity? Foot Ankle Clin 2018;23: dardization and reliability in assess- ized as weight-bearing while the 205-217. ment between studies and patients.9 latter advised GPs to order them as 9. Barg A, Pagenstert GI, Hugle T, et al. Ankle Weight-bearing radiographs are also weight-bearing. osteoarthritis etiology, diagnostics, and In the end, requesting weight- classification. Foot Ankle Clin 2013;18: This article is the opinion of WorkSafeBC bearing radiographs for elective as- 411-426. and has not been peer reviewed by the sessment of the lower extremity is 10. Weatherford BM, Anderson JG, Bohay BCMJ Editorial Board. obvious. The only question that re- Continued on page 367

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Figure. council on health promotion

Increasing physical activity in patients: By asking the questions, we can make a difference ake a moment and ask your- whereas in BC that percentage was also been shown to be effective.4 self, how many days per week significantly higher, 64.9%.2 A large study by Kaiser Perma- Tdo you engage in moderate (or These data are encouraging for nente involving almost 1.8 million higher intensity) physical activities BC, but because they come from a patients found that by promoting the (like a brisk walk), and then, on those self-reported survey questionnaire, systematic collection of these ques- days, how many minutes do you en- they likely overrepresent the number tions into EMRs they were able to gage in activity at that level? Multiply identify physical activity history in the numbers and see if you meet the the charts of 86% of patients after Canadian Physical Activity Guide- 18 months of effort.4 A subsequent lines of 150 minutes of moderate-to- The Canadian study involved 696 267 eligible pa- vigorous physical activity per week. Medical Association tients and 1 569 324 visits.5 Patients How long did that take? Did it encourages physicians to were seen in centres that either were make you reflect on your physical ac- promote physical activity, or were not systematically collect- tivity habits? ing these two simple physical activ- as physicians are lifestyle Both physicians and the public ity questions into patients’ EMRs. are looking for ways to engage in pre- change agents who The centres that were systematically ventive health measures. Many phy- remain the preferred collecting physical activity history sicians are appropriately concerned source of health showed small but significant changes that addressing physical activity will information for in weight loss in obese patients and take too long, but it doesn’t necessar- many people. improved HbA1c values in patients ily have to. with diabetes. Additionally, there was The Canadian Medical Associa- a 12% absolute increase in the num- tion (CMA) encourages physicians ber of patients who reported having to promote physical activity, as phy- of people who are adequately physi- received exercise counseling from sicians are lifestyle change agents cally active. Even if we take the sur- their physician. who remain the preferred source of vey responses at face value, it means By simply asking the questions health information for many people.1 there are over 1.3 million British Co- we can start to have an impact. Physi- Last year, the CMA’s General Council lumbian adults who are physically in- cal activity seems to have a dose- passed a resolution supporting the in- active. This costs the BC health care response effect: increasing physical clusion of physical activity questions system approximately $335 million activity even by 10 minutes per day in the vital signs section of EMRs. dollars per year.3 results in a substantial improvement Doctors of BC passed a similar reso- BC physicians have an opportun in mortality and morbidity, and this lution earlier this year. ity to continue building on existing effect is greatest when targeting those British Columbians have often strategies that promote lifestyle mod- who are sedentary.6 led the country in healthy living. Data ification and healthy living. The goal No matter how you scored at the from the 2017 Canadian Community of the Doctors of BC resolution to in- beginning of this article, hopefully Health Survey revealed that in Can- corporate exercise history as part of you are motivated to find an extra 10 ada, 57.4% of adults self-reported the vitals section of EMRs is to fur- minutes in your day for a brisk walk meeting the national guidelines, ther engage physicians and the public and a minute to discuss the same with on the importance of physical activity. your next patient. This article is the opinion of the Athletics The two physical activity ques- —Tommy Gerschman, MD, and Recreation Committee, a subcommit- tions at the start of this article are an FRCPC, MSc tee of Doctors of BC’s Council on Health example of a validated exercise his- Promotion, and is not necessarily the opin- tory screening tool that is quick and References ion of Doctors of BC. This article has not simple to use. When systematically 1. Canadian Medical Association. Healthy been peer reviewed by the BCMJ Editorial asked in all patient encounters and behaviours: promoting physical activity Board. entered into the patient’s EMR it has and healthy eating. 2015. Accessed 31

366 bc medical journal vol. 60 no. 7, september 2018 bcmj.org cohp

July 2018. http://policybase.cma.ca/dbtw -wpd/Policypdf/PD15-12.pdf. 2. Statistics Canada. Canadian health char- acteristics, annual estimates. Table 13-10- Directory of 0096-01. Accessed 31 July 2018. www senior staff 150.statcan.gc.ca/t1/tbl1/en/tv .action?pid=1310009601. Mr Allan Seckel Mr Sunny Jassal 3. Government of British Columbia. Active Chief Executive Officer Network Operations Manager people, active places: British Columbia 604 638-2888; 604 638-2897; physical activity strategy. November [email protected] [email protected] 2015. Accessed 31 July 2018. www Ms Marisa Adair Mr Adrian Leung .health.gov.bc.ca/library/publications/ Executive Director of Director, Specialist Services year/2015/active-people-active-places Communications and Public Committee Affairs; 604 638-2809; 604 638-2884; -web-2015.pdf. [email protected] [email protected] 4. Coleman KJ, Ngor E, Reynolds K, et al. Initial validation of an exercise “vital sign” Mr Jim Aikman Ms Sinden Luciuk Executive Director of Economics Executive Director of in electronic medical records. Med Sci and Policy Analysis; 604 638-2893 Members’ Products and Sports Exerc 2012;44:2071-2076. [email protected] Services 5. Grant, RW, Schmittdiel, JA, Neugebauer, 604 638-2886; Dr Sam Bugis [email protected] RS, et al. Exercise as a vital sign: A quasi- Executive Director of Physician experimental analysis of a health system and External Affairs Mr Tod MacPherson intervention to collect patient-reported 604 638-8750; Director of Negotiations exercise levels. J Gen Intern Med 2014; [email protected] 604 638-2885; [email protected] 29:341-348. Dr Andrew Clarke 6. Thornton JS, Frémont P, Khan K, et al. Executive Director, Ms Afsaneh Moradi Physician Health Program Director, Community Physical activity prescription: A critical op- 604 398-4301; Partnership & Integration portunity to address a modifiable risk fac- [email protected] 604 638-5845; tor for the prevention and management of [email protected] Ms Amanda Corcoran chronic disease: A position statement by Chief People & Technology Officer Ms Cindy Myles the Canadian Academy of Sport and Exer- 604 638-2812; Director, Facility Physician cise Medicine. Br J Sports Med 2016; [email protected] Engagement 50:1109-1114. 604 638-2834; Ms Cathy Cordell [email protected] General Counsel 604 638-2822; Ms Carol Rimmer [email protected] Director, Technology and Operations, Doctors worksafebc Ms Margaret English Technology Office Continued from page 365 Director, Shared Care Committee 604 638-5775; DR. Management of tarsometatarsal joint 604 638-2947; [email protected] [email protected] injuries. J An Acad Orthop Surg 2017; Mr Paul Straszak 25:469-479. Ms Alana Godin Executive Director of Director, Community Practice and 11. Wright RW, MARS Group. Osteoarthritis Negotiations and Chief Quality classification scales: Interobserver reli- Negotiator 250 218-3924; 604 638-2869; ability and arthroscopic correlation. J Bone [email protected] [email protected] Joint Surg Am 2014;96:1145-1151. Dr Brenda Hefford 12. Adelani MA, Mall NA, Brophy RH, et al. Ms Sarah Vergis Executive Director, Community Chief Financial Officer The use of MRI in evaluating knee pain in Practice, Quality, and Integration 604 638-2862; patients aged 40 years and older. J Am 604 638-7855; [email protected] [email protected] Acad Orthop Surg 2016;24:653-659. Ms Deborah Viccars 13. Chen A, Balogun-Lynch J, Aggarwal K, et Mr Rob Hulyk Director of Policy al. Should all elective knee radiographs Director of Physician Advocacy 604 638-7865; 604 638-2883; requested by general practitioners be per- [email protected] [email protected] formed weight-bearing? SpringerPlus 2014;3:707.

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Helping patients and families navigate dementia: The Kootenay Boundary Dementia Roadmaps s Canada’s population ages, families about signposts (the events able for distribution by other divi- dementia diagnoses are on and incidents that may occur as a re- sions and communities. Over 1500 A the rise—there are currently sult of symptoms) to look for over copies have been distributed in com- 564 000 Canadians living with de- the course of their loved one’s de- munities in Kootenay Boundary and mentia,1 and 25 000 new cases are mentia journey, they would be better East Kootenay; in the Abbotsford, diagnosed every year.1 A diagnosis of equipped to understand what happens South Okanagan Similkameen, and dementia, known as “the disease of a during each stage of the disease, and Vancouver Divisions of Family Prac- thousand goodbyes,” is life altering for provide the best care possible as these tice; and in the community of Cam- patients, their families, and their care- changes unfold. rose in Alberta. givers, and creates a need for support Both the family roadmap and the The Dementia Roadmap for Prac- and guidance as they help their loved practitioner roadmap split the pro- titioners and the Dementia Road- one navigate their dementia journey. gression of dementia into four stages: map for Families are available on As a patient’s disease progresses, • Early dementia the Kootenay Boundary Division family members often turn to GPs for • Middle dementia website at www.divisionsbc.ca/kb/ information and resources. To ensure • Late dementia residentialcare. doctors are equipped with all the nec- • Actively dying Divisions and physicians who essary information to support patients For each stage, readers are pro- wish to distribute the Dementia and their families through these con- vided with a list of symptoms and Roadmaps may contact kbdoctors@ versations, the Kootenay Boundary impacts that may be displayed by the divisionsbc.ca for permission to do so. Division of Family Practice created patient at that stage of disease, fol- —Afsaneh Moradi the Dementia Roadmap for Practitio- lowed by a list of potential signposts. Director, Community ners and the Dementia Roadmap for The practitioner roadmap then pro- Partnership and Integration Families as part of their work on the vides a list of questions physicians GPSC Residential Care Initiative.2 may ask family members about their References The Dementia Roadmaps are the loved one’s safety and comfort, and a 1. Alzheimer Society Canada. Dementia brainchild of Dr Trevor Janz, a local list of treatments and next steps. The numbers in Canada. Accessed 11 July physician and member of the Koote- roadmap for families and caregiv- 2018. http://alzheimer.ca/en/Home/ nay Boundary Division. Dr Janz theo- ers provides advice and suggestions About-dementia/What-is-dementia/ rized that if GPs were able to educate for keeping their loved one safe and Dementia-numbers. comfortable. 2. General Practice Services Committee. This article is the opinion of the GPSC and In the spirit of collaboration, the Residential Care. Accessed 11 July 2018. has not been peer reviewed by the BCMJ Kootenay Boundary Division has www.gpscbc.ca/what-we-do/longitud Editorial Board. made the Dementia Roadmaps avail- inal-care/residential-care.

Coming soon: GPSC Panel Development Incentive

This fall, the GPSC is introducing a new incentive to support family doctors manage Phases of panel management their patient panels. Valued at about $6000, the Panel Development Incentive will 1. Empanelment consist of three payments: Ensure that their list of active patients is accurate and • Payment 1 can be claimed after an eligible family doctor commits to completing the up-to-date, and that their panel size is assessed to three phases of panel management within 12 months from claiming the incentive. balance capacity. • Payment 2 can be claimed after completion of phases one and two of panel 2. Initial panel cleanup management. Develop accurate and up-to-date registries for three to five chosen disease indicators. • Payment 3 can be claimed after completion of phase three of panel management. 3. Panel optimization To be eligible for the new incentive, family doctors must be using an EMR system to Develop accurate and up-to-date registries for 10 to 15 manage patient information and have completed the GPSC PMH Assessment in the disease indicators to support planned proactive care. 12 months before applying for the incentive. Clinic staff roles are assigned and appropriate staff time Learn more: www.gpscbc.ca is dedicated to ongoing panel management.

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News continued from page 350 The Vancouver Medical Staff Hall of Honour (VCH): Remember the heroes of the past BC Medical Journal Writing Prizes

Photograph by Jennifer Laxamana J.H. MacDermot [L-R] Drs Simon Rabkin, Eric Yoshida, and Stephen Nantel inside the VCH Hall of Honour. Writing Award The Vancouver Medical Staff Hall of Dr Sheldon (Shelly) Naiman (1937– The BCMJ invites writing Honour of Vancouver Coastal Health 2016) – BC’s first clinical hematolo- submissions from student was created, with the approval of gist and first head of Hematology, authors, and each year awards the hospital administration, to com- VGH. a prize of $1000 for the best memorate both the 110th anniversary Dr George Fredrick (Fritz) Strong medical student submission of the Vancouver General Hospital (1897–1957) – former chief of medi- accepted for print and online (2016), and the 150th anniversary cine, VGH, and creator of the G.F. publication. Students are of Canada’s Confederation (2017). Strong Rehabilitation Hospital. encouraged to submit full-length Although it is appreciated that all Dr Donald Paty, MSM (civil div- scientific articles and essay health care professionals at VGH and ision) (1936–2004) – pioneer in mul- pieces for consideration. its allied institutions have provided tiple sclerosis and former head of The J.H. MacDermot outstanding service since 1906, the Neurology, UBC. Writing Award, sponsored intention of the Vancouver Commun- The VCH Hall of Honour is physic- by Doctors of BC, honors ity of Care Medical, Dental, and Al- ally located on the main floor of the John Henry MacDermot, who lied Staff Association (VMDAS) is to Jim Pattison Pavilion, VGH, and was served as editor for 34 years recognize and honor those who have unveiled prior to the annual VMDAS (1932–1968), overseeing the provided exceptional leadership and awards ceremony at the end of June publication’s transition from the dedicated clinical/academic service 2018. The Hall is the first of its kind Vancouver Medical Association that has profoundly benefited the in Western Canada and, along with Bulletin to the BCMJ in 1959. residents of BC as well as advanced the Canadian Medical Hall of Fame Dr MacDermot also served as the practice of medicine/surgery in in London, Ontario, is one of the few BCMA president in 1926. this province. In doing so, the Hall’s of its kind in the country. It is hoped inductees have brought great distinc- that the Hall and its inducted mem- BCMJ Blog tion and honor to VGH and its allied bers will be a source of inspiration institutions. to physicians, surgeons, and allied Writing Prize In the inaugural induction ceremo- health care professionals in the years To encourage med students to ny, held at VGH in February 2018, the to come. take their first foray into medical inaugural members of the Hall were: —Eric M. Yoshida, writing, the BCMJ awards an Dr Wallace B. Chung, CM, OBC – OBC, MD, FRCPC additional writing prize of $250 Professor emeritus of Surgery, UBC, Hall of Honour Committee Chair twice per year for the best 200- former head of General and Vascular —Marshall Dahl, MD, PhD, FRCPC to 400-word blog submission Surgery, UBC Hospital. Past Chair VMDAS accepted for online publication. Dr Felix Durity, OBC – Professor —Stephen Nantel, MD, FRCPC emeritus of Neurosurgery, UBC, for- Hall of Honour Committee Member For submission guidelines and mer head of Neurosurgery, VGH. —Jennifer Laxamana contest deadlines, please visit Dr Robert E. McKechnie, CBE – Administrative Assistant, VMDAS www.bcmj.org/jh-macdermot- acclaimed pioneering surgeon, VGH, —Simon W. Rabkin, MD, FRCPC writing-awards. and longest-serving UBC chancellor. Chair VMDAS

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Building interprofessional maternity care in BC

regnant women in some BC communities as they embark on lo- have clearly defined the various roles communities can face frag- cal relationship-building and infor- and now regularly communicate and P mented and siloed perinatal mation-finding activities to improve cooperate. care, split between family doctors, interprofessional collaboration and In the South Okanagan, the pro- registered midwives, and obstetri- create more patient-centred care. cess of engagement has encompassed cians—who may not communicate, It has long been known that ex- all providers, and established a new collaborate, or even trust each other. pecting various providers to “just pilot perinatal clinic at the Penticton For pregnant women, such a situ- collaborate!” simply doesn’t work. It Regional Hospital, which includes ation can be stressful and confusing, takes more than that. It takes a process four maternity GPs and a registered and can mar their maternity care jour- of trust-building engagement that has midwife. Holding weekly meetings to ney. Should they choose a midwife, maternity providers getting to know discuss cases and creating standard- GP, or OB? What if their pregnancy each other, clarifying scopes of prac- ized protocols have fostered reward- develops complications—how is care tice and roles, dispelling myths and ing collaborative relationships and shared or referred? In some commu- misperceptions, and learning about clarified patient pathways among all nities, the situation is complicated by the needs of patients and each mater- local maternity providers, not only too few providers for all the pregnant nity care provider in the region. those who work at the clinic. A sur- women needing care. In other com- With this information and that vey of providers found the process munities, too many providers com- trust, maternity professionals can has increased trust among maternity pete with each other for patients. begin working together to co-create care providers by 60%, and contribut- For providers, these issues con- community-based solutions. ed to the more sustainable delivery of tribute to professional stress and dis- local maternity services because care satisfaction, burnout, and even the Communities is collaborative, not competitive. personal decision to stop providing leading the way In Kootenay Boundary, where maternity care, which can then under- In the last 5 years, a few commun- travel can be a significant barrier for mine the sustainability of all mater- ities—Comox, Penticton/South maternity care, provider collabora- nity services in the region. Okanagan, and Kootenay Boundary— tion has resulted in the development have led the way in piloting process- of telematernity technology, meaning Building trusting driven forms of engagement, which that patients can now meet with their collaborative teams have included needs-assessment sur- GP and maternity provider through a Research has shown that effective veys of both providers and patients, virtual visit in their GP’s office. Ad- interprofessional collaborative (IPC) patient journey-mapping, and meet- ditionally, a collaborative approach maternity care increases access to care, ings and events to promote dialogue, was used to develop a perinatal men- improves quality, and enhances care relationship-building, and solution- tal health program for women at risk provider satisfaction and retention.1-3 finding. Each community developed of depression or anxiety. But how can providers realisti- solutions tailored to local needs. cally create a more collaborative net- In Comox, through events such as What’s next? work—one that puts patients’ needs at a World Cafe, providers learned that Now seven other communities— the centre while improving the work- they have more in common than the Thompson, Sea-to-Sky, Nanaimo, ing environment and relationships for differences they once perceived, and Chilliwack, Surrey/North Delta, Van- all the care providers involved? with this understanding, cooperating couver, and the East Kootenays—have Helping answer that question is to co-develop local solutions became embarked on similar engagement pro- the rationale behind a Shared Care easier. Examples of those solutions cesses with seed funding from Shared initiative aligned with other maternity included creating a well-defined, Care, using some of the lessons learn- work of the GPSC, the Rural Coor- easy-to-navigate patient pathway; ed from Comox, South Okanagan, and dination Centre of BC, and Perinatal and piloting group prenatal care that Kootenay Boundary. The majority of Services BC. Called the Maternity brings midwifery and family practice those communities are in the action Network, the initiative aims to sup- patients together for medical care, ed- phase of their projects, with providers port maternity care providers in BC ucation, and peer support. Providers Continued on page 373

370 bc medical journal vol. 60 no. 7, september 2018 bcmj.org obituaries

Dr Andrew Burger Murray Dr Murray Allen Peglar play with local bands. He fished, hunt- 1927–2018 1941–2018 ed, and scuba-dived. He embraced Dr Murray, a Murray put up many adventures and misadventures graduate of the a strong fight while working toward his goal of be- University of against Parkin- coming a doctor. Cape Town and son disease, but After graduating from med school an alumnus of passed away on in 1969, Murray drove across Canada the Boston 3 April 2018. to work in Vancouver with the World Children’s He is sur- Health Organization. He discovered Hospital, was vived by his Langley and decided that was where the first pediat- wife, Juanita; he would hang his hat and shingle. He ric subspecialist in Vancouver who his sons, Bruce (Michael) and Mur- was well respected for his 31 years of limited his practice to children’s asth- ray (Cory); stepson, Scott Napier practice and privileges at the Lang- ma and allergies. He subsequently be- (Lenora); and his seven grandchil- ley Memorial Hospital. He reluctant- came a professor of pediatrics at BC dren, Kate, Emma, Charlotte, Ben, ly retired in 2001, 6 years after his Children’s Hospital. There he estab- Malcolm, Ashley, and Ryan. He is diagnosis of Parkinson disease. He lished the Division of Allergy and be- also survived by his sisters, Ann would always talk about how much came its first head. He published the (George) Rodger and Barbara (Ron) he missed medicine. first controlled study showing that Hasan; his nephews, Peter and David Murray loved the romantic, Wild asthma in mite-sensitive children (Melanie) Rodger; and niece, Adri- West cowboy history of BC. He often could be improved, and bronchial re- enne (Adrian) Cristini. Murray was said that he must have been a cowboy activity decreased, if their bedroom predeceased by his father, Rev Bruce in a previous life. He enjoyed spend- was made dust-free. He was also the Peglar, and mother, Ethel Peglar. ing time outdoors, hunting and fish- first to show that asthma in children Born in Mount Forest, Ontario, to ing with friends, watching the local was aggravated if the parents smoked a naval chaplain, Murray grew up on Langley Rugby boys play, and meet- in the house. both the east and west coasts of Can- ing with “table 1” at the Murrayville Dr Murray retired in 1992, but ada. He attended Glenlyon Prepara- Pub for Monday Night Football. He until 1999 he continued to publish tory School in Victoria, BC, where was involved with Ducks Unlimited, research articles based on the data he excelled at sports and studies, win- the BC and Canadian Wildlife Fed- he had accumulated. In 1992 he also ning a 5-year scholarship to Ridley erations, and the Steelhead Society attended art school. He continued College in St. Catharines, Ontario. of BC. to paint, hike, and kayak for many He was accepted after graduation to His favorite place was his cabin years. He is survived by his wife, pre-med at the University of Toronto. at Gun Lake, where he would work Molly, and his daughter, son, and five In Halifax, he worked in the pathol- hard on his property, ride his quad up grandchildren. ogy lab at the Victoria General Hos- and down the mountains with the Gun —Annie Davison pital, and completed his BSc and BA Lake gang, or sit on the dock with a London, England degrees while awaiting acceptance beer in hand, dog by his side, and to Dalhousie Medical School. He simply enjoy the beauty of nature. He was president of the Phi Chi Medical loved his old tugboat trips in the Gulf Recently deceased Fraternity and compared his time in Islands, motorcycle trips across Can- physicians the fraternity to Animal House, star- ada and the US, and winter vacations If a BC physician you knew ring John Belushi. Murray would roar in Mexico, but the lake was his place. well is recently deceased, with laughter each time he watched it Murray was a strong, take-charge, consider submitting a piece for because it reminded him so much of go-for-it kind of man. Undoubtedly, our obituaries section in the his own fraternity days. he could be stubborn at times. We BCMJ. Send the content (up to Murray always followed his heart. will miss him and his “Murray-way” 500 words) and high resolution He loved music, played guitar, and of doing things. photo by email to journal@ sang. He formed a bluegrass group —Murray Peglar doctorsofbc.ca. and would drive to Peggy’s Cove in Calgary, AB his sports car or on a motorcycle to

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 371 bc centre for disease control

Weighing the options: Two shingles vaccines available for older adults bout one in three Canadians zoster but only 38% (95% CI, 25-48) lower) for those 70 and older.5,6 Effi- will develop shingles (zos- in those aged 70 and older (median cacy against PHN was 91% (95% CI, A ter) in their lifetime (with follow-up time: 3.1 years), and 66.5% 75.9-97.7) for those 50 and older, and incidence increasing after 50 years of against post-herpetic neuralgia unaf- 89% for those 70 and older (95% CI, age), and up to 40% of zoster cases fected by age.2 This vaccine is given 68.7%-97.1%). This vaccine is ex- are associated with one or more com- as a single dose subcutaneously. In pected to have value for immunocom- plications, most prominently zoster postmarketing studies, waning of im- promised people who cannot receive ophthalmicus and post-herpetic neu- munity occurs beginning the first year the live vaccine, and while specific ralgia (PHN). PHN is more common indications for this subpopulation are in older people, affecting 4% to 15% not yet listed in the product mono- of zoster cases in people aged 50 to graph with studies being conducted 59, 7% to 26% of cases in people aged RZV is given in people infected with HIV, solid 60 to 69, and 14% to 29% of cases in as a 2-dose series tumors, organ transplant, and HSCT people 70 years and older.1 intramuscularly, 2 to 6 recipients, it is not contraindicated Zoster and its attendant complica- months apart. for the immunocompromised. The tions are preventable by vaccination, immune response following RZV ap- and two vaccines are approved for use pears durable with data available to 4 in Canada. The recently approved ad- years at this time and no statistically juvanted recombinant vaccine offers after vaccination, with limited re- significant declines observed. appreciably higher and durable pro- maining protection after 6 years; this Safety of RZV has been assessed tection rates and is associated with waning is more marked when the vac- in seven randomized clinical trials more, albeit tolerable, reactogenic- cine is given at older ages.3 While the with the largest studies referenced ity, and physicians should become fa- vaccine has some limited indications above having over 14 000 enrolled miliar with these differences in order in select individuals with immuno- older adults. Local reactions were to provide appropriate counseling to compromise, it is generally contrain- common, with a median duration of patients who are considering the vac- dicated in this group of patients. 2 to 3 days; 80% of subjects reported cine, which is available through the A non-live adjuvanted subunit vac- pain and 30% reported redness; grade private market. At present only On- cine (Shingrix®, GlaxoSmithKline 3 reactions (interfering with activi- tario offers publicly funded zoster Inc., varicella zoster virus glycoprotein ties of daily living) were reported by vaccine, having introduced the live E recombinant [RZV]) was approved 8.5% and 9.5% of recipients 70 and vaccine in 2016 for those aged 65 to by Health Canada in October 2017 for older, and 50 and older, respectively, 70. adults aged 50 and older.4 The adjuvant compared to 0.2% and 1.9% by the

The live attenuated zoster vaccine is unique to this vaccine (AS01B), and corresponding placebo recipients. (Zostavax II, Merck Canada Inc.) is composed of liposomes containing Systemic adverse events of fatigue approved in 2008 in a formulation two immunostimulants: 3-O-desacyl- and myalgia were reported in half of requiring freezer storage, has been 4'-monophosphoryl lipid A from Sal- recipients, and headache in 40%; me- marketed as a fridge-stable formula- monella minnesota combined with dian duration was 1 to 2 days. Grade tion in Canada since April 2014 and 1 mg of dioleoyl phosphatidylcholine 3 systemic events were reported by continues to be available on the pri- (DOPC) and 0.25 mg cholesterol, and 11.4% of vaccine recipients com- vate market. In the pivotal clinical Quillaja saponaria Molina. pared to 2.4% of placebo recipients, trial, this vaccine was found to have RZV is given as a 2-dose series and at lower frequencies in those 70 an efficacy of 64% (95% CI, 56-71) in intramuscularly, 2 to 6 months apart. and older (6% and 2%, respectively); persons aged 60 to 69 against incident The vaccine has performed well in these were more common after the clinical trials with 3-year vaccine ef- second dose. Serious adverse event This article is the opinion of the BC Centre ficacy against zoster at 97% in people rates were similar in vaccine and pla- for Disease Control and has not been peer aged 50 to 69 and 91% (a difference cebo groups, and none were consid- reviewed by the BCMJ Editorial Board. that is not statistically significantly ered vaccine related.

372 bc medical journal vol. 60 no. 7, september 2018 bcmj.org bccdc shared care

In a prepublication statement, the References Continued from page 370 Canadian National Advisory Com- 1. Kawai K, Gebremeskel BG, Acosta CJ. working together to bring local mittee on Immunization (NACI) rec- Systematic review of incidence and needs-based solutions to fruition. ommends that for those who have complications of herpes zoster: Towards A new round of Shared Care received the live vaccine or experi- a global perspective. BMJ Open 2014;4: funding will be available this fall for enced an episode of zoster, RZV can 1-18. applications for other communities be administered 1 year later.7 NACI 2. Oxman MN, Levin MJ, Johnson GR, et wanting to explore ways to improve further recommends that the live al. A vaccine to prevent herpes zoster and maternity care collaboration in their vaccine should be offered to those postherpetic neuralgia in older adults. N region. For more information, con- without contraindications only if the Engl J Med 2005;352:2271-2284. tact Nancy Falconer at nfalconer@ RZV cannot be given (e.g., due to 3. Dooling K, Guo A, Patel M, et al. Recom- doctorsofbc.ca. contraindications or unavailability). mendations of the Advisory Committee —Nancy Falconer The US Advisory Committee on Im- on Immunization Practices for Use of Shared Care Liaison, munization Practices (ACIP) recom- Herpes Zoster Vaccines. MMWR Morb Maternity Network mends preferential use of RZV over Mortal Wkly Rep 2018;67:103-108. —Lee Yeates, RM, MHM the LZV, while continuing to recom- 4. SHINGRIX Product Monograph. GlaxoS- Collaborative Practice mend that LZV may be used in im- mithKline Canada Inc. Date of Approval Consultant, Maternity Network munocompetent adults 60 and older.3 13 October 2017. Accessed 20 July Both NACI and ACIP recom- 2018. http://ca.gsk.com/media/1350 References mend that RZV may be given at the 788/shingrix_pm-2017-10-13.pdf. 1. Blanchard MH, Kriebs JM. A successful same visit as influenza vaccine and 5. Lal H, Cunningham A, Godeaux O, et al. model of collaborative practice in a uni- other vaccines intended for adults, Efficacy of an adjuvanted herpes zoster versity-based maternity care setting. including pneumococcal polysac- subunit vacation in older adults. N Engl Obstet Gynecol Clin North Am charide vaccine and tetanus-diph- J Med 2015;372:2087-2096. 2012;39:367-372. theria containing vaccines; a study 6. Cunningham A, Lal Hi, Kovac M, et al. 2. Harris SJ, Janssen PA, Saxell L, et al. Ef- with quadrivalent influenza vaccine Efficacy of herpes zoster subunit vac- fect of a collaborative interdisciplinary has been completed and showed no cine in adults 70 years of age or older. N maternity care program on perinatal out- interference, and studies with the Engl J Med 2016;375:1019-1032. comes. CMAJ 2012;184:1885-1892. other vaccines are in progress. 7. Public Health Agency of Canada. Nation- 3. Peterson WE, Medves JM, Davies BL, —Monika Naus, MD, MHSc, al Advisory Committee on Immuniza- Graham ID. Multidisciplinary collabora- FRCPC, FACPM, tion. Updated recommendations on the tive maternity care in Canada: Easier said Medical Director, use of herpes zoster vaccines. Advance than done. J Obstet Gynaecol Can Communicable Diseases and copy, June 2018, provided to provincial 2007;29:880-886. Immunization Service immunization programs. Pages 1-72.

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bc medical journal vol. 60 no. 7, september 2018 bcmj.org 373 cme calendar

ADULT CONGENITAL the determination of relevant clinical practice. Target audience: family CARDIOLOGY terminology in SNOMED CT in a physicians, pediatricians, nurses, resi- Vancouver, 29 Sep (Sat) variety of specialty areas, applicable dents. Accreditation: Up to 7.0 Main- The Adult Congenital Cardiology in to an international setting. SNOMED pro+/MOC Section 1 credits. This the Community event is the first of its CT Expo 2018 program offers (www update will be held at the SFU Segal kind in British Columbia. The event’s .snomedexpo.org) offers educational Building in downtown Vancouver. To main objective is to provide education tutorials and workshops at no addi- register and for more information, and support to care providers around tional cost to participants, and is please visit https://ubccpd.ca/course/ the province as they partner with the available for attendees to earn cred- allergy2018, call 604 675- 3777, or St. Paul’s Hospital Pacific Adult Con- its towards maintaining their CPHI- e-mail [email protected]. genital Heart (PACH) program in MS-CA designation through Digital providing care for these patients. Par- Health Canada. WORKSAFEBC PHYSICIAN ticipants are expected to recognize the EDUCATION CONFERENCE red flags in adult congenital heart dis- MINDFULNESS IN MEDICINE Victoria, 20 Oct (Sat) ease and to define a shared care mod- Molokai, HI, 13–20 Oct (Sat–Sat) The 19th Annual WorkSafeBC Phys- el between community practice and Now is the time! Join Dr Mark Sher- ician Education Conference will be quaternary care centre for patients man on the pristine Hawaiian island held at the Inn at Laurel Point in Vic- with ACHD. This will be a 1-day of Molokai for this 7-day mindfulness toria. Attendees can expect a full-day event with a target audience of gener- meditation retreat for physicians. The of discussion, dialogue, and work- al cardiologists, internists, residents, retreat is an opportunity to learn mind- shops relating to the role of physicians fellows, nurses, and allied health pro- fulness and meditation skills, connect in work-related injuries, and the latest fessionals who care for adults with with fellow physicians, and to bring a protocols in disability management. congenital heart conditions as part restored perspective and vitality into The agenda includes 3 plenary ses- of their practice. It will be held at the your personal and professional life. sions, 14 workshops to choose from, Morris J. Wosk Centre for Dialogue in We will offer instruction in basic and and 2 short-snapper sessions that fea- Vancouver. To register and for more more advanced meditation practice ture a brief presentation followed by information, please visit https://ubc interspersed with small group discus- an opportunity for Q&A. Register be- cpd.ca/course/acc2018, call 604 675- sions and sharing, with an opportun- fore 1 Oct to get the early bird rate 3777 or e-mail [email protected]. ity for self-reflection and deep rest. of $179 + GST for physicians, and Please see http://livingthismoment. $89.50 + GST for students and resi- SNOMED CT EXPO 2018 ca/event for more information and dents. For more information, visit Vancouver, 10–19 Oct (Wed-Fri) to register. Contact mark@livingthis www.worksafebcphysicians.com. SNOMED CT Expo 2018: The moment.ca for any questions. Global Language of Healthcare will INFECTIOUS DISEASES be held at the Pan Pacific Hotel, and ALLERGY AND CLINICAL SYMPOSIUM showcase the latest achievements IMMUNOLOGY UPDATE 2018 Surrey, 20 Oct (Sat) and research in semantic interoper- Vancouver, 20 Oct (Sat) The 4th annual Infectious Diseases ability, specifically the SNOMED The Allergy and Clinical Immunol- Symposium will be held at Surrey CT clinical terminology. The themes ogy Update is back again this year! Memorial Hospital, UBC Lecture prevalent in this year’s Expo include This 1-day conference offers time- Hall, Floor-B, Critical Care Tow- the role that clinical terminology ly updates on common allergy and er. Symposium chair: Dr Yazdan plays within genomic and precision immunology issues faced by family Mirzanejad. Topics: Adult immun- medicine, and clinical data analysis. physicians and pediatricians in the ization and resurgences, necrotizing This event, attended largely by inter- clinical setting. Participants will hear fasciitis, meningitis, high-risk infec- national clinicians, showcases the from leaders in the field on topics tion during and after pregnancy, fever latest achievements and research in such as food allergy, drug allergy, in returned travelers, parasitic infec- semantic interoperability, specifically immunodeficiency, and asthma. Par- tions in refugees and immigrants, the SNOMED CT clinical terminol- ticipants last year remarked that they common infections in transplanted ogy. Further, it extends an opportun- felt more confident managing food patients, fever in children in the office ity to BC doctors to get involved in allergy and practical advice in daily and emergency room settings, and

374 bc medical journal vol. 60 no. 7, september 2018 bcmj.org cme calendar pitfalls in interpretation of infectious mation visit https://ubccpd.ca/course/ and in those we work with as pa- diseases diagnostics. Event speakers: OB2018, call 604 675-3777, e-mail tients. Please join Dr Mark Sherman Professor Tony Chow, Dr Monika [email protected]. and your fellow colleagues for one of Naus (BCCDC), Drs Alissa Wright, our transformative upcoming work- Laura Sauve, Mike Chapman, Miguel MEDICAL LEGAL REPORTS shops/retreats: Mindfulness in Health Imperial, Katherine Plewes, Meera Vancouver, 10 Nov (Sat) & 24 Nov Care—For all health care profession- Anand, Julie Schalwyk, and Yazdan (Sat) als—Brentwood Bay (23–26 Nov Mirzanejad. Further information and Medical Legal Reports—The Essen- 2018); Mindfulness in Medicine— registration: https://events.eply.com/ tials, is back again this year and will Foundations of theory and practice infectious-diseases-day-2018-10-20. feature new and refreshed content: (TBD, Feb 2019); Mindfulness in The essential components of a med- Medicine—For physicians and their CANADIAN SOCIETY OF ical legal report; how to clearly nar- partners—Tofino (26–29 Apr 2019); HOSPITAL MEDICINE rate the patient’s history, physical Mindfulness in Medicine—A phys- CONFERENCE examination findings, diagnosis, and ician meditation retreat—Hollyhock, Whistler, 25–27 Oct (Thu-Sat) prognosis; the steps to complete a Cortes Island (9–14 Jun 19). For To be held at Fairmont Château medical legal report efficiently and more information and to register, go Whistler, this interactive conference streamline the payment/invoicing to www.livingthismoment.ca/events/ will provide clinically relevant up- process; how lawyers, juries, and or [email protected]. dates to hospital medicine physicians, judges identify the good, bad, and general internists, family physicians ugly medical legal report. Medical GP IN ONCOLOGY Education providing in-patient care, and resi- Legal Reports—Advanced will help Vancouver, 4–15 Feb, dents/students. The conference will you acquire advanced skills needed to 9–20 Sept 2019 (Mon–Fri) review current work-up and thera- tackle these tough reports: Enhanced BC Cancer Family Practice Oncol- peutic approaches for common in- skills for successful medical legal re- ogy Network offers an 8-week Gen- patient clinical presentations, and port writing; how to address complex eral Practitioner in Oncology training identify essential skills required to issues of patient compliance/adher- program beginning with a 2-week care for medically complex adult in- ence, possible secondary gain, cost introductory session every spring and patients. Cost: $699. Accreditation: of future care and future treatment; fall at the Vancouver Centre. This pro- This event is accredited for up to 14.5 the role of the medical/health profes- gram provides an opportunity for rural Mainpro+ and MOC Section 1 credits. sional expert witness in court; how to family physicians, with the support of For more details and to register, visit succeed in the various parts of expert their community, to strengthen their http://ubccpd.ca/course/CSHM2018; testimony: Becoming qualified, dir- oncology skills so that they may pro- e-mail [email protected]; or call 604 ect testimony, cross examination, and vide enhanced care for local cancer 675-3777. re-direct; common pitfalls and traps patients and their families. Follow- in court and how to avoid them. All ing the introductory session, partici- 26th OBSTETRICS UPDATE these aspects will be demonstrated in pants complete a further 30 days of FOR FAMILY PHYSICIANS an engaging mock trial. Both courses customized clinic experience at the Vancouver, 25–26 Oct (Thu–Fri) will be held at UBC Robson Square, cancer centre where their patients are Please join us for this 2-day course at 800 Robson St. Register today at referred. These can be scheduled flex- Vancouver Marriott Pinnacle Down- http://www.medlegaltoolkit.com For ibly over 6 months. Participants who town Hotel. This course is designed to more information e-mail manager@ complete the program are eligible for meet the needs of a busy practitioner, coremedicalcentre.ca. credits from the College of Family no matter where you work! Suitable Physicians of Canada. Those who even if you don’t attend births: pro- MINDFULNESS IN MEDICINE are REAP-eligible receive a stipend vides updates for early pregnancy 2018–2019 and expense coverage through UBC’s care, postpartum, and newborn care. Multiple BC locations, multiple dates Enhanced Skills Program. For more Wine and cheese social event at the The challenges and blessings of medi- information or to apply, visit www. end of the day on Thursday! Hands- cine require that we, as physicians, fpon.ca, or contact Jennifer Wolfe at On Ultrasound Education Obstetrics learn skills to take care of ourselves 604 219-9579. Course as post-conference workshop even as we care for others. Mindful- on Sat 27 Oct and Sun 28 Oct. Ac- ness and meditation offer concrete, creditation: up to 13.50 Mainpro+ evidence-based tools to nurture re- credits. To register and for more infor- silience and wellness in ourselves,

bc medical journal vol. 60 no. 7, september 2018 bcmj.org 375 classifieds

Classified advertising (limited to 700 characters) Rates: Payment is required at the time that you Doctors of BC members: $50 + GST per place the ad. month for each insertion of up to 350 charac- Deadlines: Ads must be submitted or can- ters. $75 + GST for insertions of 351 to 700 celled by the first of the month preceding the characters. Payment is required at the time month of publication, e.g., by 1 November that you place the ad. for December publication. Non-members: $60 + GST per month for Visit www.bcmj.org/classified-advertising for each insertion of up to 350 characters. $90 + more information. Place your classified ad on- GST for insertions of 351 to 700 characters. line at www.bcmj.org/classifieds-advertising.

practices available VANCOUVER (W BROADWAY)—FP BURNABY—PT/FT FP LOCUM/ Well-equipped, well-established, busy, turn- SPECIALIST NANAIMO—SKIN PRACTICE key, family practice for sale. OSCAR EMR, Freshly renovated Burnaby office with beauti- OPPORTUNITY fibre-optic Internet. Lovely patients, lovely ful views looking for physicians. We feature Physician required to work long-term with a view, lovely setting. Email broadwayfamily a 75/25 split, a convenient location 7 minutes dermatologist in purpose-built, state-of-the-art [email protected]. from the Patterson SkyTrain station, flexible Vancouver Island clinic. Suitable for a derma- working hours, OSCAR EMR, and printer in tologist or GP with an interest in dermatology each room, group practice, friendly MOAs, who wishes to locate to beautiful Vancouver and free secure underground parking. Please Island. Contact Dr J.A. Hancock at jahinc@ employment contact us at [email protected]. shaw.ca. AIM MEDICAL IMAGING— RADIOLOGIST NEEDED COQUITLAM (COTTONWOOD, RICHMOND (CITY CENTRE)—FP, Radiologist needed for Vancouver private CONNOLLY, CYPRESS LODGES)— PART-TIME MRI clinic. Great location, salary, working GENERAL PRACTITIONERS Busy, well-established storefront family-prac- hours, and team! Email adelmars@aimmedical Opportunities exist for GPs at tertiary care tice clinic with two physicians looking for an- imaging.com. Call 604 733-4007. mental health rehabilitation facilities on the other part-time FP. Suitable for someone who Riverview lands. Responsibilities include wants to work only 2 to 4 days (min. 6 hours/ ARMSTRONG—FT FAMILY daily visits Monday to Friday (timing flexible), day) per week. No weekends, evenings, obs, PHYSICIAN providing direct ongoing medical care for an assigned group of mental health inpatients; hospital. Residential care optional. Modern Haugen Medical Group, located in the heart of admission assessment and discharge summary; spacious office. Profile EMR. Amiable staff. the North Okanagan, is in need of a full-time ward rounds; liaison with other support and Walk-ins optional. Future full-time possible. family physician to join a busy family practice rehabilitation disciplines. On call is shared Must speak basic Mandarin. Contact rich- group. Flexible hours, congenial peers, and between the GPs (including weekends). Psy- [email protected]. Guaranteed min- competent nursing and MOA staff will pro- chiatric care is provided by psychiatrists, with imum $90/hr. for first 4 months, and revenue vide exceptional support with very competitive split thereafter. their own on-call schedule. Remuneration via overhead rates. Obstetrics, nursing home, and APP sessions. Start date (15 August 2018) is inpatient hospital care are not required, but re- negotiable. Interested candidates submit cv to SMITHERS—TWO PRACTICES FOR main optional. Payment schedule: fee for ser- [email protected]. SALE vice. If you are looking for a fulfilling career Two family practices for sale. Acquire well- balanced with everything the Okanagan life- NANAIMO—FT/PT FAMILY established 17-year-old busy rural practices in style has to offer, please contact Maria Varga PHYSICIAN downtown Smithers, with services including for more information at mariavarga86@gmail Drs Jenny, Margo, Stefan, Seamus, Alva, and obstetrics and MOT medicals, utilizing MOIS .com. Jennifer are looking for a physician to join EMR. Hospital is located nearby with poten- their brand new, state-of-the-art clinic. Great tial for ER shifts. Embrace the rural lifestyle BRITISH COLUMBIA #1 MEDICAL support staff, Accuro-based EMR, online with activities such as golfing, boating, kayak- RECRUITMENT SPECIALISTS booking, kiosk checkin, and our friendly at- ing, lake and pool swimming, fishing, hunting, Physicians For You. For the last 10 years we mosphere sets our clinic apart from the rest. snowmobiling, cross-country and downhill have been assisting clinics looking for fam- Walk-ins available and flexible hours; no buy- skiing. If interested please email iss24@yahoo ily physicians and specialists, and assisting in, no overhead during vacation, competitive .com or [email protected]. physicians looking for short-, medium-, and % splits. Please call Jenny or Shanda at 250 long-term positions across Canada. Our goal 591-9622 (ext. 6) for details or to book a tour SURREY/NORTH DELTA—PRACTICE for everyone we work with is to provide expert of our clinic. TAKEOVER guidance, advice, and support throughout the Take over 35-year-old established practice entire recruitment process, and to be available NANAIMO—GP from two physicians. Low rent, fully furnished, for you 24/7 to make the process as efficient General practitioner required for locum or nine equipped exam rooms, free parking, lab and hassle-free as it can be for all involved. If permanent positions. The Caledonian Clinic and X-ray walking distance. EMR available. you’re interested, or just keen for further in- is located in Nanaimo on beautiful Vancou- Will assist in every aspect of transition. Call formation, please contact us: info@physicians ver Island. Well-established, very busy clinic Dr Andrew Major, cell: 604 591-2322. foryou.ca, 778 930-0265. with 26 general practitioners and 2 specialists.

376 bc medical journal vol. 60 no. 7, september 2018 bcmj.org classifieds

Two locations in Nanaimo; after-hours walk-in locations has opportunities for family, walk-in, clinic in the evening and on weekends. Com- POWELL RIVER—LOCUM or specialists. Full-time, part-time, or locum puterized medical records, lab, and pharmacy The Medical Clinic Associates is looking for doctors guaranteed to be busy. We provide ad- on site. Contact Ammy Pitt at 250 390-5228 short- and long-term locums. The medical ministrative support. Paul Foster, 604 572-4558 or email [email protected]. Visit community offers excellent specialist backup or [email protected]. our website at www.caledonianclinic.ca. and has a well-equipped 33-bed hospital. This beautiful community offers outstanding out- SURREY—GP/WALK-IN, FT OR door recreation. For more information contact NORTH DELTA—TWO FPs, LOCUM/FT LOCUM/SPECIALIST Laurie Fuller: 604 485-3927, email: clinic@ Looking for two family physicians for our Modern, zen, spacious clinic in Surrey, BC. tmca-pr.ca, website: powellrivermedicalclinic.ca. clinic at the Scottsdale Medical Centre to start Very friendly and experienced staff to make ASAP as locums, full-time, or as associates, your day as easy as possible. Fast computers with the intention of being partners in the long S SURREY/WHITE ROCK—FP with OSCAR EMR. Flexible hours: full-time/ run. Clinic is located in North Delta (open Busy family/walk-in practice in South Surrey part-time/walk-in/build your own practice. requires GP to build family practice. The com- since 1983). Fully equipped with EMR and pa- Heavy-traffic location. Up to 80/20 split. munity is growing rapidly and there is great per charts. We have a full-time family practice Private offices available for each physician. need for family physicians. Close to beaches and a walk-in clinic. Billing split negotiable. Email: [email protected]. and recreational areas of Metro Vancouver. Contact [email protected] or call OSCAR EMR, nurses/MOAs on all shifts. 604 597-1606 as soon as possible. CDM support available. Competitive split. VANCOUVER/RICHMOND—FP/ Please contact Carol at Peninsulamedical@ SPECIALIST NORTH VAN—FP LOCUM live.com or 604 916-2050. We welcome all physicians, from new gradu- Physician required for the busiest clinic/fam- ates to semiretired, either part-time or full- time. Walk-in or full-service family medicine ily practice on the North Shore! Our MOAs SOUTHERN INTERIOR, and all specialties. Excellent split at the busy are known to be the best, helping your day run BC—OPPORTUNITIES FOR South Vancouver and Richmond Superstore smoothly. Lucrative 6-hour shifts and no head- ANESTHESIOLOGISTS aches! For more information, or to book shifts Interior Health (IH) is recruiting anesthesiolo- medical clinics. Efficient and customizable online, please contact Kim Graffi at kimgraffi gists in both locum and permanent capacities in OSCAR EMR. Well-organized clinics. Please @hotmail.com or by phone at 604 987-0918. several communities, including Cranbrook and contact Winnie at [email protected]. Kamloops. In addition to improving anesthesia PITT MEADOWS—FAMILY and pain management through our collabora- VICTORIA—GP/WALK-IN PHYSICIANS tion with UBC’s Southern Medical Program, Shifts available at three beautiful, busy clinics: We are seeking three full-time family physi- you will have the opportunity to make an Burnside (www.burnsideclinic.ca), Tillicum cians to join our team at the New Pitt Mead- impact in education and research. At IH anes- (www.tillicummedicalclinic.ca), and Uptown ows Medical Clinic. We encourage physicians thesiologists provide a range of services for a (www.uptownmedicalclinic.ca). Regular and to have a full family practice with regular shifts wide range of surgical and diagnostic proce- occasional walk-in shifts available. FT/PT GP in our very busy walk-in clinic. The NPMMC dures, including general surgery, orthopaedic post also available. Contact drianbridger@ is a purpose built, well established, and highly surgery, neurosurgery, vascular surgery, OBG, gmail.com. reputed practice in Pitt Meadows with beauti- ENT, plastic surgery, urology, and multiple ful views. It is ideally situated between Co- trauma. Come enjoy a rewarding career in one VICTORIA—PERMANENT/P-T—FP quitlam and Maple Ridge in a high-visibility, of our many caring communities. See job post- Experienced family physician wishing to ex- high-traffic location. We have excellent staff. ings: www.betterhere.ca. pand medical team at Mattick’s Farm in beau- Low overheads for full-time physicians. At tiful Cordova Bay. Fully equipped office, OS- present, the clinic is open 6 days per week. SURREY/DELTA/ABBOTSFORD—GPs/ CAR EMR, congenial staff, close to schools. For further details visit www.newpittmeadows SPECIALISTS Contact [email protected], phone medicalclinic.ca or contact Dr L. Challa at 604 Considering a change of practice style or loca- 250 658-5228. 465-0720. tion? Or selling your practice? Group of seven Continued on page 378

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bc medical journal vol. 60 no. 7, september 2018 bcmj.org 377 classifieds

Continued from page 377 large, bright, comfortable interview room/ located on the lower level of our home. Private office. If interested please contact Dr Lewis entrance, fully equipped kitchen, and laun- medical office space Pullmer at [email protected], or contact dry. Expansive view of Skaha Lake. Close to the office directly at 604 872-3422. golf, wineries, and KVR bike trail. $150/night, BURNABY (METROTOWN)— $900/week. Contact Dr Glen Burgoyne: glen FURNISHED SPACE FOR SPECIALIST VANCOUVER (KERRISDALE)— [email protected] or 250 462-8270. Newly occupied medical office. Secure and SHARED SPACE AVAIL. FOR well kept. Across from Metropolis, near Sky- INTERNAL MED PRACTICE PROVENCE, FRANCE—YOUR VILLA Train. Established neurologist has set up. Of- Les Geraniums, a luxury 3-bedroom, 2½ bath fice space with two examining rooms, all fur- Subspecialist looking to share office space in modern medical office in Kerrisdale area: 899 villa, is your home in the heart of Provence. nished. Negotiable: share existing system or Expansive terrace with pool and panoramic bring your own staff and system, open to find- sq. ft. office space, two exam rooms, reception, waiting room. Practice fully set up and views. New kitchen and bathrooms. Walk to ing the best system for your practice. Beautiful lovely market town. One hour to Aix and Nice. courtyard, parking nearby. Contact Dr Cory Toth running. For more information email jamila. [email protected]. Come and enjoy the sun of southern France! at [email protected], 778 737-8684. 604 522-5196. [email protected].

BURNABY—INTERESTED IN JOINING VANCOUVER—PHYSICIANS & A PEDIATRIC PRACTICE? THERAPIST We are looking for pediatricians and pediatric Fully furnished modern medical office located miscellaneous in Fairmont Medical Building near VGH has specialists to join Kensington Medical Clinic, CANADA-WIDE—MED medical examination rooms available for phy- a large multidiscipline practice located in TRANSCRIPTION Burnaby. We have six pediatricians, a pediatric sicians/health professionals and consultation Medical transcription specialists since 2002, cardiologist, and 12 GPs on staff. Collabora- rooms for therapists. Office is open 7 days Canada wide. Excellent quality and turn- tive atmosphere and competitive remuneration. a week 7 a.m. to 7 p.m. Terms are flexible to around. All specialties, family practice, and Contact Jeremy at 604 299-9765 or jmickolwin accommodate casual, part-time, and full-time IME reports. Telephone or digital recorder. @kensingtonmedicalclinic.com. hours. Offering both basic and fee-split leas- Fully confidential, PIPEDA compliant. Dicta- ing options. Able to accommodate both paper tion tips at www.2ascribe.com/tips. Contact us VANCOUVER (KERRISDALE)—OFFICE and EMR (Accuro) practices (EMR training at www.2ascribe.com, [email protected], or SPACE available). Additional services provided, in- toll free at 1 866 503-4003. Airy, spacious, quiet office available for a psy- clude medical billing, transcription, medical chiatrist or psychologist on Fri and/or week- supplies, marketing/advertising, and support FREE MEDICAL RECORD STORAGE ends. Located in Kerrisdale Prof. Bldg., an ex- staff. For more information please email raz@ Retiring, moving, or closing your family prac- ceptionally convenient location for access by elitemedicalassociates.com. tice? RSRS is Canada’s #1 and only physician- public transit or car, with a large amount of free managed paper and EMR medical records stor- residential parking available. Close to pharma- age company. Since 1997. No hidden costs. cies, labs, a walk-in clinic, coffee shops, and Vacation properties Call for your free practice closure package: restaurants--all within walking distance. The everything you need to plan your practice office is accessible by stairs and elevator. Con- PENTICTON—OKANAGAN VACATION closure. Phone 1 866 348-8308 (ext. 2), email sists of a waiting area that seats two people; Plan your Okanagan fall wine country get- [email protected], or visit www.RSRS.com. a large reception desk; file storage room; and away. Modern two-bedroom/one-bath suite PATIENT RECORD STORAGE—FREE Retiring, moving, or closing your family or general practice, physician’s estate? DOCU- davit Medical Solutions provides free storage for your active paper or electronic patient records with no hidden costs, including a patient mailing and doctor’s web page. Contact Sid Soil at DOCUdavit Solutions today at 1 888 781-9083, ext. 105, or email ssoil@docudavit .com. We also provide great rates for closing specialists. BCMJ Advertising VANCOUVER—TAX & ACCOUNTING SVCS Rod McNeil, CPA, CGA: Tax, accounting, Want to reach BC doctors? and business solutions for medical and health professionals (corporate and personal). Spe- We’ve got you covered—in print and online cializing in health professionals for the past 11 years, and the tax and financial issues facing them at various career and professional stages. For all your display advertising requirements, please contact: The tax area is complex, and practitioners are Kashmira Suraliwalla often not aware of solutions available to them 115–1665 West Broadway, Vancouver, BC V6J 5A4 and which avenues to take. My goal is to help you navigate and keep more of what you earn 604 638-2815 • [email protected] • www.bcmj.org by minimizing overall tax burdens where possible, while at the same time providing you with personalized service. Website: www. rwmcga.com, email: [email protected], VALUE = PROVEN Readership + Audience Involvement phone: 778 552-0229.

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