What providing medical care in a refugee camp is like — and why it should matter to physicians here at home
It’s the girl in the red dress that haunts me.
I first saw her when I sat in a refugee tent, listening to a woman tell me about the horrors she’d lived through: her baby snatched from her arms and tossed into a burning homestead; her husband’s throat slit in front of her; how she endured rape over a two-week period. It was all too much to bear, but then I saw the woman’s daughter, sobbing silently in the back of the room. The girl was about 12 — the same age as my daughter — barefoot and wearing a filthy red dress.
As I looked at her, my heart sank; her mother’s account was horrifying, and it was devastating to know this girl was a part of it all. My daughter is worried about volleyball try-outs; she bristles over the injustice of the lack of a girl’s rugby team at school. That girl in the red dress will forever be haunted by her father’s murder, and will have to live with her PTSD-ridden mother in a makeshift refugee camp alongside thousands of other traumatized survivors. I never got the girl’s name, but her eyes are seared into my memory. I met this girl on my first trip to a Rohingya camp, and her tears are part of what drives me to continue to work and advocate for these refugees.
I have made several trips since then, and having returned recently from one, I thought it was important to share some reflections with my fellow physicians — both those who have done this kind of work, and those who may have never heard much about these issues.
The medical clinics I worked in were packed full of patients. Skin diseases were common, as people were living in hot, humid and cramped spaces, usually with up to eight people sharing one tent. I saw lots of children with recurrent diarrhea and upper respiratory tract infections, and many of these children came alone to the clinic with their toddler and infant siblings. I didn’t know how to take the full medical history of an infant from an eight-year-old.
These conditions also make the situation dire for those with chronic health conditions. A surgeon from the Turkish field hospital told me how devastated he was to see the complications diabetic patients were experiencing. He showed me one young patient who had his leg amputated due to infection, as his diabetes was not treated. Since there’s no electricity, people are unable to keep insulin, and are thus getting very sick due to inadequate treatment. This is the same for kidney failure patients; I was told that although there’s a lab available at the field hospital, they are unable to do any further treatment. I was also told by other doctors that the Rohingya people cannot leave the camps under any conditions, not even if they are about to die.
On this trip I also reconnected with Gulbahar, a woman I met in 2018 when she brought her two young grandchildren to the medical clinic. She told me how she escaped from Myanmar and brought her grandchildren to Bangladesh with the help of neighbours, after her son and daughter-in-law were murdered by the Myanmar army. She herself was very sick at that time; her body was skin and bones. I suspected she had some underlying cancer and took her to a Malaysian field hospital, but she couldn’t get treatment there as no one was able to take care of her grandchildren.
Last month when I returned, I asked my colleague, Bangladeshi physician Dr. Mosleh Uddin, if Gulbahar was still alive. I was glad to learn that she was, so I asked Dr. Uddin to call her back to the clinic, and she recognized me and was glad to see me. I asked her how she was doing, and if she needed anything; she told me that she needs everything, as she has nothing. I gave her some money to buy food, and she was crying towards the end in appreciation. I asked her if she needed anything else, and she said something so profound that I recorded it on my phone. She thought of me as one of the policy makers, deciding what to do with the Rohingya refugees, and she told me not to send her back to Burma — that she would rather die underneath some truck in Bangladesh than go back there.
Among these stories of extreme brutality, there are many stories of great humanity. I am humbled by this contrast, and the Rohingya people have inspired me with their resilience. I also draw inspiration from colleagues like Dr. Uddin; he’s been working in the camps since the Rohingya refugee influx began more than two years ago. I met him in 2017, and continue to work with him every time when I go back. I have heard from a few patients in his medical clinic about his life-saving efforts that go beyond basic medical care: how he has helped them buy formula for their babies, how he’s transported sick people to a local hospital and lived with those patients there for days. These are just a few examples of the noble acts he performs every day.
I met local Bangladeshi people who were busy day and night helping build shelters, arranging for children’s education, maintaining toilets and distributing food, all mostly for free. Spending just a week in those camps is extremely difficult, and these Bangladeshi volunteers are doing it for months on end. I was impressed by their attitudes, and how they still managed to smile politely every time I talked to them.
Connecting this to our lives here in Alberta, I think it is very important for us as medical doctors to get involved with some sort of humanitarian work. Physician voices are very important, and when we speak against human right issues and genocide, people listen. In this corner of the world we don’t often see these kinds of things, but our small efforts can make a huge impact, and I encourage all of you to get involved with this kind of work in some way.
I have met Turkish Red Crescent people — one of Turkey’s largest humanitarian
groups — in Bangladesh, and was impressed by their tireless work on the ground. Their on site manager showed me the Red Crescent hospital, where the operation theatre was fully functional, but was closed due to the lack of surgeons available. This is just one example of how my Alberta colleagues can donate their time, by going there to work for even just a few days. If you’re interested in humanitarian work, this is a great opportunity to step up: we need surgeons, pediatricians, OB/GYNs, infectious disease specialists, family doctors and anesthesiologists.
I never realized that the hardest part of seeing crimes like this in real time is gathering the strength to keep going: fundraising, increasing awareness, and spending days working in humid 40-degree weather in a cramped field clinic. Sometimes my efforts end up feeling meaningless; the Rohingya are still there, Myanmar still feels no need to stop wiping them out, and at times it feels like I’m ultimately just helping delay their demise. I have received lots of support from my fellow Canadian doctors for my causes, and they are a big part of what encourages me in these times of hopelessness. If nothing else, your involvement in this cause will let the victims know someone that cares, and they are not forgotten. Please donate, write to an elected official, or even simply tell a friend or family member about this issue. In the best case scenario, you’ll have played a small role in mitigating a genocide, and in the worst case, you’ll have fulfilled a commitment to your fellow human beings. After all, as physicians we are guided by the principle that each human life is precious, and equal — even the ones far away from home.
If you are interested in working overseas like Dr. Alvi, or would like to get involved with this cause somehow, please visit humanityauxilium.com.
Fozia Alvi, MD Airdrie, Alberta
We claim to value mental health.
So why don’t the numbers add up?
Calls for increased and better access to mental health services have reached an all-time high, but the public dollars to support this outcry are still too low to address needs here in Alberta, and throughout the rest of Canada. This funding discrepancy, or spending disparity, represents a persistent issue in our healthcare system: mental health is not afforded nearly as many resources as physical health.
What does this funding discrepancy look like?
This is a national issue, and here in Alberta, advocates have indicated that funding discrepancies for mental health is a recurring feature in the province’s health spending. In advance of the most recent election, the Alberta chapter of the Canadian Mental Health Association (CMHA) released a call for increased funding for mental health services in the provincial budget. The organization suggested an increase from 6 per cent to 12-13 per cent of the health budget, which would put the province on par with other jurisdictions in Canada for mental health spending. The Alberta government acknowledged this spending disparity in the 2015 report, ‘Valuing Mental Health’, stating that based on the best available research, 9 per cent of an overall budget should be the minimum allocation for mental health. Whatever the ideal number, it’s clear that current spending is falling short.
In September, the UCP government committed $140 million over four years to add more than 4,000 beds for substance use treatment and other addiction services. While this is important, it’s addressing just one facet of the myriad mental health concerns and treatment needs in Alberta. Both hospital and community-based mental health care remain severely underserved, in some cases leading to wait times of up to three years for specialty programs like the gender clinic, or up to two years for Dielectical Behavior therapy for Borderline Personality.
Due to factors like stigma and poor understanding of the complex intersection of physical and mental health, lack of funding is a global issue when it comes to treating mental health concerns. Though awareness efforts have grown tremendously in the past few years, the dollar signs to accompany this emerging culture of openness has lagged. Wait times for mental health beds in hospitals remain high, reaching up to two weeks in the emergency rooms in Calgary alone this past year. Even when family physicians refer patients to a psychiatrist, the wait can sometimes be months to years long — even though, as the CMHA reports, more than one million Albertans made an appointment to discuss mental health concerns with their primary care provider in 2017.
The Alberta government directly spent over $80,000 on mental health-specific programs in 2018 (that figure excludes front-line and/or acute delivery of mental health care). While that’s a more than 50 per cent jump from the year prior, it’s still significantly less than other spending areas, like primary healthcare at $231,511, and population and public health at $114,302.
There’s also a discrepancy when comparing mental health beds available in Edmonton and Calgary, the province’s two largest zones. In 2017, Liberal MLA David Swann lead and compiled a report for the NDP government which found that Edmonton had 97 beds per 100,000 people, while Calgary had just 67. Then-premier Rachel Notley noted that AHS had opened 30 beds in Calgary over the previous two years for various mental health treatment — but only three of those were for acute adult care. To achieve parity at that time, Calgary would’ve needed an additional 200 beds, which has yet to come to fruition.
In light of the recent MacKinnon report, in which a panel of experts provided health spending recommendations for the UCP, there is reason to expect cuts to various healthcare services in the coming years. The report discussed a troubling pattern in which the provincial government tends to spend more during economic upturns in the energy industry, only to have that cause a problem during an inevitable downturn later on. The report indicates that cutting back on frontline healthcare may be one of the only ways to salvage this overspending, which could further damage underfunded mental health services.
The cost of neglect
Some areas of healthcare — like physician compensation or infrastructure — will likely always require a larger share of public dollars. But mental health is directly tied to physical health, and if not treated, it results in a need for care that is urgent, ongoing, and costly in more than one sense. One section of the aforementioned ‘Valuing Mental Health’ report discusses what “maintaining the status quo” will mean to Albertans:
“If nothing changes, we need to be prepared for the consequences:
● Those with mental illness will continue to have shorter lives – mental illness can cut 10 to 20 years from a person’s life expectancy.
● Those with addiction and mental illness will continue to struggle with housing and homelessness, and be at higher risk of entering the criminal justice system.
● There will be more cases of addiction and mental illness, with increased pressures on health, social and justice systems.”
These consequences are widespread, and affect even those who are not personally experiencing mental health challenges, including patient families and those in the legal system. Moreover, Albertans have already been sacrificing more than their mental wellbeing as a result of this issue. The CMHA report summarizes why:
“Counselling services are out of reach for many Albertans; few publicly-funded counselling services exist. Most people who receive counselling are relying on their private insurance or pay directly. This is not the case in other provinces… Consequently, Canadians spend $950 million on counselling services each year—30% of it out of pocket.”
This shows not only that individuals are already paying steep fees for mental health care, but that those who can’t afford it privately are left to rely on an environment of limited, constrained resources.
The current situation with rising methamphetamine use in Alberta also serves as a good example of what the cost of neglecting mental health services can be. In 2018, Edmonton police reported seizing over 30,000 grams of the drug compared to less than ten thousand in 2013, and Calgary police dealt with more than 412 meth-related incidents by the end of last November, a staggering 536 per cent jump from five years prior.
Along with the harmful physical effects of the drug, up to 40 per cent of meth users experience transient psychotic symptoms, and chronic users are at high risk of developing ongoing difficulties with psychosis that can have devastating long-term consequences (1). Often times, users experiencing psychotic symptoms end up in the emergency room: Calgary ERs sometimes saw up to six of these patients per shift in 2018, with the average length of stay at 10 hours (2). This puts additional pressure on frontline health services, and is also a driver of burnout, as staff come up against the erratic and sometimes violent behaviour of these patients (2). The issue is compounded when patients may need longer term mental health care: if there aren’t enough resources for others in need to begin with, how will hospitals and treatment centres accommodate this fallout?
While the $140 million commitment from the UCP for treatment beds may address some of this need, those funds are targeted at detox and rehabilitation, not necessarily comorbid mental health conditions that may drive substance use, such as depression and anxiety. Comorbidity is the rule rather than the exception, and a focus on substance treatment alone neglects the complexity of mental illness. The recent methamphetamine situation exposes how the mental health funding discrepancy can leave us playing catch-up, and treating just one portion of a complex presentation in need of ongoing care.
An underlying cause
As physicians and as a society, we can say we care about mental health, but the numbers tell a different story; one where the system we operate within still doesn’t value mental health as much as physical health. The funding discrepancy demonstrates that we still don’t have an understanding of mental illness that includes the awareness of a need for a biopsychosocial approach for each patient, and early intervention. It shows that stigma remains pervasive, and has concrete, ongoing consequences.
While the recent past suggests that stigma against mental health will continue to decrease, there are current examples in our country of how this progress can and is being regressed. The Ontario government recently proposed limiting psychotherapy to 24 hours per patient, per year, as a way to offset the cost of mental health treatment. Psychiatrist Dr. Wei-Yi Song wrote in the Toronto Star that while this might filter out the “worried well” (i.e. patients who need less intensive mental health care) it will harm those facing severe mental disorders.
“Patients in hospital with refractory psychosis, severe depression or thoughts or plans to take their own life may see a psychiatrist on a daily basis for three to six months. Once stable enough to leave hospital, these patients often need up to an hour a week of intensive support for an additional six to 12 months,” Dr. Song wrote. “Do these proposed arbitrary limits perhaps reflect the burden of stigma affecting those with mental disorders?”
Knowing how widespread and persistent the underfunding of mental health is, it’s difficult to see how such policies are underpinned by anything other than stigma. The 2015 ‘Valuing Mental Health’ report echoes this sentiment: “People with addiction and mental illness often face attitudes of disrespect, fearfulness and, within the healthcare system itself, judgment.” And an environment of constrained resources takes a toll on care providers: “A lack of focused funding, inpatient beds, coordination, and accountability leaves service providers demoralized and exhausted, yet knowing that more could be done.”
Why this problem impacts all physicians
According to the Mental Health Commission of Canada and the College of Family Physicians of Canada, family physicians deliver up to two thirds of mental health care in our country (3). This is reinforced by the above CMHA statistic that over 1 million Albertans reached out to their primary care provider to discuss mental health in 2017. The link between cardiovascular disease — which accounts for the largest burden of disease in Canada — and poor mental health has been well established (4), and many common conditions with no clear anatomic cause have significant overlap with poor mental health (5).
What this demonstrates is that regardless of your specialization, with few exceptions, physicians of all disciplines are either directly treating mental health conditions, or are treating conditions influenced by a patient’s mental health, or lack thereof. Furthermore, it can be challenging for non-psychiatric specialties to manage mental illness in acute care settings, and the presence of a mental illness can impact a patient’s adherence with treatment.
If, as physicians, we don’t have a nuanced understanding of mental health, it will impede our ability to provide quality care in any setting, and will make it difficult to advocate in the right ways. Just like resources for treating mental illness are in short supply, there is a shortage of mental health professionals in our hospitals and communities available to support the practitioners from other health disciplines and their patients. As the saying goes: “There is no health without mental health.” (5)
In order to demand the proper value for mental health, we need advocates across all disciplines: from family medicine, to ER, to surgical specialities. Given the demand and intersectionality with physical illness, mental illness requires a broad approach to strengthen resources in all settings, and at all stages. This issue cannot be siloed, and we all stand to benefit from equal funding and a more widespread, consistent commitment to support mental health services in Alberta
Shauna McGinn, Vital Signs Staff Editor/Writer
Rachel Grimminck, MD, FRCPC, DABPN
Clinical Medical Director, Psychiatric Emergency Services,
Foothills Medical Center; Clinical Assistant Professor, University of Calgary
1. Presentation: “Methamphetamine and Psychosis: Etiology, Diagnosis & Treatment,” David Crockford, MD. Alberta Health Services, April 2019.
2. Presentation: “Crisis in the Emergency Department: A Guide for Responding to Methamphetamine Presentations,” Eddy Lang, MD. University of Calgary ODT Virtual Health Learning Session, 2018.
3. Mental Health Commission of Canada, “A new resource to help family physicians support individuals with mental health and substance use problems,” (News release). October 2018.
4. State of the Art Review, “Depression, Stress, Anxiety, and Cardiovascular Disease.” November 2015.
5. Lancet, “No health without mental health,” Series – Global Mental Health: 1. September 2007.
Silenced by Stigma: Meet the team working to bring awareness to physician substance use disorder
The Substance Use Disorder (SUD) video (a collaborative project of the College of Physicians and Surgeons of Alberta, AMA’s Physician and Family Support Program and Dr. Teresa Eliasson) is an outcome of the 2016 “Strategic Framework to Reduce the Risks of Substance Use Disorder in Anesthesiologists.” The framework recommended that materials be developed to educate physicians about SUD: what it is, how to identify it and where to seek help. This video “What is substance use disorder (SUD) and how can the AMA’s PFSP help?” is an introduction to SUD and will support PFSP’s education program and efforts to promote physician wellness across the province. Responses have been edited for length and clarity.
Can you give us an overview of the prevalence of substance use disorders in physicians?
It’s thought that the prevalence of substance use disorder in physicians is about equal to the prevalence in the general population. A large survey of American physicians published in 2015 found that overall about 15% of respondents met the criteria for substance abuse or dependence. Female physicians had a higher rate than males: 21.4% vs. 12.9%. Other factors associated with increased risk are younger age, dissatisfaction with the relationship with a spouse or partner, and the presence of burnout or depression. Personal factors such as family history and adverse childhood experiences also increase risk.
Physicians with substance use disorders were more likely to report having made a medical error within the past three months, to have a decreased quality of life, and to have decreased career satisfaction.
Alcohol is the most commonly abused substance, followed by opioids and stimulants.
Stigma is a big part of substance use disorders and mental health challenges in general, but perhaps even more so when it comes to physician SUD. Can you discuss the role of stigma in this problem, and what can be done in the physician community to help reduce it?
Stigma certainly is a major issue in preventing physicians from seeking help for SUDs, as it is for any other mental illness. Stigma can be either enacted or felt. Enacted stigma refers to discrimination against people with mental health issues because of their perceived unacceptability or inferiority, while felt stigma is interior and refers to both the fear of enacted stigma and a feeling of shame associated with having a mental illness.
There is no “magic bullet” that would reduce the stigma of SUD, and we need a multi-pronged approach. As the neurobiology of mental illnesses become clearer, medical schools could better integrate mental health and cognition with physiology and pathology.
Physicians individually also have a responsibility to educate themselves on the issue of stigma and its role in inhibiting access to appropriate treatment. We also need to engage in self-reflection about our attitudes towards colleagues who suffer from mental health issues, to reduce as far as possible any barriers to a colleague seeking and accessing help.
The most powerful tool for reducing stigma may, in large part, lie in the hands of those physicians in recovery from mental illness. The courage and willingness to disclose one’s own personal story of SUD, or any mental illness, can significantly reduce the stigma and shame that is inevitably associated with these diseases.
How did the physician SUD project come to be, and what will it do for physicians in Alberta?
As the founder of the “Office of Staff Wellbeing” for the Department of Anesthesiology and Pain Medicine at the University of Alberta, in 2012 I was invited to be a member of a CPSA committee designed to address the risks associated with substance use disorder in the field of medicine, and in particular, in anesthesiology.
This committee was organized and chaired by Dr. Janet Wright, an Edmonton Psychiatrist and former CPSA Assistant Registrar. The committee produced a document outlining a strategic framework to help reduce substance use disorder in anesthesiologists (link: https://bit.ly/2MvtB52). Dr. Wright was determined that an important goal of the committee be about de-stigmatizing SUD in physicians. Her goal was important to me, not only as a concerned physician colleague, but as an Albertan whose family has also been affected by SUD. In 2018, I approached the new Anesthesiology Departmental Chair at the U of A, Dr. Andrew Shaw, about the aforementioned strategic framework. He was supportive, and I took his suggestion of an educational video about SUD to Dr. Terrie Brandon, Clinical Director of PFSP.
Dr. Brandon procured funding from the AMA and CPSA for the production of the video (link at end of article). A presentation was also produced about SUD in physicians, which PSFP Presents may use during requested educational rounds. Input was solicited from all the PFSP Assessment physicians, Case
Coordination physicians, and other Alberta doctors not directly associated with PFSP. We hope that this work will not only help to destigmatize SUD for the benefit of physician colleagues and their families, but all Albertans affected by this issue.
What kinds of support and treatment are available to physicians with substance use disorders?
Any physician who has concerns about their use of an addictive substance is encouraged to talk to a healthcare professional. This could be a family doctor, a psychiatrist, a therapist, or it could be a call to the PFSP support line (1-877-767-4637) to talk with one of our assessment physicians.
Physicians are often concerned about the confidentiality of their information. Calls to the PFSP line as well as referral to our therapists are confidential, and are not documented in the provincial electronic health record.
If a diagnosis of SUD is confirmed, the physician should seek treatment appropriate to the severity of the condition and to their role as a physician.The practice of medicine is a safety sensitive occupation, so recommended treatment is more intensive than it is for the general population. Physicians in treatment do best when provided with cohort-specific treatment at facilities with experience in treating health care professionals. With this type of treatment and appropriate follow-up, physicians with SUD have an excellent prognosis. PFSP can assist physicians in accessing this type of specialized treatment.
What can the profession as a whole do to help?
We can start by cultivating a supportive culture, by watching out for signs that a colleague may be struggling, and by reaching out to that person. We need to understand addiction as a disease process that can have devastating effects on health, relationships and careers. Effective treatment is available and the suspicion of a problem shouldn’t be ignored or dismissed. We can educate ourselves about the signs of substance use disorder and know where to refer our colleagues for support and treatment.
For any physician who has a concern about their own substance use or that of a colleague, a call to the PFSP line is a great first step.
The physician SUD project team:
Dr. Terrie Brandon
PFSP Clinical and Program Director
Dr. Teresa Eliasson
Dr. Eliasson graduated from medical school and completed a residency in family medicine at the University of Alberta. She was a general medical officer for the Department of National Defence for four years. She later entered a residency in anesthesia at the University of Manitoba and followed that with a fellowship in pediatric anesthesia at the same institution. Dr. Eliasson then moved to Edmonton and has been in the Department of Anesthesia & Pain Medicine at the U of A since that time. She is a pediatric anesthesiologist at the Stollery Children’s Hospital and an assessment physician for PFSP.
Dr. Paul Flynne
Dr. Flynne has practiced medicine for fifty years. He has worked as an Assessment Physician for the AMA’S Physician and Family Support Program since 2012. He has previously provided medical services to AADAC’s Opiate Dependency Program, and sat on the AMA’s Committee on Alcohol And Other Drugs and was a board member of the Elizabeth Fry Society.
The ‘Understanding physician SUD’ video will be available on the PFSP website as of September 11, 2019 https://www.albertadoctors.org/services/pfsp/substance-use-disorder and also on YouTube. If your group would like more information on this topic, please contact PFSP at email@example.com.
Picture yourself standing in front of a blank map, ready to chart the course of physician wellness over the next five years. The surge in its recognition, general awareness, and the many sub-topics would leave you staring at countless plot points, a web of criss-crossing lines obscuring the path.
Enter Well Doc Alberta: a new organization that is here to hand out the travel guide. At an important moment in the conversation on mental health and medical culture, Well Doc Alberta is helping lay out the directions so that all physicians can get a handle on the route to wellness.
What is Well Doc Alberta?
Well Doc Alberta is an initiative aimed at advancing a collaborative, co-operative, pan-provincial approach to physician wellness.
“The big picture is, physician wellness is a relatively new concept, and there is a tsunami of people realizing that it’s important,” says Dr. Jane Lemaire, Well Doc Alberta’s Physician Lead. Dr. Lemaire is a clinical professor in the Division of General Internal Medicine, Vice Chair, Physician Wellness and Vitality, Department of Medicine, and Director of Wellness at the Office of Professionalism, Equity and Diversity at the University of Calgary.
She says it’s important for physicians to understand that it’s not just about saying, ‘Doctors should be well, they’re too stressed out.’ “There’s a body of science, and one of our goals at Well Doc Alberta is to help people understand that science. When we talk about prevention and advancing change, it should be evidence-based,” she says. This encapsulates one of the organization’s main goals: to help people get to know the science behind physician wellness, and then use that knowledge to change things for the better.
Dr. Lemaire’s co-lead is Program Manager Alicia Polachek, who is currently enrolled as a student in the Master of Business Administration program at the University of Calgary, and holds Bachelor of Arts and Master of Arts degrees in Sociology. “There were a lot of different pockets of work [on physician wellness] that were happening across the province, but it was very piecemeal and wasn’t always integrated,” Polachek says. She says that Well Doc Alberta was born partly out of “a need to increase capacity across the province, and put our efforts together to move forward.”
The rest of their team consists of two physician associates, a program assistant, an evaluation and measures specialist, a communications specialist, and an education specialist. Together, they run the household of Well Doc Alberta: the place from which education resources and other relevant information on physician wellness is developed, shared, and disseminated. It’s different from the Physician and Family Support Program (PFSP), which provides treatment to physicians in distress. Well Doc Alberta is here to connect those with expertise and interest in physician wellness, and then capture those resources to serve as a consultant and partner to those working on such efforts throughout Alberta. As Dr. Lemaire says, “our goal is education and prevention.”
On the ground, this could take the form of a presentation at a retreat where the goal is a lecture to raise awareness, or Well Doc Alberta helping to coach individuals or groups towards positive change. If, say, a group of rural family physicians wanted to host a discussion on wellness, a Well Doc Alberta team member would consult with them to find out what issues they’d like to address, and take into consideration the specific context. Then, they’d either give a presentation, or train someone within the group to do so, using vetted Well Doc Alberta education resources.
“I think one of our strengths is how tailored it is to each individual group,” Polachek says. “It’s really about working with them to develop what’s helpful, and empowering them to go and make changes in their division, department, or unit.”
The key strength of Well Doc Alberta is its partnership with the many individuals and groups that are already doing work around physician wellness, or are interested in it. Together, the hope is that they can strengthen a consistent understanding and unified plan for better physician wellness across Alberta.
Why are doctors unwell?
With all of the talk about wellness, it’s important to remember the reasons why many physicians are unwell in the first place. “Just like a firefighter is at risk of smoke inhalation, we’re at risk of being unwell and having burnout, and more mental illness and substance use disorder,” Dr. Lemaire says. “That’s very well documented, more than the general population, and it’s because we’re doctors.”
Doctors are less likely to self-care
“There’s this idea in the culture of medicine that you have to be a super person,” Dr. Lemaire says. This is exacerbated by the intense nature of the work itself, long hours, and increasing demands, which all leave little room for things like getting enough sleep or eating properly. “That makes it hard to take care of ourselves, and then there’s the expectation that it’s never good enough, and if you make one mistake you’re bad,” she says. “Those are some of the toxic aspects of the culture of medicine.”
Specific personality traits
Dr. Lemaire says it’s common for physicians to be type-A perfectionists, high achievers, and have obsessive compulsive tendencies. “Some little sprinkles of [these traits] make us really good doctors, but can also tip us over into not being very well,” she says. These characteristics are also part of the reason doctors are less likely to think about the effect the work is having on them. If you’re used to things getting done a certain way and by a certain time, it can be hard to know when to step back.
The working environment
“The health systems we work in often don’t provide the infrastructure for self-care; there may be no doctors’ lounge, limited quiet places, and few healthy food choices at night,” Dr. Lemaire says. She also notes that when physicians are unwell, they can negatively impact the system they work in: “Burnout has been linked to medical errors, not spending enough time with patients, prescribing unnecessarily... all of those things cost the healthcare system billions of dollars.” Dr. Lemaire gives the example of a paper published this spring, where it was estimated that the cost of burnout in terms of turnover, early retirement and lack of productivity was $4 billion USD a year; about $7,500 USD per doctor, per year. “And that doesn’t even include the cost to patients,” Dr. Lemaire says, “so there are professional consequences as well as personal consequences.”
A space for everyone
Well Doc Alberta is a neutral space, not directed or regulated by any of the existing healthcare bodies in the province. “We collaborate with all the healthcare stakeholders in the province, but we’re not here to strong-arm anyone,” Dr. Lemaire says. Rather, Well Doc Alberta is about using existing expertise and resources, building partnerships, and applying the best available evidence to effect change from the ground up, and to engage leadership. Polachek echoes this, adding that they’re focused on, “coaching and empowering physicians at the grassroots level to make individual and systems-level changes, that then enhance and support physician wellness.”
Dr. Lemaire says ultimately, Well Doc Alberta isn’t limited to the core team. “It’s everybody who might be interested in physician wellness,” she says. “We’re just trying to be the glue and the infrastructure that help hold it all together, so we can increase capacity to meet the substantial need.”
If you would like more information on Well Doc Alberta or would like to get involved, visit: www.welldocalberta.org.
Physician wellness is only the beginning: We need to start talking about physician mental illness
I applaud the recent flurry of research and news articles focused on physician burnout and ways to improve physician wellness. This is an important topic, but it needs to be followed by a frank discussion about mental illness among medical students, residents and physicians. The reality is that we work in one of the highest risk professions for suicide because of the high rates of mental illness, and it’s a risk that deserves more attention, conversation, and action.
Medical students start medical school with the same levels of mental illness as the general population,(1) but through the process of training, we emerge with increased rates of depression, anxiety, substance use, and as a result, suicide. The suicide rate in the general population worldwide is 11 per 100,000, whereas the suicide rate amongst physicians is 28-40 per 100,000,(2) which is close to rates in American Military veterans. Suicide occurs in the context of mental illness in over 90% of cases. Therefore, if we want to address physician suicide, we must talk about physician mental illness.
Mental illness is often misunderstood and used interchangeably with mental health, even amongst medical professionals. We all have mental health, just as we all have physical health, and it is important to ensure that we maintain both. Guidelines recommend moderate intake of certain foods or alcohol in order to reduce cancer risk and improve physical health, just as wellness initiatives such as yoga, relaxation, and healthy eating can improve one’s sense of mental wellbeing.
However, doctors would never recommend a diet low in processed meat to treat cancer. Similarly, treatment for mental illness requires a comprehensive biopsychosocial plan. A doctor with cancer would see an oncologist, so why wouldn’t a doctor with depression see a psychiatrist? We need to be wary of blurring the lines between the concepts of improving mental health, and seeking treatment for mental illness. By minimizing illness and focusing only on wellness, we perpetuate stigma, and run the risk of conveying the message that mental illness is more of a personal failing. This notion misses the enormous complexity of mental illness.
Mental illness is treatable, and a diagnosis of a mental illness does not need to equate with impairment. If you have a mental illness, it does not mean that you will always have an illness, nor does it mean that it will end your career. Many physicians practice medicine while getting treatment for mental illness. As a consequence of appropriate treatment, which often includes medications and psychotherapy, they have good mental health despite having a chronic mental illness. This is analogous to a patient with diabetes who manages and treats their chronic illness, but still experiences good overall physical health.
Mental illness is treatable, and a diagnosis of a mental illness does not need to equate with impairment.
As an emergency psychiatrist, I have been a treating physician for medical students, residents and staff physicians suffering from mental illness. It often seems that by the time a physician or a physician in training comes for help, it is frequently later in the course of illness. What prevents us from seeking help sooner? I recognize the answer is complex, but I think it is important to emphasize one aspect of medical culture that I see as a unique challenge: stigma.
Stigma against mental illness is insidious, pervasive, and occurs at both the individual and systemic level. It is present in the attitudes and behaviours towards “psych” patients and mental health providers, and the gross disparities in funding for mental illness compared to other areas of medicine. Sadly, the emergency department remains one of the places that patients experience the most stigma.(3) The stigma manifests on a system level in the quality of rooms available in emergency departments, and the wait for mental health beds across the city, which have hit record highs of close to two weeks in the last year. On an interpersonal level, it manifests in dismissive or derogatory comments towards psychiatric patients and mental health providers. I suspect many of us can recall an instance when we witnessed stigmatizing statements or behaviours towards individuals with mental illness, both in professional and personal settings.
These are the concrete ways stigma is seen, but there are also attitudes about psychiatry within medical culture itself that create further obstacles for physicians seeking care. For example, I regularly faced criticism from other medical professionals about my desire to pursue a career in psychiatry during medical school. I was told that I would be “wasted” in psychiatry because I was “smart.” I frequently encounter the perception that mental health treatment is futile, and that psychiatry is not considered as legitimate a form of medicine as other disciplines. The reality is that mental illness is very treatable with evidence based treatments. A major barrier is funding and access to services, not that effective treatment doesn’t exist. With so many aspects of stigma at play, why would anybody — physicians especially — come forward for treatment?
Approximately one in four people are affected by mental illness worldwide. There are 1,200 staff physicians at Foothills Medical Centre in Calgary, and 800 resident physicians. Going by available statistics, that means there are approximately 500 physicians at FMC who are affected by mental illness. If not you, then many of the medical students, residents or staff physicians are suffering in silence. We need to support one another, talk about mental illness, and encourage seeking treatment. Sharing stories of recovery is one of the most powerful ways of reducing stigma. I took time off for mental health reasons as a resident, and it was probably the best decision I have ever made. My experience of being a patient has been invaluable personally and has made me a better doctor professionally. We do not need to suffer alone. Addressing physician suicide and the other risks associated with mental illness requires an ongoing, open discussion, and a shared hope of recovery.
Rachel Grimminck, MD, FRCPC, DABPN
Clinical Medical Director, Psychiatric Emergency Services, Foothills Medical Center; Clinical Assistant Professor, University of Calgary
1 The Impact of Medical School on Student Mental Health, Academic Psychiatry 40(1). March 2015
2 Tanwar, APA 2018 https://www.medscape.com/viewarticle/896257, accessed April 9, 2019.
3 Canadian Psychiatric Association Position Paper on Stigma and Discrimination 2011.
The myth of ‘breast implant illness’ When misinformation amongst physicians causes harm
I have been practising plastic surgery in Banff for 35 years. Recently, about two weeks after my patient underwent a breast augmentation procedure, she developed an itchy rash all over her back. When I learned that an ER physician told her that she could be allergic to her breast implants, I was shocked. That is akin to telling the parent of an autistic child that it was probably the measles vaccine that caused the autism. The ER doc didn’t ask her about her medications or even discuss their potential role (she was on Flagyl). He did not comment on the fact that she had a similar rash on her flank several months ago, and he didn’t know that her son recently had a similar rash.
This is extremely frustrating, because there is now a list of 60 “symptoms” circulating the Internet and the media called “breast implant illness.” The internet can be helpful, but in this situation, it is frightening patients unnecessarily — just like the antivaxxers. We went through this in 1992 when the FDA (and Health Canada) put a moratorium on silicone gel breast implants. In Canada, we were restricted to using saline implants for 10 years, and for 15 years in the U.S. Finally, after the Institute of Medicine concluded that there was no relationship between silicone implants and any disease — specifically autoimmune diseases — silicone gel implants were again allowed.1
It’s important to note that we do now know there is a disease associated with breast implants. Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is associated almost exclusively with aggressively textured surface breast implants (silicone or saline). This is a new disease, but now that we understand it better, it appears to be completely treated with surgery, which entails removal of the implants and the capsules and then replacement with smooth walled implants. There is no case so far where only a smooth implant was used. At first we thought this was an extremely rare disease, but it seems to occur in about one in 3,000 patients with implants. It is not a breast cancer; it is a lymphoma in the capsular tissue around the implant.
Usually, BIA-ALCL presents with a late seroma around the implant; rarely, it presents as a mass. This means that physicians should be alert to the fact that late breast swelling should be inves-tigated with an ultrasound to check for fluid. Breast augmentation patients are notorious for failing to keep follow-up appointments, so their family physician may be the first to see this problem.
I stopped using the textured implants 10 years ago — they had other mechanical problems. The aggressively textured implants were commonly used outside North America but here in Canada and the U.S., they were mainly used for breast reconstruction. Canada has now banned their use, but the FDA just stated at the beginning of May 2019 that they are not taking that step.2 They have reviewed the science to date and are establishing registries that will help give us answers. We need a similar registry in Canada.
But does “breast implant illness” actually exist? Sadly, the two are being confused in the media, and maybe also in the minds of physicians. Studies have shown that the same number and types of illness develop when women with implants are matched with women without implants. Breast implants are often placed in young to middle-aged women so, over time, some of those patients will become ill. It is of course normal for patients to won-der whether it is their implants that are causing the disease. They wonder if it is pesticides or transformers — but they rarely consider that all the heavy metals in their tattoos could be a problem, for example.
These patients can be quite sick and disabled physically, and of course they get angry if we ask if their symptoms might be related to life events. But we all know — especially as physicians — that the mind and the body are completely interconnected. I try to explain to patients that we are not “calling them crazy,” but I remind them of the simple fact that being in a difficult situation can give them “butterflies.” I try to be empathetic and I will remove implants if patients request. Of course, some of them will get better because of the placebo effect. In my experience, however, very few patients get better.
These patients are normal — they are searching for answers and a solution. They do not like the answer “I don’t know” when they have a rash, for example. That is partly why alternative health practi-tioners are so successful — they usually give an answer.
It is sad to see a physician giving an “answer” that will unnecessarily increase a patient’s anxiety. Breast implants do have mechanical issues and definitely have problems associated with them. And there are many misleading “studies” that further confuse the situation, but the science is clear: breast implants are rarely — if ever — the culprit in that list of 60 symptoms.
We need to take these patients seriously, but we, as physicians, should not be misleading patients. My patient couldn’t help but wonder if her breast implants caused her rash or not. This patient actually works with me and is well aware of all the science. We seem to lose the battle of convincing our own colleagues that getting the flu shot is a good idea — so why would we be surprised that well educated patients blame their symptoms on “breast implant illness”?
A week ago, a patient called my office because her physician told her that she needed to have her breast implants removed because they might make her sick. I suspect that there are physicians who are also paying too much attention to misleading media. The bottom line is, when it comes to addressing this problem, we need to be more scientific.
Elizabeth J Hall-Findlay, MD, FRCSC Banff Plastic Surgery
1 Stuart Bondurant, Virginia Ernster, and Roger Herdman, Editors, Safety of Silicone Breast Implants. Institute of Medicine (US) Committee on the Safety of Silicone Breast Implants; Washington (DC): National Academies Press (US); 1999.
2 Van Slyke AC, Carr M, Carr NJ. ‘Not all breast implants are equal: A Thirteen-year review of implant longevity and reasons for explanation’. Journal of Plastic Reconstructive Surgergy, 142: 281e, 2018.
It seems you can’t open a magazine, turn on the TV, or even sit down to a holiday family dinner these days without hearing the word “keto.” What exactly is keto, and why should we as healthcare providers be paying attention?
Ketogenic diets fall under the broader umbrella of LCHF diets: Low Carb High Fat. Some call it Low Carb Healthy Fat to emphasize that a LCHF diet is based on healthy whole foods such as dairy, nuts, seeds, avocados, olive oil, meat, and fish. In fact, this is likely where a lot of the benefits are derived: shifting people to whole foods. LCHF diets cover a wide spectrum of carbohydrate intake, but in general, a daily carbohydrate intake of less than 130g per day is considered LCHF, and is described as low carbohydrate. A ketogenic diet is a diet in which carbohydrate intake is restricted to the point that the primary fuel source for much of the body and brain becomes fatty acids and/or ketones. Intake in the < 50g range is considered ketogenic. For context, the average Canadian eats 250-350g of carbohydrates per day, often from sources such as added sugars, refined grains, and ultra-processed foods like baked goods or prepared meals.
Historically, the first time carbohydrate restricted diets were described in the medical literature was in William Banting’s 1864 “Letter on Corpulence,” where he described his own weight loss and improved health using this approach. In the early 20th century, LCHF was the mainstay for treatment of diabetes, and endorsed by medical luminaries such as William Osler and Elliott Joslin, but interest waned once exogenous insulin became widely available. In 1921, the ketogenic diet was introduced at the Mayo Clinic for the treatment of epilepsy, and for the majority of the last century, that has been the only medical condition for which it’s been prescribed. Low carbohydrate diets gained popularity for weight loss in the 1970s through to the 1990s, the most well-known being the Atkins diet. At that time, dietary recommendations such as those published by the American Heart Association recommended keeping fat intake to a minimum as it was felt to be a major contributor to heart disease, and so LCHF diets were dismissed as dangerous.
There has recently been a resurgence of interest in low carbohydrate diets as clinical interventions for a variety of conditions. This has been fueled to some degree by patient experiences with these diets, which are then amplified through social media. The body of evidence for its safety and efficacy has also grown substantially. In April 2019, the American Diabetes Association released a Consensus Statement, which reads: “Reducing overall carbohydrate intake for individuals with (Type 2) Diabetes has demonstrated the most evidence for improving glycemia.” Several other worldwide Diabetes organizations, such as those in Europe, Australia, and the U.K., have released similar statements. Low carbohydrate/ketogenic diets, along with very low energy diets and bariatric surgery, have been shown to substantially increase rates of diabetes remission compared to standard management. A recent Western Australian government report stated that remission, rather than just management, should be the goal of interventions for Type 2 Diabetes. Given the growing prevalence of Type 2 Diabetes — currently 11 million Canadians are living with prediabetes or Type 2 Diabetes — it behooves us as health professionals to understand what constitutes a low carbohydrate/ketogenic diet, the specific considerations for patients following them, and that remission of Type 2 Diabetes is possible through the use of carbohydrate restriction.
The rationale for diets that restrict carbohydrate is the following: the pancreas secretes insulin in response to ingested carbohydrates, and to a lesser degree, to protein. Many factors affect insulin secretion, but certainly the degree of refining or processing of the carbohydrate affects the rapidity of the insulin rise, the peak insulin level, and how quickly insulin returns to normal. This is reflected in postprandial blood glucose levels. In those who are insulin resistant, we often see higher blood glucose levels, and longer times to return to baseline. We now understand that insulin resistance is present in many chronic diseases beyond Type 2 Diabetes. Among these, the most common are Hypertension, Cardiovascular Disease, Osteoarthritis, and Alzheimer’s disease. It remains unclear how large a role chronically elevated insulin levels (hyperinsulinemia) plays in the development of these diseases, but it is clear that decreasing carbohydrate intake reduces insulin secretion and decreases hyperinsulinemia. In the setting of low insulin, glucagon stimulates ketone body production in the liver. Ketone bodies, along with free fatty acids, serve as a fuel source for tissues, but ketogenesis isn’t the goal of these diets, other than in specific therapeutic circumstances.
Historically, resistance to ketogenic diets are based upon some of the following concerns:
“The brain needs glucose.” Traditionally, the minimum Dietary Recommended Intake for carbohydrates has been 130g. The brain’s glucose requirements can be adequately met through gluconeogenesis, glucose generated from fat and protein. Ingesting carbohydrates is not a requirement to meet the brain’s glucose needs. In the setting of carbohydrate restriction, ketone bodies also provide energy for the brain and other tissues.
“Ketogenic diets lead to ketoacidosis.” A ketogenic diet, and the state referred to as “nutritional ketosis,” is not ketoacidosis. Serum levels of ketones are in the range of 1-4 mmol/L, are accompanied by adequate basal insulin levels, and low blood glucose. Ketoacidosis occurs most often in people with Type 1 Diabetes, very rarely in people with Type 2 Diabetes, and results from a lack of insulin and markedly elevated blood glucose levels.
“A ketogenic diet lacks essential nutrients.” The nutrient cited most often is fibre, as cereals and whole grains are eliminated on these diets. Adequate fibre can be obtained through above ground vegetables, seeds and nuts, as well as other sources. A more liberal approach permits small amounts of beans, legumes, and fruit, which also provide fibre.
“A ketogenic diet is high protein/high in meat.” Ketogenic diets are by definition not high in protein and LCHF diets are moderate protein, in the range of 0.8-2g/kg per day, depending on the nutritional needs of the individual.
Finally, those most opposed to ketogenic diets will state, “These diets are unsustainable, highly restrictive, and/or dangerous.” The large body of evidence for the safety and efficacy of carbohydrate restriction shows the opposite, so these views should be reconsidered.
From a practical standpoint, what constitutes a LCHF/ketogenic diet? Contrary to popular myths, people eating LCHF diets are not living off of buttered coffee and bacon. Their diets include: above ground vegetables, meat, fish, dairy, seeds and nuts, avocados, and olive oil. For those adopting a more liberal approach, fruit, beans and legumes can be eaten in small quantities. Sugar and refined grains are eliminated, as are ultra-processed foods. Those in the healthcare community who promote LCHF diets promote a diet that, ideally, is based entirely on whole foods, but there is also recognition that this can be challenging for those living in poverty, or lacking food and health literacy.
Taking all of this into consideration, there are several reasons why we as healthcare providers must increase our understanding of these diets. First, the public is looking for alternatives to medications and surgery. Dietary choices are one of many factors contributing to chronic disease, and supporting patients in making healthier dietary choices can prevent and even reverse some diseases. Second, ketogenic diets have profound, often rapid, physiologic effects, especially with regards to blood pressure and glycemia. Patients adopting these diets who are on medications for Hypertension, Type 1 Diabetes, or Type 2 Diabetes must be counselled to be vigilant, as well as on how to reduce their anti-hypertensives, hypoglycemics, and insulin. It’s important to note that SGLT2is are of particular concern, as they have been associated with Diabetic Ketoacidosis, and little is known about causal pathways. Those on ketogenic diets should be counseled on the risks, and prescribers should consider discontinuing SGLT2is in patients who are on or considering low carbohydrate or ketogenic diets.
The question of what happens to cardiovascular risk and lipids is the one raised most often by health professionals when this dietary approach is presented. With adoption of LCHF diets, biomarkers usually change as follows: TGs decrease, HDL increases, glycemic control/HbA1C improves, HTN improves, hsCRP improves, LDL atherogenicity improves (moves from pattern B to pattern A). In a minority of people, LDL does increase, and in a very small minority of people, it increases dramatically. These individuals and their physicians are then faced with the dilemma of having to address a high LDL when the diet that caused it has improved other markers. In these cases, replacing saturated fat in the diet with unsaturated fat often improves LDL. If it doesn’t, statins may be discussed in the context of other risk factors. Prior to starting a low carbohydrate diet, baseline lipid testing is very useful to enable tracking of the impact of nutritional changes.
Although social media platforms have allowed for the success of online “gurus” who perceive LCHF diets as a “cure all,” it is not an appropriate intervention for all people, and should be tailored to the individual patient’s needs and health goals. Its use in seizure disorders is well-established. With the recent ADA Consensus Statement, low carbohydrate/ketogenic diets will become a dietary pattern offered as Nutrition Therapy to patients with Type 2 Diabetes. The use of low carbohydrate/ketogenic diets in Type 1 Diabetes is growing, but robust long-term data are lacking. A very active community of people with Type 1 Diabetes have adopted these diets, and some early research has been published. The groups studied showed significantly better glycemic control with greatly reduced variability in glucose levels — fewer highs and perhaps more surprisingly, fewer lows.
These diets are also being studied in neurologic disease, including dementia, as there is interest in whether ketone bodies are an effective alternative fuel source for the brain.
There are many studies looking at the anti-inflammatory properties of ketone bodies and whether they might prevent or alleviate symptoms of chronic inflammatory diseases.
Additionally, there is very early research looking at ketogenic diets as an adjunct to traditional treatment for specific cancers, either to increase the efficacy of the treatment regimen, or to reduce side effects related to treatment regimens.
The literature has shown LCHF diets to be as effective as low-fat diets with regards to weight loss. There may be some evidence that ketone bodies reduce hunger, which may improve adherence to the diet. As is true for all weight loss diets, some people respond particularly well to one approach, while others do not. Obesity is a chronic disease, with patients often requiring lifelong support in order to adhere to their diet and avoid weight regain. Unfortunately, these types of long-term support programs are virtually non-existent in Canada.
If you’re wondering where to start in supporting patients who may be interested in or require a LCHF diet, there are an increasing number of resources available for healthcare providers to learn more about the use of carbohydrate restriction as part of a “food-first” approach to chronic disease management. Clinical Guidelines for its use were recently published and are available at https://www.lowcarbusa.org/clinical-guidelines/
Several Canadian organizations are preparing health professionals to safely provide guidance to patients wishing to pursue these diets. More information on these organizations can be found at www.therapeuticnutrition.org (Institute for Personalized Therapeutic Nutrition) and www.ccfortn.ca (Canadian Clinicians for Therapeutic Nutrition).
Miriam Berchuk, MD, FRCPC
Diplomate of the American Board of Obesity Medicine Department of Anesthesia, Rockyview General Hospital, Calgary
Things I learned in my first ten months of practice
Attention fellow new-in-practice physicians and residents: here are ten pieces of wisdom I’d like to pass on from my first ten months of practice as a family physician
1. You can never give yourself too much time for paperwork
Any assumption I had that I would only need a few minutes at the end of my day to chart and be done the day’s work was demolished by 4 p.m. on my first full day of practice. Learning how to chart as I go has allowed me to be at least somewhat finished by a decent hour each day.
2. No one looks for lost billing, and the government doesn’t care
Every physician probably under-bills during their first year of practice, and hopefully it’s limited to that. I regularly touched base with my colleagues to see how they structured their billing to ensure I wasn’t missing anything major. As a rural family physician, I had to learn in-patient, emergency, clinic, and long-term care billing. Running a billing question by my colleagues was very helpful in discovering what I didn’t know.
3. The EMR thinks it is smarter than I am
I came up against numerous glitches in our EMR that had me convinced that I was in the wrong at times — like when the EMR told me that some form of iron replacement therapy available by prescription no longer existed. Fortunately, a prescription pad and a pen with a quick documented note in the chart overcame that.
4. It is important to block off random days and half-days
I discovered how important it is to periodically book a half-day off. Whether it was to be used for wellness (read: taking my wife out for lunch to remind her what I look like) or just paperwork, it was an important part of the week. I found that if I was relatively rested and caught up, I could open it up to patient visits a few days prior, and it inevitably filled up.
5. Come out swinging
I structured my patient meet and greets with a firm but friendly approach. If the patient had a current family doctor, I asked them what exactly they expected me to do differently than their current MD. I also let patients on benzos and opioids know that if they wanted to come and see me, we would be working on tapering strategies. Unsurprisingly, some patients have not returned.
Similar to point #5, some patients arrived for a meet and greet wanting to go on long-term disability, and expected me to fill in the forms for them that same day. I declined, and suggested they return for a head-to-toe exam and an opportunity to look through their health records with me to see if they qualify. This gave me time to check their records and see them again, armed with information to discuss with them.
It felt as though I was barely breaking even financially over the first few months. Loan and interest payments were coming due and registration fees, my split, office furniture, and membership dues were coming off the top. Plus, some days were less busy and weren’t fully booked. But as days became busier, major asset purchases were finished, and I found efficiencies in my schedule, the income flow evened out.
There should be more teaching in medical school and residency on the importance of your relationship with your staff. Arriving at an established clinic made the transition relatively seamless, as staff were already familiar with each other – but the importance of fostering good relationships with staff can’t be stressed enough. It was easy to forget just how much they would go to town for me on an almost daily basis, from ensuring my schedule was just full enough, to moving patients to give me a half day to catch up, to appealing the many rejected bills I clumsily attempted to submit before I knew what I was doing.
9. Paperwork flow
During my first two months of practice, I only worked in my local emergency department and did a handful of walk-in shifts. I progressed to meet and greets in my third month. These first two months allowed me time to figure out the EMR, establish my paperwork routine, and ask the other doctors all of my inane and simple questions, without the pressure of 20 patients waiting to see me in the waiting room. By the time I was doing 15-minute appointments, my workflow was established.
10. Being a doctor
It was easy to forget amidst everything that I was officially a family doctor for many people, and that the relationship building when patients began coming back to see me was everything I had hoped for in medicine. Sure, some patients are needy, some ignore my medical advice, and others refuse to help themselves. But I discovered that for the most part, they are all grateful to have a doctor and a familiar face to return to.
And I am grateful to be their doctor. Just so long as I don’t forget all the things I’ve learned in my first ten months.
Gregory Sawisky, MD, CCFP
Family Medicine, Ponoka, Alberta
Dr. Gregory Sawisky completed medical school at the University of Alberta in 2016. He completed his rural family medicine residency through the University of Alberta’s Red Deer Regional Hospital location in 2018. He now practices full-scope rural family medicine in Ponoka, Alberta.
Read the complete June issue here
Healthcare is always an election issue in Alberta — and rightly so, as it accounts for more than 35 per cent of the provincial budget.
But in the 2019 Alberta general election, healthcare wasn’t — for once — the dominant issue. As the Primary Care Network Physician Lead for the Calgary Zone, I see that as a positive sign; maybe even cause for cautious optimism.
There was still plenty of debate and discussion about healthcare, of course. The response to the opioid crisis, access to care throughout the system, and the need for mental health services and support came up frequently. These are important issues and we need Albertans to be engaged and involved in these discussions.
Perhaps we are starting to see Alberta take small steps towards what the province’s Auditor General described in his 2017 report as the depoliticizing of healthcare and a renewed focus on patients’ needs. Merwan Saher’s report, titled “Better Healthcare for Albertans”, outlined the need for government, legislators, healthcare providers and the general public to contribute to realizing the vision of a fully-integrated health care system. This vision sees patients engaged and empowered to take an active, responsible role in their own care. We have made strong progress in recent years, but there is much work to be done.
Maybe I’m guilty of looking through rose-coloured glasses, but I think we saw a growing consensus about the importance of primary care during the recent election; of the need to build strong medical homes and create patient-centered care.
The work PCNs have done to establish Alberta as a leader in Medical Home adoption was recognized in the College of Family Physicians of Canada’s Report card on medical home implementation in February 2019.
In the Calgary Zone, our physicians and Primary Care Networks have a long history of partnership and collaboration that predates the formal governance structures implemented in 2017. The strong relationships we had already developed gave us a solid foundation on which to build. That spirit is reflected in our mission statement, ‘Better together’ — leveraging our strengths and sharing our resources to better serve patients through the integrated patient’s Medical Home (iPHM).
Some examples of the work we’ve done through these partnerships include:
Specialist LINK: Family doctors and specialists are connected through a real-time advice line and other resources that help ensure patients receive the right care by the right provider. The tele-advice line helped avoid 2,898 unnecessary consults and ER visits last year – cutting wait lists and saving the system more than $1.2 million since its inception.
Find a Doctor: The Calgary Zone helped spearhead a new provincial Find a Doctor website at albertafindadoctor.ca that has made it quicker and easier for all Albertans to find a doctor.
Supported transitions: Ensuring patients transition safely from home to hospital, and hospital to home, is central to our work in this area. In the last year, more than 60,000 hospital admission and discharge notifications were sent to help ensure better continuity of care.
Opioid response: The Calgary Zone is working hard to support family physicians and patients as part of the urgent response to the opioid crisis in Alberta. Training and other supports are central to our strategy.
As physicians and PCNs, we have a key role to play in supporting efforts to ensure patients are at the heart of the healthcare system. As the Calgary Zone Physician Lead, I am a representative of the Calgary area and advise the ministry through the provincial PCN Committee. This committee is chaired by the Assistant Deputy Minister of Health, Workforce Planning & Accountability Division, and attended by two other Assistant Deputy ministers, senior AHS leaders, Zone PCN dyads, and AHS and AMA provincial leaders. We are partners, aligned to improve healthcare for Albertans.
A new government can bring change, but it can also bring opportunity. The United Conservative Party’s platform points to the importance of primary care and recognizes the need to fill gaps in mental health services and tackle the opioid crisis. These are priorities that closely align with the work we are already doing in the Calgary Zone and, in fact, throughout the province.
I’m looking forward to working collaboratively with the incoming government, alongside my colleagues and partners, to continue to move our work forward and address the challenges we face in delivering better patient care.
It’s not easy to build a fully-integrated healthcare system. There’s no simple solution or quick fix. The government may have changed but our work continues. Let’s get to it.
Ernst Greyvenstein, MBChB, CCFP FCFP Dip. PEC
PCN Physician Lead, Calgary Zone; South Calgary PCN Board Chair; SAPCA Director; Clinical Associate Professor University of Calgary; Medical Director Circle Medical Ltd.
On April 16th, Albertans elected the United Conservative Party, led by Jason Kenney, as the new provincial government. It’s common for healthcare to be at the forefront of political debate, and this election was no exception.
As is the nature of politics, promises made during campaigns don’t always translate into visible, concrete changes. However, official platforms and statements provided throughout the course of the election can give us a sense of the UCP’s priorities, and their stance on key issues in Alberta healthcare.
As physicians, it’s important to stay informed when it comes to politics, no matter who is in power. Below is a brief evaluation of where Jason Kenney and the UCP stand on some major healthcare points, as well as specific promises that have been made thus far.
Universal & private healthcare
“Supporting a universal, comprehensive healthcare system is a core part of the UCP’s policy declaration agreed at our founding conference,” Kenney stated at a news conference in Edmonton in February. He also promised to maintain, but not necessarily increase, current spending on healthcare — which was $22 billion last year, or about 40 per cent of the provincial budget.
Kenny also said the UCP is open to exploring private healthcare options, noting that private care for minor procedures had reduced wait times in provinces like Saskatchewan. The UCP’s platform (available in full online) gives the example of inviting third-party surgical clinics to bid into the publicly insured system, meaning surgeries would be contracted out to these clinics.
Alberta Health Services
One of Kenney’s main campaign promises was that within his first 30 days in office, the UCP would “commission a comprehensive performance review of Alberta Health Services,” with the purpose being to “identify possible savings and efficiencies and to reallocate significant resources away from administration to front-line service delivery.”
The UCP projects that this review will cost between $2-3 million, and is aiming to have it completed by December 31st of this year. According to the UCP’s official platform, “subject matter experts from an outside consultancy firm will be assigned to employee teams.” These employee teams will then, “solicit cost-savings, best practices, innovative delivery mechanisms, etc. from front-line employees and recommend ways to cut costs and improve service.”
Addiction & mental health
Speaking in Calgary at the end of March, Kenney said the UCP would conduct a review of operating safe consumption sites throughout the province to see if there are better locations, “that could provide the service without creating a serious crime problem.”
Kenney also promised to appoint an associate minister of health focused solely on addictions and mental health. This part of the UCP’s platform also includes: expanding support for opioid treatment centres, adding detox beds and mobile detox programs, and a $5-million per-year investment for drug treatment courts. Mental health funding was promised at $100 million over four years, and Kenney said this funding would further support First Nations and Metis peoples in accessing mental health and addictions treatment.
The UCP promised to lift the cap on midwifery services in Alberta, with Kenney noting that midwives are cost-effective and help relieve burden from the primary healthcare system.
The official platform also promises $20 million over four years in palliative care funding, and $5 million per year to sexual assault centres.
What has been done so far?
As promised during the campaign, as of April 22nd, the UCP halted construction at the site of the proposed “superlab” in Edmonton. The $590-million project was aimed at consolidating lab services at a site in south Edmonton. Kenney previously called the project “unnecessary” and said cancelling it would save important funds for the province.
Vital Signs Staff