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November-December 2015 | Volume 40 | Number 6

DIGESTAlberta Doctors'

Patients First®

Physician-assisted dying

A national framework and approach

Canadian Medical Association favors principles-based recommendations for a Canadian approach to assisted dying

Caution and respect for patient autonomy frame

College of Physicians & Surgeons of Alberta advice on

physician-assisted death

Assisted death: an altered landscape

COVER PHOTO: Dr. Cindy Forbes, President, Canadian Medical Association (CMA). ( provided by CMA)

7 Canadian Medical Association favors principles-based recommendations for a Canadian approach to assisted dying On February 6, 2015, the Supreme Court of Canada unanimously struck down the law prohibiting assisted dying.

10 Caution and respect for patient autonomy frame College of Physicians & Surgeons of Alberta (CPSA) advice on physician-assisted death This fall, the CPSA circulated for feedback a draft advice document on informed consent as it applies to physician-assisted death. The issues are complex.

1 1 Assisted death: an altered landscape Views from a palliative care physician and clinical ethicist.

20 Alberta blue in a sea of red What does the 2015 federal election mean to health care?

24 Lice. The Orr disinfestor. Venereal disease. Alberta’s first dermatologist makes a lasting imprint in war and peace.

CONTENTS

FEATURES

DEPARTMENTS

5 From the Editor

14 Health Law Update

16 PFSP Perspectives

18 Mind Your Own Business

22 Dr. Gadget

26 In a Different Vein

30 Classified Advertisements

NOVEMBER - DECEMBER 2015

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AMA MISSION STATEMENT

The AMA stands as an advocate for its physician members, providing leadership and support for their role in the provision of quality health care.

Patients First® is a registered trademark of the Alberta Medical Association.

Alberta Doctors’ Digest is published six times annually by the Alberta Medical Association for its members.

Editor: Dennis W. Jirsch, MD, PhD

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP

Editor-in-Chief: Marvin Polis

President: Carl W. Nohr, MDCM, PhD, FRCSC, FACS

President-Elect: Padraic E. Carr, BMedSc, MD, FRCPC, DABPN

Immediate Past President: Richard G.R. Johnston, MD, MBA, FRCPC

Alberta Medical Association 12230 106 Ave NW Edmonton AB T5N 3Z1 T 780.482.2626 TF 1.800.272.9680 F 780.482.5445 [email protected] www.albertadoctors.org

To request article references, contact: [email protected]

January-February issue deadline: December 11

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor.

The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.

© 2015 by the Alberta Medical Association

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To request article references, contact: [email protected]

AMA - ALBERTA DOCTORS’ DIGEST

All Canadians listened and wondered about what the future would bring in the wake of the Supreme Court of Canada’s decision in support of physician-assisted dying. In this issue of Alberta Doctors’ Digest, we bring you several perspectives on considerations for physicians on the front lines of this new era in Canadian health care.

As the national organization of physicians, the Canadian Medical Association (CMA) has provided leadership in developing a framework for implementation. That framework document, presented at the August 2015 General Council of the CMA, is published in this edition of Alberta Doctors' Digest. We also bring you thoughts on physician-assisted dying in some other feature stories and from our regular columnists.

A SPECIAL ISSUE4

Physician-assisted dying: A national framework and approach


FROM THE EDITOR

Dennis W. Jirsch, MD, PhD | EDITOR

Bad ideas

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My recent reading has included an unusual

little book titled This Idea Must Die.1 Editor John Brockman notes that science generally advances by abandoning

old truths that no longer fit new ideas. Brockman quotes Max Planck: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.”

Brockman goes on to ask: What scientific idea that currently prevails is ready for retirement? More than 100 of the world’s most notable scientists, philosophers, economists, authors and so on pose answers in essays that are generally a page or two long. They are little bonbons of intriguing argument.

Topics range from authors’ small bugbears to large canons of thought and many are pertinent to health care. In the submission Mouse Models, for instance, Azra Rasa takes issue with the murine model used for most cancer research and finds it wanting, inadequately reflecting the human situation, especially in the search for new drug therapies.

On a larger front, Evidence-based Medicine itself comes in for criticism from author Gary Klein. Randomized, controlled trials have helped weed out ineffective therapies to be sure, notes Klein, but many studies cannot be replicated. Publication bias means, too, that many contrary or negative results never see the light of day and it may prove difficult or even impossible to properly account for unique study conditions. Even findings that can be replicated may be used inappropriately, as when they are forced to become simple but unyielding rules for therapy in populations of heterogeneous individuals without accounting for increasingly complicated diagnoses. On the other hand, treatments that appear ineffective because they are submerged in a welter of data may actually benefit a subset of patients.

Every medical student is familiar with the “law of parsimony,” or Occam’s razor, which holds that of two or more competing theories, the simplest one is likely to pertain. While still useful, Occam’s razor is increasingly challenged by complexity and I am pleased to learn there is a countervailing view, called Hickam’s dictum: “A patient can have as many diagnoses as (she) damn well pleases.”

Nicholas Carr, the journalist who described our tendency to tiptoe or browse through information superficially in the age of the Internet, finds trouble in our hierarchy of evidence in research studies. Here the acme of achievement is the robust and well-designed, well-populated, well-controlled randomized study. In this artificial situation, Carr finds that anecdote gets short shrift compared with abstract data derived from experimental study. Anecdotal evidence, generally the sole support for alternative or complementary medicine, is likely successful because the capacity for narrative is imbedded in us, and it is through stories that we relate one to another and figure out our lives.

In the essay Science, by video game designer Ian Bogost, the whole of scientific endeavor comes in for a drubbing. We’re guilty of “scientism,” according to Bogost, a term that usually implies belief not only in the scientific method but the presumptuous view that there is no other source of knowledge. Many might agree that, science notwithstanding, mankind will retain a need for philosophy and ethos. Indeed, once we know (or think we know) how every little thing works, and works in concert

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.

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6 > with our universe, it will trumpet the day we are no longer human but have become an arm of the machine.

At the same time as science has assumed such importance, it has also come to mean less: we have a science of child-rearing, a science of acting, a science of composting and so on. Who knows what these word concoctions mean?

Paul Bloom argues that there is a common, longstanding view that science can make us happy and that this is faulty on several accounts. Happiness is difficult to define. Distinguishing “happy” from “good” is a vexing but persistent obstacle, as is the question of whose happiness, when and at what cost.

In Brockman’s book physicists have “a go” at things they find useful or useless and come down, for example, on both sides of the now decades-old notion of “string theory” and its multiple universes, recently rebranded as M theory (for membrane, matrix or possibly magic?). Several authors find this peculiar invention a good or a bad idea in turn, though the difficulties proving it either true or false are duly noted.

The submission I particularly like is that of former astronomer royal, Martin Rees (We’ll Never Hit Barriers to Scientific Understanding), who suspects that some aspects of comprehension are beyond us. Our brains have likely not changed much in the few millennia since we wandered from the African savannahs, when presumably our intellect matched our environment. Though our computers may have formidable powers, we may be unable to grasp our digital output. As Rees goes on to say, it would be hubristic or anthropocentric to expect that all the underpinnings of our world are matters we can fathom.

In further regard to our mental abilities, Robert Provine (Common Sense) finds that we are mostly wrong when we think we’re intelligent, logical beings. We often delude ourselves: our perceptions are snap judgments, imprecise estimates of a world that is too often threatening. We make decisions before we’re conscious of them and our memories are an ongoing construct that is subject to bias. We negotiate our lives via a series of guesstimates that are imperfect, yet sufficiently accurate to make our way in the world.

There’s more – lots more. Further essays look to correct our understanding of brain function and consciousness, altruism, nature versus nurture, the “big bang” and so on. Not all authors are academics. Actor Alan Alda (Things are Either True or False) argues that we tend to regard truth and falsehoods as absolutes, making them regrettably permanent structures. Novelist Ian McEwan (Beware of Arrogance!) cautions us that all ideas, even the ones we have discarded, have value and should be remembered as monuments to human ingenuity.

There is something for everyone. Just the right size for bedside reading, these small diversions promise to leave us a little smarter and at a comfortable remove from our more mundane concerns.

I recommend them.

Reference available upon request.

Gerontologist Aubrey de Gray, known for longevity studies and the conviction that we can all live forever, argues that funding research on the basis of peer review is a bad idea. Funding should proceed on the basis of peer recognition rather than peer review and, according to de Gray, this would free researchers of the unproductive time presently spent submitting and resubmitting applications and it would more readily allow researchers to follow “hunches” or “wild ideas” that would fail traditional support by peer review.

Some of the contributions are particularly controversial. Matt Ridley, in Malthusianism, takes on Robert Malthus, who famously predicted several hundred years ago that a growing population must eventually outstrip its food supply. This didn’t happen, of course, and Ridley thinks it never will. We now use 65% less land than we did 50 years ago to produce the same amount of food because of better fertilizers, and, in any event, Ridley expects world population will stabilize sometime this century.

The trouble with Ridley’s post hoc thinking, of course, is that there are limits to biological growth everywhere we look. Blinkered and buoyant faith in future technology absolves us of both individual and collective responsibility for an over-crowded planet. How long can we count on last minute ingenuity to see us through?

All ideas, even the ones we have discarded, have value and should be remembered as monuments to human ingenuity.


COVER FEATURECanadian Medical Association favors principles-based recommendations for a Canadian approach to assisted dying

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As the national organization of physicians, the Canadian Medical Association (CMA) has provided leadership in developing an implementation framework for assisted dying. That framework document, presented at the August 2015 General Council of the CMA, is reproduced below for your consideration. Please note: This document could change and evolve over time - it is not intended to be static.

On February 6, 2015, the Supreme Court of Canada (SCC) unanimously struck down the law prohibiting assisted dying. The SCC suspended

that decision for 12 months. This has provided an opportunity for the Canadian Medical Association to build on its past work and pursue further consultation with provincial and territorial medical associations, medical and non-medical stakeholders, members, legislatures and patients for processes, whether legal, regulatory or guidelines, that respect patients’ needs and reflects physicians’ perspectives.

The goal of this process is two-fold:

1. Discussion and recommendations on a suite of ethical-legal principles.

2. Input on specific issues that are particularly physician-sensitive and are worded ambiguously or not addressed in the SCC’s decision. The touch points are reasonable accommodation for all perspectives and patient-centeredness.

For purposes of clarity, CMA recommends national and coordinated legislative, and regulatory processes and systems. There should be no undue delay in the development of these laws and regulations. The principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or provide a standard of care. Rather, the CMA wishes to provide physicians with guidance and a vision of what physicians might strive for to further their professional and legal obligations in a complex area.

The CMA recommends adopting the following principles-based approach to assisted dying in Canada:

Foundational principles

The following foundational principles underpin CMA’s recommended approach to assisted dying. Proposing foundational principles is a starting point for ethical reflection, and their application requires further reflection and interpretation when conflicts arise.

1. Respect for patient autonomy: Competent adults are free to make decisions about their bodily integrity. Specific criteria are warranted given the finality of assisted dying.

2. Equity: To the extent possible, all those who meet the criteria for assisted dying should have access to this intervention. Physicians will work with relevant parties to support increased resources and access to high-quality palliative care and assisted dying. There should be no undue delay to accessing assisted dying, either from a clinical, system or facility perspective. To that end, the CMA calls for the creation of a separate central information, counseling and referral service.

3. Respect for physician values: Physicians can follow their conscience when deciding whether or not to provide assisted dying without discrimination. This must not result in undue delay for the patient to access these services. No one should be compelled to provide assistance in dying.

4. Consent and capacity: All the requirements for informed consent must clearly be met, including the requirement that the patient be capable of making that decision, with particular attention to the context of potential vulnerabilities and sensitivities in end-of-life circumstances. Consent is seen as an evolving process requiring physicians to continuously communicate with the patient.

5. Clarity: All Canadians must be clear on the requirements for qualification for assisted dying. There should be no “grey areas” in any legislation or regulations.

6. Dignity: All patients, their family members, or significant others should be treated with dignity and respect at all times, including throughout the entire process of care at the end of life.

7. Protection of patients: Laws and regulations, through a carefully designed and monitored system of safeguards, should aim to minimize harm to all patients and should also address issues of vulnerability and potential coercion.

8. Accountability: An oversight body and reporting mechanism should be identified and established in order to ensure that all processes are followed. Physicians participating in assisted dying must ensure that they have appropriate technical competencies as well as the ability to assess decisional capacity, or the ability to consult with a colleague to assess capacity in more complex situations. >

Canadian Medical Association


8 9. Solidarity: Patients should be supported and not abandoned by physicians and health care providers, sensitive to issues of culture and background, throughout the dying process regardless of the decisions they make with respect to assisted dying.

10. Mutual respect: There should be mutual respect between the patient making the request and the physician who must decide whether or not to perform assisted dying. A request for assisted dying is only possible in a meaningful physician-patient relationship where both participants recognize the gravity of such a request.

Recommendations

Based on these principles, the Supreme Court decision in Carter vs. Canada (2015)1 and a review of other jurisdictions’ experiences, CMA makes the following recommendations for potential statutory and regulatory frameworks with respect to assisted dying. We note that this document is not intended to address all potential issues with respect to assisted dying, and some of these will need to be captured in subsequent regulations.

1. Patient eligibility for access to assisted dying

1.1 The patient must be a competent adult who meets the criteria set out by the Supreme Court of Canada decision in Carter vs. Canada (2015).

1.2 Informed decision

• The attending physician must disclose to the patient information regarding their health status, diagnosis, prognosis, the certainty of death upon taking the lethal medication, and alternatives, including comfort care, palliative and hospice care, and pain and symptom control.

1.3 Capacity

• The attending physician must be satisfied that:

– The patient is mentally capable of making an informed decision at the time of the request(s).

– The patient is capable of giving consent to assisted dying, paying particular attention to the potential vulnerability of the patient in these circumstances.

– Communications include exploring the priorities, values and fears of the patient, providing information related to the patient’s diagnosis and prognosis, treatment options including palliative care and other possible interventions and answering the patient’s questions.

• If either or both the attending physician or the consulting physician determines that the patient is incapable, the patient must be referred for further capacity assessment.

• Only patients on their own behalf can make the request while competent.

1.4 Voluntariness

• The attending physician must be satisfied, on reasonable grounds, that all of the following conditions are fulfilled:

– The patient’s decision to undergo assisted dying has been made freely, without coercion or undue influence from family members, health care providers or others.

– The patient has a clear and settled intention to end his/her own life after due consideration.

– The patient has requested assisted dying him/herself, thoughtfully and repeatedly, in a free and informed manner.

2. Patient eligibility for assessment for decision-making in assisted dying

Stage 1: Requesting assisted dying

1. The patient submits at least two oral requests for assisted dying to the attending physician over a period of time that is proportionate to the patient’s expected prognosis (i.e., terminal vs. non-terminal illness). CMA supports the view that a standard waiting period is not appropriate for all requests.

2. CMA recommends generally waiting a minimum of 14 days between the first and the second oral requests for assisted dying.

3. The patient then submits a written request for assisted dying to the attending physician. The written request must be completed via a special declaration form that is developed by the government/department of health/regional health authority/health care facility.

4. Ongoing analysis of the patient’s condition and ongoing assessment of requests should be conducted for longer waiting periods.

Stage 2: Before undertaking assisted dying

5. The attending physician must wait no longer than 48 hours, or as soon as is practicable, after the written request is received.

6. The attending physician must then assess the patient for capacity and voluntariness or refer the patient for a specialized capacity assessment in more complex situations.

7. The attending physician must inform the patient of his/her right to rescind the request at any time.

8. A second, independent, consulting physician must then also assess the patient for capacity and voluntariness.

9. Both physicians must agree that the patient meets eligibility criteria for assisted dying to proceed.

10. The attending physician must fulfill the documentation and reporting requirements.

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9Stage 3: After undertaking assisted dying

11. The attending physician, or a physician delegated by the attending physician, must take care of the patient until the patient’s death.

3. Role of the physician

3.1 The attending physician must be trained to provide assisted dying.

3.2 Patient assessment

• The attending physician must determine if the patient qualifies for assisted dying under the parameters stated above in Section 1.

• The attending physician must ensure that all reasonable treatment options have been considered to treat physical and psychological suffering according to the patient’s need, which may include, independently or in combination, palliative care, psychiatric assessment, pain specialists, gerontologists, spiritual care and/or addiction counseling.

3.3 Consultation requirements

• The attending physician must consult a second physician, independent of both the patient and the attending physician, before the patient is considered eligible to undergo assisted dying.

• The consulting physician must:

– Be qualified by specialty or experience to render a diagnosis and prognosis of the patient’s illness and to assess their capacity as noted in Stage 2 above.

3.4 Opportunity to rescind request

• The attending physician must offer the patient an opportunity to rescind the request at any time; the offer and the patient’s response must be documented.

3.5 Documentation requirements

• The attending physician must document the following in the patient’s medical record:

– All oral and written requests by a patient for assisted dying.

– The attending physician’s diagnosis and prognosis, and their determination that the patient is capable, acting voluntarily and has made an informed decision.

– The consulting physician’s diagnosis and prognosis, and verification that the patient is capable, acting voluntarily and has made an informed decision.

– A report of the outcome and determinations made during counseling.

– The attending physician’s offer to the patient to rescind the request for assisted dying.

– A note by the attending physician indicating that all requirements have been met and indicating the steps taken to carry out the request.

3.6 Oversight body and reporting requirements

• There should be a formal oversight body and reporting mechanism that collects data from the attending physician.

• Following the provision of assisted dying, the attending physician must submit all of the following items to the oversight body:

– Attending physician report

– Consulting physician report

– Medical record documentation

– Patient’s written request for assisted dying

• The oversight body would review the documentation for compliance.

• Provincial and territorial jurisdictions should ensure that legislation and/or regulations are in place to support investigations related to assisted dying by existing provincial and territorial systems.

• Pan-Canadian guidelines should be developed in order to provide clarity on how to classify the cause on the death certificate.

4. Responsibilities of the consulting physician

• The consulting physician must verify the patient’s qualifications including capacity and voluntariness.

• The consulting physician must document the patient’s diagnosis, prognosis, capacity, volition and the provision of information sufficient for an informed decision. The consulting physician must review the patient’s medical records and should document this review.

5. Moral opposition to assisted dying

5.1 Moral opposition by a health care facility or health authority

• Hospitals and health authorities that oppose assisted dying may not prohibit physicians from providing these services in other locations. There should be no discrimination against physicians who decide to provide assisted dying.

5.2 Conscientious objection by a physician

• Physicians are not obligated to fulfill requests for assisted dying. There should be no discrimination against a physician who chooses not to participate in assisted dying. In order to reconcile physicians’ conscientious objection with a patient’s request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling and referral service.

Reference available upon request.

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Central to our advice is the physician’s professional obligation to act in the best interests of the patient.

This fall, the College of Physicians &

Surgeons of Alberta (CPSA) circulated for feedback a draft advice document on informed consent as it applies to

physician-assisted death (PAD). The document can be found at http://bit.ly/cpsapad.

This is a challenging issue for our profession. With no legislative framework yet in place, the college took a conservative approach to interpreting the Carter vs. Canada Supreme Court decision, including in the draft advice many of the safeguards employed by other jurisdictions.

A physician whose deeply held personal beliefs conflict with PAD will not be required to personally carry out a patient’s request, but must assist the patient in accessing all options for care – a principle long embedded our standard of practice Moral or Religious Beliefs Affecting Medical Care (http://bit.ly/cpsa_moral-religious-beliefs). While this particular standard will soon be subject to consultation, review and possible amendment, in my view the principles on which it is based are unlikely to change.

If you haven’t already read the advice document, I’d encourage you to do so. Council will be reviewing the feedback in December, and a refined version along with other resources will be posted to our website to support physicians as PAD becomes a legal option in Canada.

10 FEATURE

Caution and respect for patient autonomy frame CPSA advice on physician-assisted death

Trevor W. Theman, MD FRCSC | REGISTRAR, COLLEGE OF PHYSICIANS & SURGEONS OF ALBERTA

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After receiving a lot of feedback, we are now re-examining some of our positions. For example, how different should PAD be from other medical acts regarding consent? We initially advised mature minors should be excluded as the Carter decision limited physician-assisted dying to consenting adults. As this position is not legally defensible, the next version of our advice document will advise that mature minors seeking PAD should be treated as adults. There is also the question of whether a personal directive by a competent adult should be accepted as consent; it can be argued this is not excluded by the facts of Carter.

These issues are complex, and our positions may well change based on the work of the federal panel, the provincial-territorial expert advisory group and the feedback we receive.

Central to our advice is the physician’s professional obligation to act in the best interests of the patient.


FEATURE 11

Much conversation has risen from the Supreme

Court of Canada’s (SCC’s) decision in Carter vs. Canada, and considerable behind-the-scenes planning has

recently emerged. By the time this edition of Alberta Doctors’ Digest is published, we may know better what the federal response will look like. This short article cannot hope to address the range of challenging issues that patients, families, clinicians and health systems now face, as potential provincial legislation and regulation is developed leading to the availability of assisted death (AD) in Canada. Many articles have summarized the SCC’s decision and interpretations of it, so I will not repeat those details here. Rather, I will briefly comment on several issues of concern.

Language matters. Withdrawing and withholding interventions, leading to a person’s expected death from the physiologic effects of their illness, is not the same as AD. Further, “medical aid in dying” is part of what clinicians rightly do every day as they help their patients live and approach death through the provision of exemplary palliative end-of-life care. The characterization of the new landscape captured by the conditions set forth by the SCC can best be described as “patient requested, state sanctioned, chemically induced death facilitated by a physician.” While not a catchy moniker, this is the essence.

The SCC decision names physicians as the providers – in itself a point of contention – but the current practice of medicine embodies teams. Unfortunately, in removing the criminality of counselling or assisting suicide only for physicians, the court was silent on the need for legal protections for pharmacists, nurses and all other colleagues. Thankfully, the SCC specifically signalled that the conscience rights of physicians need to be harmonized with patient rights to access AD. However, failure to address conscience rights for other staff, many of whom are employees, and failure to recognize the risk of moral harm to them, is a glaring omission.

The specific act of intentionally and legally helping a person to die at a moment in time should not be confused with the holistic, often team-based, encompassing care that comprises palliative end-of-life care. The differences are important to distinguish, regardless of the position one might take regarding the legitimacy or morality of AD. A key for palliative care colleagues is to advocate strongly for appropriate responses to suffering, while we can still acknowledge that for some people, continued living is too burdensome or has too little meaning, in their own eyes. Non-abandonment is central to the commitments we make as physicians, regardless of the choices made by our patients. There are ways to sensitively manage the issue of referral, continuity of care and conscientious objections – for clinicians and for facilities and programs.

Assisted death: an altered landscape

Eric A. Wasylenko, MD BSc MHSc

It seems to me that a cautious approach – especially in the initial years – would serve us best as our society, and beliefs about our professional commitments, wade into contentious and dramatically altered territory.

In the interests of transparency, I am always comfortable to say four things about my own professional and moral stance for this issue:

1. Society has a right to decide that it wants access to AD.

2. In my clinical role as a palliative care physician, I will not provide AD.

3. I will also not judge or abandon my patients.

4. In my role as a clinical ethicist, I have a duty to listen intently to all voices and try to help sort out the best possible way forward.

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12 The SCC expressed confidence that a carefully designed system of safeguards would adequately protect vulnerable individuals. Many of the current attempts to design a monitoring scheme focus on retrospective review, as occurs in most countries with currently legislated AD. Some proposals, in line with the approach in Colombia, call for oversight and granting of approvals for AD by a central authority. Current debate focuses on this aspect of regulatory schemes and the variance between what is termed “restrictive legislative and regulatory approaches” and “permissive” ones. It seems to me that a cautious approach – especially in the initial years – would serve us best as our society, and beliefs about our professional commitments, wade into contentious and dramatically altered territory. We need to better understand the long-term psychologic and sociologic effects of this new practice.

There are many vexing issues to work through: how declaration of death should be registered on death certificates; how we will deal with organ and tissue donation requests in association with AD; how we will deal with AD and suicidality in incarcerated individuals; what actions surrounding AD can be delegated to trainees; how timely and valid capacity assessments can be achieved for patients with fluctuating capacity; how society will deal with life insurance coverage provisions and AD; to name only a very few.

It will take our collective wisdom, goodwill and respect for diverse views to get this as right as possible for the sake of our patients, our colleagues and our profession.

In Alberta, and partnering with others across Canada, a large group of people, including clinicians, are working on the solutions to these problems. Consultation, policy and regulation development, awareness-building and guidance regarding the kind of language that may be helpful in responding to requests for AD are being developed.

It will take our collective wisdom, goodwill and respect for diverse views to get this as right as possible for the sake of our patients, our colleagues and our profession.

Editor’s note: Dr. Wasylenko is a palliative care physician and clinical ethicist. The views expressed herein are his own and are not intended to reflect those of any of the organizations he works with.

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13


On February 6, 2015, the Supreme Court of Canada ruled

that sections 241(b) and 14 of the Criminal Code of Canada unjustifiably infringed s. 7 on the Canadian Charter of Rights

and Freedoms, and were therefore of no force or effect to the extent that they prohibited physician-assisted suicide for a competent adult person who (a) clearly consented to the termination of life, and (b) had a grievous and irremediable medical condition that caused enduring suffering that was intolerable to the individual in the circumstances of his or her condition. As you read this, approximately two months remain in the one-year period of suspension provided by the Supreme Court to allow the federal government to draft and pass the necessary amendments to the Criminal Code to address this declaration.

What has occurred in the intervening 10 months? Not as much as persons impacted by this decision would have hoped for.

First of all, during the period of suspension, it continues to be a criminal offence for anyone, including physicians, to assist another person in ending his or her life, which places them at risk of imprisonment for up to 14 years, if prosecuted. The federal government, faced with the prospect of addressing a volatile and controversial issue in an election year, did little, if anything toward creating the necessary legislation. It did establish an expert panel chaired by Harvey Max Chochinov, the Canada research chair in palliative care at the University of Manitoba with co-panelists: University of Ottawa law professor Benoît Pelletier, a former Quebec cabinet minister who is a constitutional expert; and Catherine Frazee, former co-director of Ryerson University’s institute for disability research and education. Their job: consult with stakeholders and advise the minister of justice regarding proposed legislative change. However, the makeup of that committee has drawn the ire of various groups across Canada, including the British Columbia (BC) Civil Liberties Association, with concerns regarding the bias of the committee members.

Carter vs. Canada (Attorney General): what next?

HEALTH LAW UPDATE

Jonathan P. Rossall, QC, LLM | PARTNER, MCLENNAN ROSS LLP

The Canadian Medical Association (CMA) continues to work toward the development of a regulatory framework. The CMA’s Committee on Ethics discussed the ruling and its implications at its April 26-27 meeting, and the CMA itself undertook extensive stakeholder and member consultations leading up to a detailed discussion and debate of the issues this past August at the CMA Annual General Meeting and General Council.

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Approximately two months remain in the one-year period of suspension provided by the Supreme Court to allow the federal government to draft and pass the necessary amendments to the Criminal Code to address (physician-assisted suicide).

14

Provincial governments and regulatory colleges are presumably developing legislation and policies/guidelines for the practical administration of end-of-life decisions and actions although to-date there is little evidence of that. Ontario has taken the lead as other provinces and territories, except for BC and Quebec, have set up a nine-member expert panel to advise the provinces how to implement physician-assisted death. The panel is co-chaired by University of Toronto bioethicist Dr. Jennifer Gibson and Dr. Maureen Taylor, a physician assistant whose late husband, Dr. Donald Low of SARS crisis fame, made an impassioned video plea for physician-assisted suicide in his final days of fighting brain cancer two years ago. The committee has been tasked with researching legislative approaches in other jurisdictions and coming up with a “Canadian solution,” according to Dr. Taylor. In addition, the College of Physicians & Surgeons of Alberta has published an advice to the profession document relating to physician-assisted death.


15

During the period of suspension, it continues to be a criminal offence for anyone, including physicians, to assist another person in ending his or her life …

worst have undertaken the emotional and financial burden of continuing care, for their loved ones who desire to end the suffering.

In addition, there are the physicians who are prepared to provide the assistance to allow those patients to end their lives, as well as those physicians who, while not prepared to provide the assistance, are prepared (or potentially required) to refer their patients to those physicians who will.

Finally, there continues to exist myriad interest groups monitoring the consequences of the Supreme Court decision on behalf of their constituents. Many of these, such as the Council of Canadians with Disabilities, the Physicians’ Alliance Against Euthanasia, and Dying With Dignity, were intervenors in the court case and continue to advocate from their perspectives.

What all of these persons and groups deserve is some certainty. That was the expectation in February 2015 when the court, speaking as one, stated the following:

“In our view, nothing in the declaration of invalidity which we propose to issue would compel physicians to provide assistance in dying. The declaration simply renders the criminal prohibition invalid. What follows is in the hands of the physicians’ colleges, Parliament and the provincial legislatures. However, we note … that a physician’s decision to participate in assisted dying is a matter of conscience and, in some cases, of religious belief. In making this observation, we do not wish to pre-empt the legislative and regulatory response to this judgment. Rather, we underline that the Charter rights of patients and physicians will need to be reconciled.”

The sooner that reconciliation occurs, the better.

> Bill 52, An Act Respecting End-of-Life Care, which was introduced into the Quebec National Assembly in June 2013 and assented to in June 2014, is expected to come into force in late 2015. That act will provide additional guidance and comfort for physicians providing end-of-life care in that province, but does not supercede the obligation of the federal government to amend the Criminal Code.

While laudable, these actions have not, to date, resulted in any legislative changes in direct response to the Supreme Court decision, nor have they provided any definitive policy or guidelines to give guidance for those persons impacted by the decision. Uncertainty and indecision continue to guide the issues.

And who are these persons affected by this delay and lack of effective action? Well, the first and most obvious group would be those adults who are prepared to consent to the termination of their lives, and who are suffering from a grievous and irremediable medical condition that continues to cause intolerable enduring suffering.

Add to that list the relatives and friends of those individuals who at best must continue to witness the suffering and at

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Being Mortal—Medicine and What Matters in

the End, by American surgeon, public health researcher and writer, Dr. Atul Gawande, is a book about health care

at the end-of-life. Its focus is quite different than his 2011 The Checklist Manifesto, but his readership continues to be health care workers and the educated general public.

One thread of Gawande’s latest narrative is the medicalization and resultant institutionalization of elder care in America after the end of World War II (WWII). Gawande begins by outlining the historical development in industrialized societies that saw institutions like “poorhouses” for the aged and indigent replaced by nursing homes, retirement communities and assisted-living facilities.

Gawande’s book is primarily a collection of well-told stories. He interviewed individuals on both sides of the medical divide – many of whom had become patients confronting the progressive debilities of later life and the “crisis and fear” that may accompany them. The author combines detailed reportage and thoughtful reflection. Each person he listens to reveals their own insights, resources and limitations in “the battle to maintain the integrity of one’s life.” For Gawande, an irrevocable part of being human is that we “be allowed to remain the writers of our own story … [W]hatever happens we want to retain the freedom to shape our lives in ways consistent with our character and loyalties.”

The book contains some very personal writing. Central among the numerous illness narratives is the final chapter in the life of Gawande’s father – a urologist with a slowly progressing high spinal cord astrocytoma. He describes the stepwise end of his father’s surgical career, the resultant changes in his living arrangements and intimate relationships, and

Vincent M. Hanlon, MD | ASSESSMENT PHYSICIAN, PFSP

his eventual death. In writing about his father’s illness, Gwande recreates a number of their father-son/surgeon-surgeon conversations – hard conversations for both of them. They give Gawande’s desire to understand “the modern experience of mortality” a special poignancy.

Gawande the surgeon describes his own re-education regarding the questions that we need to ask in the challenging conversations about the end-of-life with our patients, our own families and ourselves. He is grateful to a number of geriatricians, family physicians and palliative care specialists who helped him see the incompleteness of his former approach

Can we continue to be the writers of our own story at end-of-life?

PFSP PERSPECTIVES16

Life is not permanent. Gawande desires to understand "the modern experience of mortality." ( provided by Dr. Vincent M. Hanlon)

>


17to surgical history taking. Palliative care physician, Dr. Susan Block, provided him with a list of questions she covers with patients to provide mutual clarity and understanding for their decisions:

What do they understand their prognosis to be? What are their concerns about what lies ahead? What kinds of trade-offs are they willing to make? How do they want to spend their time if their health worsens? Who do they want to make decisions if they can’t?

A double imperative for the physician is to ask these questions, and then listen carefully as the patient answers them. Gawande doesn’t discuss the preferred format for such conversations: face-to-face, digitally mediated or some combination of real and virtual. “Our responsibility, in medicine,” he writes, “is to deal with human beings as they are. People only die once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen….”

In forging and implementing a new law about doctors assisting people to die, we need to avoid diminishing our individual and collective humanity in the process. Gawande helps us understand what it means to be both mortal and fully human. People only die once. They have no experience to draw on. ( provided by

Dr. Vincent M. Hanlon)

> 17


Are you working in a group arrangement without a formal practice agreement? You are

not alone. Verbal agreements can work until a change occurs where all members in the clinic have different assumptions about what should happen and someone is negatively impacted by the change.

If you and your colleagues have been operating for some time with only a verbal agreement, or if you are deciding to join a practice or share office space with another physician, it may be time to put your agreement in writing.

The best time to document a practice arrangement is before you commit to working together. However, when your practice is functioning well and everyone is getting along, it can also be an opportune time to discuss and agree on how changes in how you operate will be handled. A formal agreement should include many aspects of your business including decision making, entering and exiting the clinic, leaves of absence and obligations required by one other.

One area that can be the most difficult to determine is the cost-sharing arrangement – particularly on what happens if your current circumstances change.

There is no right answer on which cost-sharing arrangement

Practice Management Program Staff

should be used. However, asking the right questions will help lead you to an answer that will work for your particular clinic and current situation.

Say "I do" and put it in writing Cost-sharing arrangements can be like a marriage contract

MIND YOUR OWN BUSINESS

>

18

Verbal agreements can work until a change occurs where all members in the clinic have different assumptions about what should happen and someone is negatively impacted by the change.

Know your costs

Before you decide on the formula to share costs, it is important to understand what expenditures are needed to operate the clinic and where costs may increase or decrease based on how much time the physician is working. Review your financial reports and consider if there are costs that are higher when you are working more. Most costs continue even when you are not seeing patients.

Some questions to ask that may influence the cost allocation model are:

• Who has signed the lease? Are they assuming more risk and should this be factored into their cost allocation?

• Is there a cost to enter a practice and do you receive anything when you leave? Over what period of time are any leasehold improvements or equipment costs expected to be recovered?

• Do all physicians work in the clinic for a similar amount of time in an average week? Are fewer resources needed, such as reduced staff, when they are not in the clinic?

• Does everyone use the same resources or should costs such as support for billing or dictation be charged to a specific physician? Are there other variations in practice that cost more and should not be shared equally?

Know your practice

Do all physicians in your group share the same values? Although you may not initially connect values with a cost-sharing arrangement, the guiding principles for your practice will overlay how all decisions, including financial decisions, are reached by your group. Values will establish the importance of patient care, the freedom to practice medicine in your own style and the motivation to maximize financial return. By looking at the big picture of what you are trying to achieve, you will be able to create a financial model to reward the type of behavior desired. Base your overhead plan on what is important to the members in your practice.


19• Are physicians allowed to take a leave of absence from the practice? Are you required to pay the same amount for overhead when you are not in the clinic?

• Do any physicians provide teaching, resident support or other leadership roles? Do these choices impact the resources and do all physicians support this function?

• Are there ways to reduce overhead costs by subletting excess capacity at the clinic or arranging for locums for the clinic?

> contribute more or less based on their style of practice, including the number and type of patients seen and amount of time spent at the clinic. Total costs for any specific period of time need to be calculated to determine the shortfall or excess of contribution to costs which will then be distributed to each member. Full disclosure of income and billing information by all physicians is necessary to provide for transparency.

When using this method, consideration should be given to establishing a minimum contribution per month as a contribution toward fixed costs to offset increased costs due to absences. Maximum contributions can also be established where there is a large discrepancy in the income generated to avoid penalizing the physicians who work more and bill more. Physicians who make the highest income do not necessarily use more resources.

2. Split all costs equally

This method works best when the group works in a similar manner and everyone sees themselves as equal participants in running the clinic. Part-time physicians may be accommodated with reduced overhead when the clinic is operating at close to capacity and they are able to share resources.

3. Build your own model

When the physicians believe that there is a variation in how costs should be shared based on how they practice or how costs are incurred, a mixed approach can be developed to accommodate any factors. An example of this is to split fixed costs equally and pay a share of variable costs based on hours per week in the clinic. Larger and more complex practices may have to be creative to develop a model that will work for everyone.

Just like a marriage contract for your business, (a cost-sharing arrangement) allows you to agree on the best course of action up front and cover the various circumstances that may arise.

Know your options

Simple is often better. A good cost allocation model should be easy to understand and calculate. Equity does not mean exactly equal, but the formula to share costs should result in all physicians agreeing that the amount they pay is fair in relation to each other.

There is myriad information on various models that can be applied to sharing costs. In general, they are some variation of the following:

1. Cost based on amount of income generated

Although this a common method, it is not truly a cost-sharing arrangement. Physicians will

Whatever cost-sharing arrangement you settle on, plan to review it regularly to ensure that the group collectively believes that the formula is fair and equitable and reflects your common set of values.

If you have not already done so, have a lawyer draw up a legal contract that reflects your practice arrangement, including the cost-sharing arrangement. Just like a marriage contract for your business, it allows you to agree on the best course of action up front and cover the various circumstances that may arise.

The Practice Management Program is available to assist in a number of areas related to the effective management of your practice. For assistance, please contact Linda Ertman at [email protected] or 780.733.3632.


If any hermit missed the outcome of the federal election: the Liberals have a majority government with the Conservatives providing a strong opposition. The NDP

are a distant third (with less than half of their previous seats) and there is some Bloc resurgence to 10 seats.

Still, two main political parties dominate federal politics: the Liberal Party of Canada and the Conservative Party of Canada (which arose from the ashes of the Progressive Conservative Party: 1943 to 2003).

The Liberal Party’s health care platform

Earlier this summer their health platform was a bit sparse – the website has been updated:

• We will make home care more available, prescription drugs more affordable and mental health care more accessible.

• It has been more than a decade since a Canadian prime minister sat down with provincial and territorial premiers. We will negotiate a new Health Accord with provinces and territories, including a long-term agreement on funding.

• We will invest $3 billion, over the next four years, to deliver more and better home care services for all Canadians. This includes more access to high-quality in-home caregivers, financial supports for family care and when necessary, palliative care.

• We will make the Employment Insurance Compassionate Care Benefit more flexible and easier to access, so that it provides help for more than just end-of-life care.

• We will also develop a pan-Canadian collaboration on health innovation and will improve access to necessary prescription medications. We will join with provincial and territorial governments to buy drugs in bulk.

• We will make high-quality mental health services more available … including our veterans and first responders.

• To eliminate systemic barriers and deliver equality of opportunity to all Canadians living with disabilities, we will consult with provinces, territories and other stakeholders to introduce a National Disabilities Act.

• We will increase funding to the Public Health Agency of Canada by $15 million in each of the next two years, to support a national strategy to increase vaccination rates and raise awareness on concussion treatment.

And of course we have the “liberal” position on marijuana!

• We will remove marijuana consumption and incidental possession from the Criminal Code, and create new, stronger laws to punish more severely those who provide it to minors, those who operate a motor vehicle while under its influence and those who sell it outside of the new regulatory framework.

Being blue in Alberta, perhaps it is important to review the areas of health care which are the purvey of the feds?

Health Canada 101:

Health Canada is the fifth-largest direct health care provider in the country.

The feds are responsible for:

• National principles for health care through the Canada Health Act.

• Financing toward provincial/territorial health care services.

• Direct health service provision to First Nations and Inuit (approximately 640 communities totalling about 900,000 people) refugees, federal inmates and veterans.

• Other related functions such as public health and research.

Canada Health provides recall and safety alerts; the Canada food guide; drug and health product registration; Canadian immunization guide; and protects Canadians from unsafe food, health and consumer products. It regulates:

• More than 13,000 pharmaceutical drugs.

• Approximately 35,000 medical devices.

• Non-marketed drugs authorized for life-threatening conditions.

• More than 300 biologics and biotechnology products.

• More than 1,350 veterinary drugs for food-producing animals and pets.

• More than 72,000 natural health products.

20 FEATURE

Alberta blue in a sea of red What does the 2015 federal election mean to health care?

Kevin M. Hay, MB, BCh, BAO, MRCPI, CCFP, FCFP

>


21In 2012, total health expenditures in Canada were about $207 billion, of which 70% were publicly funded. Canadian health transfers will be stable until 2017, when the formula is planned to change, but there are worries as to how they will reduce thereafter (… to the greater of 3% or nominal GDP growth through 2012-24).

Provincial and Federal Health Accord

The Council of the Federation was established in 2003 and comprises Canada’s 13 provincial and territorial premiers to enable premiers to:

“work collaboratively to strengthen the Canadian federation by fostering a constructive relationship among the provinces and territories and with the federal government.”

In September 2004, the first ministers reached agreement (the ‘Accord’) on a 10-year plan to strengthen health care. In exchange for $41.3 billion in new federal funding, the first ministers agreed to 10 commitments:

1. Adoption of wait-time benchmarks by December 2005 for five procedural areas.

2. Release of health human resource action plans by December 2005.

3. First-dollar coverage for home care by 2006.

4. An objective of 50% of Canadians having 24/7 access to multidisciplinary primary care teams by 2011.

5. A five-year $150 million Territorial Health Access Fund.

6. A nine-point National Pharmaceuticals Strategy.

7. Accelerated work on a pan-Canadian Public Health Strategy including goals and targets.

8. Continued federal investments in health innovation.

9. Reporting to residents on health system performance and the elements of the accord.

10. Formalization of the dispute advance/resolution mechanism on the Canada Health Act.

The government did not renew the Health Accord in 2014. In 2012, the premiers announced the formation of a Health Care Innovation Working Group.

• Scope of practice: examining the scope of practice of health care providers and teams in order to better meet patient and population needs in a safe, competent and cost-effective manner.

• Human resources management: address health’s human resource challenges and explore more coordinated management to address competition across health systems.

• Clinical practice guidelines: accelerating the development and adoption of best clinical and surgical practice guidelines so that all Canadians benefit from up-to-date practices.

The only area where there is current activity is in the pan-Canadian Pharmaceutical Alliance. Through the alliance, the provinces and territories work together to achieve greater value for both brand name and generic drugs for publicly funded drug programs. As of December 31, 2014, this resulted in 49 completed joint negotiations on brand name drugs and price reductions on 14 generic drugs with over $315 million in combined annual savings.

This is a good start, but remember that Canadians spent roughly $35 billion on drugs in 2013 (42% of drug costs were from the public purse, 24% were personal and 34% covered by private insurance).

The Liberals have committed to renew the Health Accord and it sounds as if they will expand the pan-Canadian Pharmaceutical Alliance.

Editor’s note: Thanks to M. Pascal Charron, Canadian Medical Association, for some information and statistics.

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I don’t like paper. It’s not personal, but since my

first introduction to computers in 1983, my goal has been to use as little of it as possible. I haven’t suffered any

severe paper cuts, nor has my paper use been the curtain call for large numbers of trees, but over the years when I need to take notes I often do not have paper with me, and when I do, I tend to lose it and the information it contained.

My first attempts to go completely paperless were not particularly successful as the available technology provided an experience akin to looking at the world from murky water through a periscope while breathing with a straw. As the Internet and mobile devices became faster and technology allowed for increased screen size and clarity, my paperless experience became far more satisfying. I quickly adopted e-books, including medical journals and textbooks, as I discovered that my portable device could carry far more highly searchable information than my tattered Washington Manual or even the shelf full of medical textbooks at my office. I gave up the smell of freshly printed books and the tactile pleasure of turning pages for the convenience, availability and flexibility of backlit text and interactive graphics.

The next hurdle in my paperless quest was to find some way to organize the many updated websites, teaching tools, videos, clinical pathways and other medical information that was coming from many different sources. I, like some 74% of my peers,1 had become a ‘digital omnivore,’ using at least three different devices to access information. I needed something that would allow me to efficiently produce visually appealing, easily searchable notes that would be readily available across all of my devices. The solution had to be inexpensive and reliable.

Paper cuts and saving treesDR. GADGET

Wesley D. Jackson, MD, CCFP, FCFP

>

22

It has been years since I have had a paper cut.

Both Evernote and OneNote are excellent choices for those who wish to take the leap into a paperless world.

About three years ago, I discovered Evernote,2 an app that allowed me to accumulate my favorite digital scraps, web clippings, reminders, patient handouts, audio recordings, pictures, clinical guidelines, doodles and so on in a highly searchable format. I was able to access this collection from any device, as long as I could remember my password. I also learned that I could share my favorite information en masse with my friends and colleagues, allowing them to add their own digital discoveries to my accumulating knowledge treasure. This dependable service is free, assuming less than 60 MB of data is used each month (often enough for most) and that the user is content with the information only being available with Internet access. A fee of about $30 per year will give up to 1 GB of data and the ability to store the information on your device.

OneNote by Microsoft3 has been available for Windows users for many years, but, within the last year or so, has been upgraded and made available for most devices. It offers a visually appealing interface in which each note is a blank canvas allowing for entry


23of blocks of text, PDF’s, images, audio recordings and almost any other element. OneNote also allows for handwritten input with a stylus (or your finger if necessary) anywhere within the note. Like Evernote, OneNote allows for sharing with colleagues, including the ability to do ‘live editing’ on the same document. This app is free and includes the ability to store all information locally and 1 GB of data per month, plenty of space for all but the super-users.

Both Evernote and OneNote are excellent choices for those who wish to take the leap into a paperless world. Personally, I moved all of my Evernote data to OneNote a few months ago as I am a very visual person and the organization and presentation of my data in OneNote is more important to me than the more advanced web-clipping and searching

> capabilities of Evernote. Now, when my student asks me about anti-CCP, I simply search ‘CCP’ in OneNote and am able to quickly find the recent Alberta College of Family Practice ‘Tools for Practice’4 regarding its utility in the diagnosis of rheumatoid arthritis and direct my student to several valid references.

Paper has been an incredibly important contributor to our civilization for more than two millennia and continues to have utility in our society. However, even Dr. Gadget will admit that paper has some functions that electronic devices will never comfortably replace (example: https://www.youtube.com/watch?v=ksO35s3Bffc). It has, however, been years since I have had a paper cut ...

References available upon request.

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In August 1914, Alberta was too new, too young and had too

few doctors and medical institutions to make an organized contribution to the Canadian Army Medical Corps. Instead,

individual physicians voluntarily enlisted in exceptional numbers and contributed from the home front to the battle fronts in France.

Two of the most significant individual contributors were Drs. Allan C. Rankin and Harold A. Orr. Together they identified the new Trench Fever syndrome (Rankin) and designed a heat chamber to kill the lice source in the soldiers clothing (Orr) that led to its spread and recurrence. Their contributions avoided the hospitalization of hundreds of thousands of allied soldiers and the misery that accompanied the infection.

Dr. Orr was appointed the medical officer of the 3rd Canadian Rifles.

After his transfer to the #3 Canadian Sanitation Section, he was directed to find a way to delouse the clothing of soldiers in the Canadian rest and rehabilitation centers in England. Initially he used sulfur fumes from coke-heated ovens but soon discovered that the important element was heat. A temperature of 60°C (20° above body temperature) for 10 minutes was effective.

Dr. Orr designed a simple and economical unit that became known as the “Orr disinfestor” in late 1915. It was a 7’ x 14’ x 5’ dugout that used a double tent or galvanized tin linings covered with one foot of dirt. Heated with one or two coke braziers, it provided an even heat. Adding rails with clothes racks, it could delouse the clothes of 1,000 men in a day. Orr huts became commonplace at the Canadian army respite facilities and were mandated for American and allied troops in 1917.

Although lice infections were not fatal, their effects were debilitating and demoralizing. Typical hospitalized cases had a temperature of 39-40°C, with fainting, vertigo, frontal headaches, back pain, nausea and general malaise lasting three days. Relapses were common. No treatment worked other than symptomatic therapy and delousing clothes to avoid recontamination.

There were over 17,000 hospitalized trench fever cases amongst the Canadian soldiers, including 14 deaths. At its peak, trench fever patients occupied up to 25% of all Canadian hospital beds in France.

By the end of the war, Lt. Col. Orr had been awarded an OBE, mentioned in dispatches twice, and was given the prestigious silver Medaille des Epidemies by the French government.

Demobilized, Dr. Orr returned to Edmonton where he was appointed the provincial Director of Venereal Disease (VD) Control. He wrote the first VD Control Act in Canada (1919). Later he introduced mandatory reporting requirements, and premarital and prenatal blood testing for syphilis.

Determined to continue his interest in public health, Dr. Orr took his Diploma in Public Health (DPH) at the

24 FEATURE

Lice. The Orr disinfestor. Venereal disease. Alberta’s first dermatologist makes a lasting imprint in war and peace

J. Robert Lampard, MD

Dr. Orr designed a simple and economical unit that became known as the “Orr disinfestor” … it could delouse the clothes of a 1,000 men in a day.

Alberta was fortunate Dr. Orr came to the province following his 1911 graduation from the University of Toronto (U of T) at 21. His first position in Medicine Hat was as the medical director of the isolation hospital and the part-time medical office of health. Following Dr. Malcolm Bow’s initiative after the Regina tornado, Dr. Orr minimized the spread of typhoid fever by introducing daily, early morning sewage removal.

During his hospital rounds, he met Margaret West, a nurse from Sainte-Foy, Quebec. Both enlisted to serve in World War I (WWI). Nurse West was sent overseas to Étaple, France. Following military medical training, >


25U of T in 1920. From 1921-23 he studied current VD drug and fever treatment at the London Hospital in England. He extended his studies to Europe and expanded his knowledge into the new field of dermatology.

Dr. Orr returned to Alberta in 1923. He would remain head of the surveillance program until 1951. With his interest and training in skin problems, he was appointed the first head of dermatology in 1925, holding that position until 1952 when he was succeeded by Dr. Paul Rentiers. For many years Dr. Orr was the only trained dermatologist in the province.

Through surveillance studies he found positive Wasserman’s (for syphilis) existed in 10% of the population and 25% of those in the jails. Under his supervision, the rate in the jails dropped to under 3%, facilitated by closing bawdy houses and by the discovery of penicillin.

In 1930, Dr. Orr received his FRCP from the newly formed Fellowship in the Royal College of Physicians and Surgeons of Canada. He would again go back to his dermatological studies to earn an FACS in 1940. During World War II (WWII) he was a consultant to the Canadian army for venereal and dermatological diseases.

A dynamic teacher, Dr. Orr loved to present live cases to students, which they easily remembered many years later as instruction highlights. Unhappy with the current textbook, he joined mycologist Dr. Silver Keeping to write a new one on fungal diseases. Although not a prolific author, he had 25 papers published in the British and Canadian medical literature.

Administratively respected, Dr. Orr was elected president of the Edmonton Academy of Medicine in 1933, the Canadian Dermatological Society in 1937 and the Alberta Medical Association in 1946. In his community he chaired the Edmonton Board of Health for five years, the Community Chest for two years, and was on the Edmonton Museum of Art Board for 10 years, including several as its president. His office was a rotating gallery of Leightons, Grandmaisons and Japanese woodcuts all from his own collection.

Alberta colleagues had long recognized his leadership ability, dedication to the profession, brilliance of mind and thought, boundless energy and enthusiasm, incisive and decisive intellect, scrupulously fair approach to everything in his life, as well as his vitality and time-tested organization skills.

It was not surprising that in 1952 Dr. Orr was elected the fourth president of the Canadian Medical Association (CMA) from Alberta and the first from Edmonton. His presidential year was to be the highlight of his dedication to his profession.

As CMA President, Dr. Orr resolved to visit every region of Canada. During a visit to the maritimes, he was accompanied by guest speakers Drs. Donald R. Wilson and Walter C. Mackenzie. While there, Dr. H.E. McDermott encouraged them to form a branch of the Alpha Omega Alpha Society in Alberta, which followed.

One notable achievement during his tenure was to secure the approval of Princess Elizabeth to be the patron of the CMA.

While on an international tour to the World Health Conference in Europe in October 1952, he developed angina and was hospitalized in London for three weeks, then four weeks in New York, before he reached Toronto. There he unfortunately suffered another heart attack and passed away on December 26 at age 62.

As one of his colleagues acknowledged after his death, “he made his contributions to humanity in full measure.”


Dr. Harold Orr, August 1916, Shorncliff, England. ( provided by Orr family archives)

Dr. Harold Orr, University of Toronto graduation in 1911. ( provided by Orr family archives)

>


“Here’s to alcohol, the cause-of and solution-to all life’s problems.” — Homer Simpson

An old friend, John (master raconteur and recently retired obstetrician and gynecologist) and I were chatting about alcohol

over drinks (herbal tea and a tablet of thiamine B1). We veered onto the approaching dementia epidemic and whether it might swell due to the chronic effects of alcohol on the lengthening human brain’s physical lifespan. It’s risky pontificating on a topic in which one has little scientific expertise (although that’s never stopped me) but as subjective alcohol experts, John and I can stand our ground with anyone. Here’s a rough transcript of our conversation:

Alexander H.G. (Sandy) Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

longer and are at increased risk from the harmful effects of excessive alcohol – blood dyscrasias, hypertension, cardiac failure, gastro-intestinal complications, etc., and cognitive function.

John: Younger doctors need to be aware that the guidelines from Health Canada may be okay for younger drinkers but alcohol intake in the oldies can lead to unpredictable effects on memory, behavior and general cognitive function. Alcohol is best reduced to a minimum.

Sandy: Agreed. Two years ago I found myself locked out of a London hotel third floor room at 4 a.m. completely naked, mistaking the main door for the bathroom door; this occurred after jet lag, only four drinks at the Chelsea Arts Club and a prophylactic ibuprofen. Security was called: “Don’t worry, sir. It’s not the first time this has happened …” So we know what we’re talking about! What’s the point of possible protective effects on the cardio-vascular system, if you’re losing your marbles?

John: When did you first start to lose your marbles?

Sandy: I’ve had an up-and-down relationship with alcohol. As a teenager it was a love affair. The liver’s ability to detoxify alcohol is genetic and I was lucky to have (in those days) high levels of alcohol dehydrogenase – a happy end-result of millennia of ruthless Darwinian winnowing out of lesser livers.

At 17 I went to school in Paris. At the Lycee, lunch was amazing – we had wine! Although diluted with water, we slugged it back.

My hosts were evening announcers on French TV, so around 5 p.m. I was presented with a meal on a tray with a large bottle of beer and a bottle of wine. “Vous pouvez diner quand vous voulez, Alexandre,” Mme Brayer would say and she’d leave for her work. Being a well-brought-up lad who knew it was polite to finish everything, I later discovered that I had astonished my hosts by nightly downing both bottles.

Booze and the boomers

IN A DIFFERENT VEIN

>

The post-war baby-boomers are living longer and are at increased risk from the harmful effects of excessive alcohol.

26

John: The pendulum of permissiveness in drinking has swung too far. Scenes of riotous, animal behavior on Edmonton’s Whyte Avenue and other areas, and 11th Avenue in Calgary where police have to stand by and watch because there’s not much they can do, have become sickening. The tragedy of alcoholism in the young and fetal-alcohol syndrome (FAS) in the unborn is abominable and reminiscent of Hogarth’s Gin Lane (see illustration). Some one-third of people diagnosed with FAS end up in jail, often with severely diminished mental capacity.

Sandy: And a related problem is Canada’s demographic aging. The post-war baby-boomers are living


27 A few of us would meet in the evening for a stroll down the Rue Saint-Denis to Les Halles where porters unloaded fruit and vegetable trucks. Lurking in the shadows were an array of French hookers. We’d order “un demi” in a café and watch them conducting business.

Not all was well. I developed a localized morning headache in the right frontal sinus and after battling my way to the Lycee on the metro, packed tight, with the reek of garlic from an unshaven passenger blowing in my face. I’d stop at a brasserie for a shot of brandy before school, finding that the headache magically disappeared.

John: Drinking stories are always good for a chuckle, a proffered free drink is always acceptable as a sign of goodwill and alcohol does break the ice at a party. Never refuse a drink from an Irishman or Scotsman (the latter being a fairly rare event). And as Ogden Nash wrote in Reflections on Ice-Breaking:

“Candy is dandy but liquor is quicker.”

The British comedian Tommy Cooper used to spend a lot of money on tips until he found a solution to his problem: he carried a pocketful of tea bags. Getting out of a taxi, he’d press one into the hand of the driver: “Have a drink on me.” The laughter usually allowed a quick exit. Caution: this might not work with the head waiter at a smart Edmonton restaurant.

Drunks and drinking have been a wellspring of clowning. But the archetypal tipsy flaneur in evening garb dancing with a lamp post is no longer hilarious. A clever raconteur and public speaker, Sheriff Irvine Smith, used to say of Scotch whisky: “It’s not the taste that matters, it’s the ideas it puts into your head – unfortunately not all the ideas are good ideas.”

And booze put a few ideas into the heads of Sir Winston Churchill and Franklin D. Roosevelt who conducted much of the strategy of the World War II in a cigar haze of cocktails, fine wine, brandy and Scotch whisky usually starting at lunch and coming to a grand finale at midnight. Adolf Hitler, on the other hand, was a vegetarian and almost a teetotaler. This has perhaps led to a spurious popular feeling that alcohol might lead to grand plans and that teetotalers were losers.

“I feel sorry for people who don’t drink. When they wake up in the morning, that’s as good as they’re going to feel all day.” – Dean Martin.

Sandy: It’s difficult to spot excessive drinking. A pharmacist friend, and a successful 15-year Alcoholics Anonymous (AA) graduate, tells me: “The world’s best actors aren’t at the Oscars. They’re in the detox centers in any big city.”

On a visit to Scotland (20 years ago) I was drinking with an old friend in Glasgow. We drank a bottle of Johnny Walker. The conversation soared. We retired to bed at 3 a.m., leaving the required finger’s worth at the bottom of the bottle for the gods.

At 7 a.m., I was woken by someone breezing into the bedroom. My joints ached, head pounded and my cheek sought a cool piece of pillow like a baby at the breast. It was John, fully dressed and off to work. “Hey! Johnny Walker, wakey, wakey!”

I emerged at noon, head still tender, amazed he’d put in a full day at work.

So when I heard he’d been admitted to hospital for a hernia repair and the day after surgery he’d had a grand mal seizure, and in his absence from home his wife had found a stash of bottles, the penny dropped. John was a drinker with a liver teeming with alcohol dehydrogenase. The sudden withdrawal of alcohol had led to his alcohol-dependent neurons rebelling and firing off his diagnostic whisky fit.

He spent the next two years attending AA meetings down in London. (“It’s a really interesting group, Sandy. Movie stars, politicians, business titans. We don’t let just anybody in.” He named a few and I whistled: “Wow. I had no idea.”)

Hogarth's Gin Lane. ( provided by public domain)

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>


28 > It has now become a major plank of public health policy in the United Kingdom (UK) as a result of a series of studies – most recently by Rao et al.1

John: “Elderly people warned over alcohol consumption” screamed the British Broadcasting Corporation and all major UK newspapers in August this year. The study from King’s College explored the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation in 27,991 people aged 65 plus, using a primary care database. 9,248 older drinkers were identified, of whom 21.4% drank “above safe limits.” Compared with other older drinkers, older “unsafe drinkers” had a higher proportion of males, white and Irish ethnic groups and a lower proportion of Caribbean, African and Asian groups. Socioeconomic deprivation and comorbidity were not significant predictors of unsafe alcohol consumption in older drinkers. Sadly, no morbidity data were given – a hard study to do.

Sandy: The National Institute on Alcohol Abuse and Alcoholism (of the United States National Institutes of Health) recommends that over age 65 you should have no more than seven drinks a week and no more than three drinks on any one day. That sounds too much for older people, especially smaller, thinner women and especially if they use alcohol regularly, for example, as a nightcap. Do you have a health problem? Are you taking medicines that could interact? You may need to drink less or not drink at all.

Some think that drinking hooch provides protection from many ailments, but the evidence is thin indeed:

“Alcohol may have both a neurotoxic and neuroprotective effect. Brain imaging in the elderly show that excessive alcohol consumption may increase the risk of cognitive dysfunction and dementia, but low to moderate alcohol intake may protect against cognitive decline and dementia and provide cardiovascular benefits. However, because of varying methodology and lack of standardized definitions, these findings should be interpreted with caution.2

An otherwise excellent document from the College of Family Physicians of Canada in 2012 mentions but doesn’t emphasize the necessity to scale down daily drinking in the elderly.3 Surely this is a priority. Ten drinks a week for women, with no more than two drinks a day most days and 15 drinks a week for men, with no more than three drinks a day most days sounds way too much for old geezers like you, John.

John: Alcoholism is a malignant addiction and has been the ruin of many a poor boy (and girl) – but also many a poor middle-aged soul and – now – it seems it may be contributing to late-age dementia. It’s ruined marriages; it’s a major cause of domestic violence and crime; it kills on the roads; and has wreaked havoc in the native communities of North America (who genetically have low levels of alcohol dehydrogenase and get drunk more easily than other racial groups). It’s pretty good, though, for getting you to leap from muddy trenches blasting away with your .303 rifle:

Inspiring bold John Barleycorn! What dangers thou canst make us scorn! Wi' tippeny, we fear nae evil; Wi' usquabae, we'll face the devil! — Robert Burns.

Midnight on Whyte Avenue, Edmonton, is the most unpopular beat for the city’s finest. 11th Avenue is similar in Calgary. These police officers have to endure being sworn at, spat on, called names. They have to break up brawls and look to distressed men and women who have been stabbed or shot. They hate it.

Says Joe Marshall, a retired policeman from Edmonton: “The solution (if there is one) lies partly with proper training of staff in licensed premises from managers to bouncers. When they are held accountable for over-service and poor behavior, it makes a difference.”

>

What’s the point of possible protective effects on the cardio-vascular system, if you’re losing your marbles?

Sandy: In the elderly, common triggers for excess drinking are retirement, sleeping difficulties, loneliness, pain, devastating illness and depression. Social drinkers can escalate to unsociable drinkers. Affluence is actually a risk factor.

Alcohol intake in the elderly may be contributing to a rise in mild cognitive impairment and even dementia and many are becoming “concerned” (as people in Canada like to say). Even regular moderate drinking – while better than excess – may itself be thinning the number of working neurons as the years go by.


29John: “It was the first of May A lovely warm spring day I was strolling down the street in drunken pride, But my knees were all a-flutter, And I landed in the gutter And a pig came up and lay down by my side.

Yes, I lay there in the gutter thinking thoughts I could not utter when a lady passing by did softly say 'You can tell a man who boozes by the company he chooses' – and the pig got up and slowly walked away.” — Anonymous – Public Domain.

Sandy: “Although rates of alcohol-related dementia in late life differ depending on the diagnostic criteria used and the nature of the population studied, a consensus is emerging that alcohol contributes to the acquisition of cognitive deficits in late life.”4

John: Engaging licensees and their staff to promote better behavior; mandatory warning labelling on bottles of beer, wine and liquor; a ban on the advertising of liquor (as are tobacco companies now); stiffer sentences for drunk driving and bad behavior. In Norway, the limit for alcohol and driving is 0.2 mgs/100 mls blood.

Sandy: Anything we can do to lower the complications of excessive alcohol drinking in the young and the probable coming rise in cognitive dysfunction in the elderly is worth doing. I’d suggest one or two glasses of wine or beer a day for younger people and for the over 65’s no more than one a day, two on a birthday and three at a funeral …

Editor’s note: This story featured Dr. John Boyd as Dr. Alexander (Sandy) Paterson’s conversation partner.


CUMMING SCHOOL OF MEDICINE Office of Continuing Medical Education and Professional Development

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DECEMBER 3-4, 201525th Annual Calgary Pain Conference

DECEMBER 11, 2015Friday at the Medical School: Choosing Wisely

JANUARY 22, 2016 Common Fractures and Dislocations Course

JANUARY 22, 201618th Annual Rural Anesthesia for GP Anesthesiologists

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JANUARY 22-24, 201632nd Annual Emergency Medicine for Rural Hospitals

Two years ago I found myself locked out of a London hotel third floor room at 4 a.m. completely naked, mistaking the main door for the bathroom door; this occurred after jet lag, only four drinks at the Chelsea Arts Club and a prophylactic ibuprofen.

>


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30

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31EDMONTON AB

Two positions are immediately available at the West End Medical Clinic/M. Gaas Professional Corporation at unit M7, 9509 156 Street, Edmonton AB T5P 4J5. We are also looking for specialists; internist, pediatrician, gynecologist and orthopedic surgeon to join our busy clinic. Full-time family physician/general practitioner positions are available. The physician who will join us at this busy clinic will provide family practice care to a large population of patients in the west end and provide care to patients of different age groups including pediatric, geriatric, antenatal and prenatal care.

Physician income will be based on fee-for-service payment and the overhead fees are negotiable. The physician must be licensed and eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA), their qualifications and experience must comply with the CPSA licensure requirements and guidelines. We offer flexible work schedules, so the physician can adopt his/her work schedule. We also will pay up to $5,000 to the physician for moving and relocation costs.

Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 F 780.756.3301 [email protected]

EDMONTON AB

Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC) want you. To meet the growing needs, we have a practice opportunity for family physicians at PMC and MMMC. Both clinics are in south Edmonton. PMC and MMMC are high-patient volume clinics with friendly reliable staff for billing, referrals, etc., as well as an on-site manager. Enjoy working in a modern environment with full electronic medical records. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatric). Both clinics have on-site pharmacy, ECG machine, lung function testing and offer a large array of specialist services including: ENT, endocrinologist, general surgeon, internist, orthopedic surgeon, pediatrician and respirologist.

PMC and MMMC are members of the Edmonton Southside Primary Care Network which allow patients to have access to an on-site dietitian and mental health/psychology/psychiatry health services. Overhead is negotiable, flexible working hours and both clinics are open seven-days-a-week.

Contact: Harjit Toor T 587.754.5600 F 587.754.8822 [email protected]

EDMONTON AB

Family medical clinic in west Edmonton is seeking part- and/or full-time family physicians. We offer flexible hours, low overhead (negotiable), fully computerized clinic using Mediplan electronic medical records. The clinic is associated with Edmonton West Primary Care Network

Contact: Dr. Patocka T 780.487.7532 [email protected]

> EDMONTON AB

Dx Medical Centres is a new, spacious and modern clinic in Mill Woods with high-visibility exposure in a busy residential area. We are looking for general practitioners for the growing practice to join our team working collaboratively with multiple disciplines of the health care field.

Our clinic offers a pleasant working environment in a contemporary facility. The clinic is paperless with excellent support staff. We would like to offer you the opportunity to work in an enhanced practice environment that fits your lifestyle, needs and availability without investment or administrative time commitments. We provide competitive split to our valued physicians on a fee-for-service schedule.

Candidates must be licensed or eligible to apply for licensure with the College of Physicians & Surgeons of Alberta.

Contact: Christina T 780.705.8400 [email protected] >

PHYSICIAN(S) REQUIRED FT/PT

MILLWOODS EDMONTON

Also locums required

Phone: Clinic Manager (780) 953-6733 Dr. Paul Arnold (780) 970-2070

ALL-WELLPRIMARY CARE CENTRES


32 EDMONTON AB

Family physicians needed in Edmonton. The Beverly Towne Medical Clinic is a new medical clinic in Edmonton at 11730 34 Street. (The clinic is operated by the Beverly Medical Clinic Inc.)

We are currently seeking three family physicians to join this new practice.

Terms of employment and wages: These family physician positions are permanent, full-time, fee-for-service with anticipated annual income of $300,000. The physician and the clinic will share fee-for-service billings, 70% (physician) and 30% (clinic) for overhead expenses.

Flexible work hours: The clinic is open 9 a.m. to 9 p.m. during the week, and also on weekends, allowing physicians to have flexible work hours and flexible work arrangements.

Job duties: The physician will be providing primary care to patients of the Beverly Towne Medical Clinic, including diagnosing and treating medical disorders, interpreting medical tests, prescribing medications, and making referrals to specialist physicians as appropriate.

Education and experience: Medical degree with specialist training in family medicine. Preference will be given to candidates with family practice experience and candidates must be eligible for registration with the College of Physicians & Surgeons of Alberta. Preference will be given to candidates that are College of Family Physicians of Canada certified and preference will be given to Canadian citizens and permanent residents.

Skills required: Specialist training in family medicine; ability to work effectively, independently and in a multidisciplinary team; effective written and verbal communication skills.

Contact: Dr. A. Elfourtia or Dr. Z. Ramadan T 780.756.7700 C 780.224.7972 Beverly Towne Medical Clinic 11730 34 St Edmonton AB T5W 1Z1

EDMONTON AND FORT MCMURRAY AB

MD Group, Lessard Medical Clinic, West Oliver Medical Centre and Manning Clinic each have 10 examination rooms and Alafia Clinic with four examination rooms are looking for six full-time family physicians. A neurologist, psychiatrist, internist and pediatrician are required at all four clinics.

Two positions are available at the West Oliver Medical Centre in a great downtown area, 101-10538 124 Street and one position at the Lessard Medical Clinic in the west end, 6633 177 Street, Edmonton. Two positions at Manning Clinic in northwest Edmonton, 220 Manning Crossing and one position at Alafia Clinic, 613-8600 Franklin Avenue in Fort McMurray.

The physician must be licensed or eligible to apply for licensure by the College of Physicians & Surgeons of Alberta (CPSA). For the eligible physicians, their qualifications and experience must comply with the CPSA licensure requirements and guidelines.

The physician income will be based on fee-for-service with an average annual income of $300,000 to $450,000 with competitive overhead for long term commitments; 70/30% split. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records (paper free) and member of a primary care network.

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Work with a nice and dedicated staff, nurse available for doctor’s assistance and referrals. Also provide on-site dietician and mental health/psychology services. Clinic hours are Monday to Friday 8:30 a.m. to 8:30 p.m., Saturday and Sunday 10:30 a.m. to 5 p.m.

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HIGH PRAIRIE AB

High Prairie Medical Clinic is seeking two permanent full-time family physicians. High Prairie is 368 kilometers from Edmonton and 201 kilometers from Grande Prairie.

We offer flexible work schedules with Healthquest electronic medical records, very pleasant working conditions and friendly, helpful staff.

Physician must be licensed or eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA). For eligible physicians, their qualifications and experience must comply with the CPSA license requirements and guidelines.

>

>


33The physician’s income will be based on fee-for-service payment with a very attractive contract. No investment.

For more information and to submit your CV by fax.

Contact: Dr. R. Laughlin President, High Prairie Medical Clinic T 780.523.4501 (clinic) C 780.523.7477 F 780.523.4800 or Nancy Starko Business Manager, Physician Services T 780.523.4501 (clinic) C 780.523.7658 F 780.523.4800

ST. ALBERT OR SPRUCE GROVE AB

Flexible, part- or full-time work in a friendly, relaxed environment. True Balance Medical Spa is seeking a physician to provide medical-spa services and act as medical director in our St. Albert or Spruce Grove location.

> As a regional leader in the industry, we are a well-established medical spa with three locations in the Edmonton area. Our vision is “A Better U” and our mission is “Enriching lives with premier products and services delivered with integrity.”

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PHYSICIAN AND/OR LOCUM WANTED

EDMONTON AB

Summerside Medical Clinic and Edge Centre Walk-in Clinic require part- and full-time family physicians, specialists and locums are welcome. The clinics are in the vibrant, rapidly growing communities of Summerside and Mill Woods. Examination rooms are fully equipped with electronic medical records, printers in all examination rooms and affiliated with the Edmonton Southside Primary Care Network.

The Edge Centre has 5,000 sq. ft. and can accommodate other medical professionals such as dentist, massage therapist, physiotherapist, chiropractor, etc.

Contact: Dr. Nirmala Brar T 780.249.2727 [email protected] >

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34 SHERWOOD PARK AB

The Sherwood Park Primary Care Network is looking for several physicians to cover a variety of locum periods in a variety of Sherwood Park offices. Practice hours vary widely. Majority of practices run electronic medical records. Fee splits are negotiated with practice owners. Some practices are looking for permanent associates.

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Dr. Patti Farrell & Associates is a new busy modern family practice clinic with electronic medical records and require locum coverage periods throughout 2015. Fee split is negotiable. Current clinic hours are Monday to Friday 8 a.m. to 4 p.m. are negotiable. Dr. Farrell is a lone practitioner (efficient clinic design built for two doctors) looking for a permanent clinic associate.

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>

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DISPLAY OR CLASSIFIED ADS

“THE ADVICE I GET FROM MD MAKES ME FEEL SECURE.”

1 Fifty-three per cent of Canadian Medical Association members trusted MD Financial Management as their primary financial services firm, four times more than the next closest individual competitor at twelve per cent. Survey respondents (MD clients and non-MD clients) were also asked to identify their primary financial institution (MD or Other), and rate their level of trust associated with that institution. MD received the highest trust rating compared with all other firms rated. Source: MD Financial Management Loyalty Survey, June 2014.

MD Financial Management provides financial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca. Incorporation guidance limited to asset allocation and integrating corporate entities into financial plans and wealth strategies. Professional legal, tax and accounting advice regarding incorporation should be obtained in respect to an individual’s specific circumstances. Banking products and services are offered by National Bank of Canada through a relationship with MD Management Limited.

– Dr. Placide Rubabaza, Obstetrician and Gynecologist

EVERY PHYSICIAN HAS A STORY. HEAR MORE FROM YOUR PEERS: MD.CMA.CA/MYSTORY

FOUR TIMES MORE PHYSICIANS TRUST MD.1

“MD offers a comprehensive package that covers all aspects of business and personal financial planning—specifically for doctors and their families. MD makes me feel that I’m taken care of in terms of preparing for the future and planning for my family. I’m confident that MD is looking after my investments, which means I can focus on what I do without worrying about day-to-day financial investments. I believe that MD has my best interests in mind at all times.”

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