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eConsult service sees growth, speeds patient access to specialist community

MOC Tip of the Month

The breaking point for Dr. Clare Liddy, a family physician, came 10 years ago when she received an email that highlighted the waiting game that patients face when it comes to accessing specialist care.

Clare Liddy Dr. Clare Liddy

“I had referred a patient to the endocrinology clinic. The message that I got back was thank you very much for the referral; please let them know that they will be seen in six to nine months,” said Dr. Liddy.

Together with her colleague, endocrinologist Dr. Erin Keely, FRCPC, they figured they could either wait for someone else to fix the problem or work together to improve the system.

Erin Keely Dr. Erin Keely

The result of their brainstorm sessions was Champlain BASE™ (Building Access to Specialists through eConsultation) known as eConsult. It’s a secure, web-based platform that connects primary care physicians and nurse practitioners with specialists to discuss non-urgent patient cases.

The pilot program started with five specialists and 15 family doctors in Winchester, Ont. Within a year, the service connected family doctors with 27 specialty groups. eConsult now has over 111 specialty groups. Word of mouth has been the biggest driver of growth.

“One primary care provider would tell another how great eConsult is and that they should have access to it,” said Dr. Keely. “We used our network and went after people who wanted to help and engage with their primary care colleagues.”

Key facts about eConsults

  • The average response time for an eConsult is two days
  • 28,792 – the number of eConsult cases completed without the patient requiring a face-to-face specialist visit
  • 64 national research publications
  • 97 per cent of eConsult patients surveyed consider this service to be an acceptable alternative to traditional face-to-face referrals
  • 94 per cent of eConsult specialists surveyed state that this service improves inter-provider communication
  • $47.35 is the average cost of an eConsult, compared to $133.60 for traditional referrals
  • Specialists and primary care users provide feedback after each eConsult, leading to a better understanding and learning around a patient’s case

**Stats from www.champlainbaseeconsult.com (July 2018)

Measured growth, immeasurable impact

Drs. Liddy and Keely made sure the benefits of their eConsults were grounded in solid evidence. Their success has drawn a great deal of interest. They have acquired over $2 million dollars in funding for operational support and research for the eConsult service from organizations such as the Royal College and the Canadian Institutes of Health Research.

Through this funding, they have established a national collaborative and a program of research grounded in the Quadruple Aim framework, showing benefits in the following categories

  • improving the health of populations,
  • enhancing the patient experience of care,
  • reducing the cost of health care, and
  • providing improved work/life balance for health care providers.

Their eConsult model is growing in Ontario – 85,000 patients have benefited from the service so far. They are also seeing growth across the country: eConsult services or initial projects based on their model are underway in Newfoundland and Labrador, New Brunswick, Québec, Manitoba and Alberta.

November 1st marks the third annual eConsult policy forum, hosted this year hosted by the Royal College in Ottawa. This year’s forum topic is “Building on a BASE™ of Success: Establishing best practices for eConsult/eReferral in Canada.”

Though rewarding to see the growth of eConsults throughout Canada, its success is rooted in seeing the positive impact the service has had on patients.

“One gentleman who lives an hour outside of the city was able to have an eConsult done through his family doctor, which he said ended up saving him a visit to the specialist. This was not only good for him, but saved a visit for his son who normally would’ve accompanied him on these types of specialist visits,” said Dr. Liddy.

Dr. Keely added, “The eConsult has promoted a better relationship between primary care and the specialist community. We’ve been able to provide a really positive communication tool that everyone knows is all about helping patients and that’s what we’ve been able to do.”

Want to find out if eConsult is available in your region? Contact eConsultCOE@toh.ca


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Worth the wait: Dr. Borsuk leads surgical team in Canada’s first facial transplant

It made headlines across the country: the first face transplant in Canada. It took five years to plan, 30 hours to complete and the participation of more than 100 people.

Although this procedure — a vascularized composite allotransplant — is over a decade old, it remains uncommon and relatively new in the field of transplantation. It’s only been done about 40 times in the last 13 years, in large part due to the complexities inherent to this kind of procedure. The few teams in the world who perform this surgery are all in contact, eager to learn from one another and to make the surgery safer and maximize the benefits to the patient.

Dr. Daniel Borsuk, MD, FRCSC, a plastic surgeon at the Maisonneuve-Rosemont in Montreal, led the team of nine surgeons who performed this Canadian first. He emphasized that extensive planning was the cornerstone of their success.

“There was a plan B, C, D, E, F and G,” he said with a laugh.

“We weren’t going ahead saying, ‘well, if it doesn’t work, it doesn’t work’; there were a lot of contingency plans, but the idea being that we have to plan for [the transplant] as if there is no plan B. We have to train and prepare every type of scenario possible and prepare for every possible eventuality. Basically our plan – which encompassed a lot of contingency plans - had to work.”

Dr. Borsuk trained in Baltimore at Johns Hopkins and the University of Maryland Shock Trauma Unit. In 2012, he assisted on a 36-hour facial transplant. At the time, it was the most extensive transplant of its kind ever performed. When he returned to Canada that same year, he felt strongly that Canadians should also have access to new forms of transplantation like upper extremity and facial.

Transplant recipient, Mr. Maurice Desjardins, before and after surgery – front and side views (photos courtesy of Dr. Daniel Borsuk)

Dr. Bosuk spent years building his team in Montreal and working with Transplant Quebec to find and gain consent for a donor who matched the patient’s skin colour, bone proportions and many other physical parameters. Emphasizing the need, patient benefits and new research possibilities stemming from this form of surgery, he earned support at the federal, provincial and local levels.

“It’s one thing to do a face transplant. It’s another to have one that is beautiful and one that achieves all of our goals of restoring aesthetics and function. It took five years, but I think we finally got that plan to be as close as possible to perfect for that transplant.”

Dr. Borsuk confirmed that more patients are currently being evaluated for a facial transplant.


Read more about this pioneering surgery


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Futuristic virtual reality therapy shows promise

A patient in the therapy room (photo courtesy of Dr. Alexandre Dumais)

Imagine facing your demons head-on. For some patients, that’s quite literally what a new form of virtual reality therapy is empowering them to do.

Dr. Alexandre Dumais Dr. Alexandre Dumais

The man behind this new approach, Alexandre Dumais, MD, FRCPC, is a researcher and psychiatrist at the Institut Philippe-Pinel of Montreal. Dr. Dumais is using virtual reality to help patients living with treatment-resistant schizophrenia. Over a series of about nine sessions, he mixes classical cognitive behavioral therapy (CBT) strategies for psychosis with a new form of avatar therapy.

Patients who participate have not responded well to anti-psychotic medications. This new treatment allows them to confront their persecutor head-on in the form of an avatar, modelled after the voice(s) they hear. Using virtual reality goggles, the patient will interact with Dr. Dumais in character as their avatar — usually a demon. The dialogue is based on patient-reported hallucinations.

“We are building coping skills with the avatar but the approach is really different because it’s experiential. The patient is inside the emotion; they live it right away. The avatar is saying ‘you’re an idiot.’ The person is saying ‘I feel like an idiot. I’m worth nothing.’ And we work on that on the spot.”

The software used to create the avatars (photo courtesy of Dr. Alexandre Dumais)

Dr. Dumais was inspired by London-based psychiatrist, Dr. Julian Leff, who has pioneered treating patients with refractory hallucinations using virtual reality. Dr. Dumais adapted the therapy from a two-dimensional screen to a 3D environment so that patients are completely immersed.

“At the beginning, it was not easy to get funding and approval because it’s really different from what people are used to doing in Psychiatry,” said Dr. Dumais.

The therapy took about five years to develop. Treatment of the first patient began in 2015. The results of that first phase have been published in Schizophrenia Research. The second phase of this pilot will be complete by the end of the year. The third and final phase, a single blind randomized trial funded by a Canadian Institutes of Health Research grant, will begin in the New Year.

Dr. Dumais is testing the hypothesis that avatar therapy is superior to traditional approaches to treatment-resistant schizophrenia. While he concedes that this therapy is not the right fit for everyone, it has been transformative for some.

“We had really good results with some patients who before were not working, and now they’ve gone back to school and found jobs. It can change lives. One of my colleagues said that the avatar therapy will be the next generation CBT. It’s only the beginning.”


Read more about this pioneering therapy


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“Fall” into MOC with these autumnal tips

Falling leaves are heralding the close of yet another year of learning. This is the perfect time to look back and reflect on your continuing professional development accomplishments. Start by checking your credit situation. Remember, there’s still time to take action to apply the necessary credits to your account before the January 31, 2019, reporting deadline.

Follow these five easy steps to reach MOC Program compliance before January:

Check your credit balances overall and in each MOC section.

Log in to MAINPORT ePortfolio and verify your credit situation on your dashboard. How many do you still need to achieve your 400 credits per cycle requirement? Remember that you must also document at least 25 credits in each section — 1, 2 and 3 — of the MOC Program before your five-year cycle ends. Your MAINPORT dashboard shows a handy visual summary of this information.

Claim Section 1 credits waiting in your Holding Area.

If you went to any conferences over the summer or in September, you may have conference activities awaiting your action in your Holding Area in MAINPORT ePortfolio. Take the time to apply these Section 1 credits to your account.

Claim Section 1 and 3 credits from our list of accredited activities.

Check the Royal College’s website, where we list accredited group learning, self-assessment and simulation assessment activities by specialty, to see what’s available in your speciality and area this fall!

Claim Section 2 credits for renewing your advanced life support training.

Did you re-certify this year? You can document the learning you acquired following a traineeship (such as a PALS, NALS, ATLS, ACLS or BLS course) as two credits per hour in Section 2: Traineeship.

Claim Section 3 credits from your reappointment.

Fall is often the time for departmental or hospital reappointments, significant milestones in the professional development of specialists. Leverage your reappointment by reflecting on data and feedback you’ve received about your practice performance for Section 3 Assessment credits.

Fall can be a busy time of year but it’s also a great time to do an MOC check-up. You’ll beat the winter rush ahead of the January reporting deadline and feel more prepared to successfully close your MOC cycle when the time comes.


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Free download: Toolkits on resource stewardship

In a complex system with competing demands, engaging in the stewardship of limited health care resources can be a challenge. Perhaps you are a busy clinician educator or simply interested in improving your understanding of this theme — take advantage of our free toolkits!

Download the toolkits now (free download)

Choose from three toolkits

We’ve updated three toolkits on resource stewardship, first launched last year, that are aimed at preparing young physicians for the challenges associated with resource stewardship. While the content is written for medical educators and aligned with competencies in CanMEDS 2015, the lessons serve as a good refresher for all practising physicians.

  • Foundations of Resource Stewardship: Gain a foundational knowledge of resource stewardship and the ability to recognize opportunities to apply its concepts in daily practice through clinical care, teaching and assessment. Access it now.
  • Undertaking a Resource Stewardship Project During Postgraduate Training: Faculty who supervise residents’ scholarly projects will benefit from assistance in the planning, supervision and assessment of resource stewardship projects. Access it now
  • Communicating with Patients and Families about Resource Stewardship: This toolkit provides a framework that you can use to teach residents how to communicate with patients and families that request a medically unnecessary test/treatment. Access it now

About the CanMEDS Resource Stewardship Curriculum Toolkit Series
These toolkits were developed by a group of physicians and residents, the College of Family Physicians, Choosing Wisely Canada and the Royal College. They aim to help clinician educators teach residents the foundations of resource stewardship, undertake a resource stewardship project, and assess communication with patients about resource stewardship.


Learn more: www.royalcollege.ca/rcsite/canmeds/resource-stewardship-e


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November 16 deadline for Royal College Honorary Fellowship nominations

Celebrate someone whose work is exceptional!

Submit a nomination for Royal College Honorary Fellowship »

Honorary Fellowship is one of the most prestigious awards that the Royal College can bestow upon individuals who are ineligible for Royal College Fellowship. A nomination is a significant way to pay tribute to a health care leader or innovator (in Canada or abroad) whom you admire and respect.

The deadline to submit a nomination is November 16, 2018.

Find out more about Honorary Fellowship (plus, meet our 2018 recipients): www.royalcollege.ca/honorary


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Advice for new specialists

Last month, we asked you to share your words of counsel for newly certified specialists. Have something to add? Email us your response at communications@royalcollege.ca.

  1. "After 30 years in practice, I began to realize the importance of taking time to 'stop and smell the roses.' Busy years fly by, and one needs to set priorities. The newer generation of physicians is much better at making quality of life decisions and balancing work and personal life than those of us from the 'workaholic' past generation." - Dr. Philip Stuart (Urology)
  2. "I have been practising for 20 years. I have only gotten involved in formal leadership training opportunities in the last 3-5 years. I have learned so many things through my leadership training that have helped me be a better doctor and develop better relationships with patients and colleagues. Don't wait. Do this early in your career. It’s worth it." - Anonymous
  3. "In almost 35 years of clinical pediatric practice, I've learned to listen very carefully to the children's mothers. They know their kids better than anyone. When they are worried, there is usually something significant that needs to be addressed." - Dr. John Freedman (Pediatrics)
  4. "Listen to your doubts and your patients. Sometimes overcalling is better than a miss. I once found a primary immune deficiency in a well-seeming five-year-old. Testing seemed like overkill, but the asthma history was a bit off, Mom felt the puffers didn't work and there were zero immunoglobulins. On IVIg, the child is truly well". - Dr. Anne Hicks (Pediatric Respiratory Medicine)
  5. "It takes only a moment or two to burn a bridge, and years to build it back up again. Suck it up, give the benefit of the doubt, when all else fails be respectful and treat others with respect and dignity. The return on investment is priceless." (Originally shared in 2017) - Dr. Joy Liao (Geriatric Medicine)

Link to more advice shared in 2017


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Members in the news

Doctor walking down a hospital hallway

"If you can imagine, we have these florescent green or blue human cancer cells that are growing and dividing in the zebrafish and we can track their movement in the fish and how they behave," Jason Berman, MD, FRCPC (“How zebrafish are changing the way doctors treat children with cancer,” CBC News – Nova Scotia)

"I think the virtual autopsy has a role to play going forward — but so does the regular autopsy," Jagdish Butany, MBBS, FRCPC (“Beyond the scalpel: Why 'virtual' autopsies may be the way of the future,” CBC News)

“In rare diseases, access issues begin with diagnosis,” Aneal Khan, MD, FRCPC (“Not so rare: The fight for rare disease treatment,” Maclean’s – Sponsored content).

“Patient asks if I can also fix teddy bear just before being put off to sleep ... how could I say no?,” - Daniel McNeely, MD, FRCSC (“Halifax doctor sutures beloved teddy bear before child’s surgery,” The Star Halifax).

“I can’t see myself ever wanting to practise the way we used to practise,” Raj Rampersaud, MD, FRCSC (“Renowned spine surgeon is transforming the way Ontario deals with back pain,” Toronto Star).

“This wire could mean the difference between the success and failure of a CTO angioplasty because it will be able to break through areas where other guides fail to penetrate,” Stéphane Rinfret, MD, FRCPC (“MUHC cardiologist scores world first with Live Wire artery unblocker,” Montreal Gazette).

“The diagnosis still rests on the story that the patients tell and the findings that we find on the physical exam,” Jonathon Squires, MD, FRCPC (“Extra Dosage of When Life Gives You Parkinson’s: What’s up, Doc? Larry talks to his neurologist,” Global News)

“If you see a real personality change in someone … you need to pay attention to that,” Carmela Tartaglia, MD, FRCPC (“Depression or young onset dementia? Here’s how to tell the difference,” Global News)

“What we have done is develop a virtual care pathway that makes same-day total joint replacement routine for many patients,” David Urbach, MD, FRCSC (“One solution to hallway medicine: outpatient hip-replacements,” Toronto Star)

“There are five orthopedic surgeons on P.E.I. All of us perform knee replacement surgery, and three of us perform hip replacement surgery,” Scott Wotherspoon, MD, FRCSC (“OPINION: Unavoidable increase in wait times,” The Guardian)


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Phil was born in Leeds, England, on September 4, 1945, and passed away peacefully on March 20, 2018, in West Vancouver, B.C.

Phil had an idyllic childhood in Hornsea, a seaside town in Yorkshire, where he raced dinghies and played rugby. He obtained his medical training at Cambridge University (attaining First Class Honours) and St. Thomas’ Hospital, London, graduating as a physician in 1969. After obtaining his MRCP in 1972, he pursued a career in Pediatrics.

Phil and I met in the Churchill Hospital in Oxford in 1975. I was a medical student doing my Pediatric rotation and he was the senior registrar on call. We got married in November 1976. A year later, we moved to the United States for his subspecialty training in Neonatal Medicine at Denver Children’s Hospital in Colorado.

We enjoyed living in the West so much that we decided to move to Edmonton in 1980. Phil joined the Department of Pediatrics at the University of Alberta as a staff neonatologist based at the Neonatal Intensive Care Unit (NICU) in the Royal Alexandra Hospital (RAH), which served one of the largest newborn delivery services in Canada. Phil went on to become director of the RAH NICU. He was also the first regional director and head of Newborn Medicine with the Capital Health Authority in Edmonton.

Phil was part of the RAH team that developed the first and most active neonatal extracorporeal membrane oxygenation (ECMO) program in Canada; for many years, it was the only program of its kind in Western Canada. The RAH team was also one of the first to use inhaled nitric oxide therapy in term neonates. These interventions saved many babies.

Phil was a compassionate and caring physician, an excellent clinician and a well-respected mentor and colleague. His commitment to patient care was exemplary. His co-workers felt he was someone with whom they could always share their concerns. During his long career at the RAH, Phil taught generations of residents and medical students, for whom he was an excellent role model.

In 2000, Phil spearheaded the planning, design and establishment of a new state-of-the-art NICU at the RAH; it was one of his fondest legacies. For his longstanding service on the Alberta Medical Association (AMA) Committee on Reproductive Care, which was instrumental in the development of the Alberta Perinatal Health Program, he was recognized with the AMA Member Emeritus distinction in 2006 and the Canadian Medical Association Honorary Membership Award in 2011.

Phil devoted all his time outside of work to his family. He was thrilled when our son Nick was born in 1985. He taught Nick the values he observed all his life: compassion, integrity, generosity, a constant readiness to help others and a great work ethic. He was delighted when Nick decided to follow in our footsteps to pursue a career in medicine.

Phil grew up with a strong sense of social justice. He was a passionate supporter of environmental causes, numerous charities and Medicare. He was profoundly grateful for the excellent care he received in the last two years of his life.

Phil will live on in our hearts and minds forever.

This is the first article in a new series of memorial tributes. Is there a Fellow you’d like to honour in a remembrance piece? Email communications@royalcollege.ca with details.

  1. Philip C. Etches, MA, MB, FRCPC, FRCP (Lond), FAAP, FRCPCH, DCH
  2. Phil and Nick.
  3. Phil and me on one of our many trips together.
  4. Phil wears his hard hat during the construction of the hospital’s new NICU. He felt very fortunate to be a part of that project, which few doctors get to experience.
  5. Phil in the NICU.
  6. Together with our son, Nick.

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In memoriam

Stethoscope

Elmer Moreno Andrade, MD, FRCSC, died on July 22, 2018, in Saint John, N.B., at age 83. Dr. Andrade was certified by the Royal College in Obstetrics and Gynecology in 1966. From 1966 to 1995, he co-ran his own practice in Saint John. It is estimated that he delivered more than 6,000 babies during his career. Read more about Dr. Andrade.

Roger Caudwell Bland, MBChB, FRCPC, died on July 31, 2018, in Edmonton, Alta., at age 80. Dr. Bland was certified by the Royal College in Psychiatry in 1971. He held many academic and administrative leadership positions, and devoted a great deal of his career to the treatment and quality of life of patients living with mental illness. Read more about Dr. Bland.

Franҫois Beaudoin, MD, FRCSC, died on July 20, 2018, in Montreal, Que., at age 61. Dr. Beaudoin was certified by the Royal College in Obstetrics and Gynecology in 1986. He worked at CHU Sainte-Justine in Montreal, where he was well-liked by patients and colleagues. He will be remembered for his generosity, love of his family and passion for his work. Read more about Dr. Beaudoin.

Nancy Madeline Dunne, MD, FRCPC, died on August 4, 2018, in North York, Ont., at age 63. Dr. Dunne was certified by the Royal College in Anesthesiology in 1985. She worked at the Humber River Regional Hospital. Outside of medicine, she pursued many hobbies and was especially passionate about horseback riding. Read more about Dr. Dunne.

Stanley Andrew Dziurdzy, MD, FRCPC, died on August 19, 2018, in Burlington, Ont., at age 80. Dr. Dziurdzy was certified by the Royal College in Psychiatry in 1968. A recipient of the Gold medal for Psychiatry, he practiced in the Burlington and Hamilton area for more than 50 years. Read more about Dr. Dziurdzy.

Rubin Manuel Feldman, MD, FRCPC, died on August 4, 2018, in Vancouver, B.C., at age 87. Dr. Feldman was certified by the Royal College in Physical Medicine and Rehabilitation in 1971. He worked in pain management and as a physical therapist in the Vancouver area.

Brahm Bhushan Gulati, MBBS, FRCSC, died on June 17, 2018, in Charlottetown P.E.I., at age 84. Dr. Gulati was certified by the Royal College in General Surgery in 1975. He worked in many cities, including opening a medical clinic in Dehradun, India. After retirement from professional practice, he worked with Veterans Affairs Canada for more than 20 years. Read more about Dr. Gulati.

Sriram Iyer, MBBS, FRCPC, died on August 2, 2018, in Maple Ridge, B.C., at age 47. Dr. Iyer was certified by the Royal College in Pediatrics (2011) and Endocrinology and Metabolism (2015). A graduate of Gujarat University in India; since 1994, he worked as a pediatrician in Maple Ridge.

Gerald (Gerry) A. Klassen, MD, FRCPC, died on August 6, 2018, in Halifax, N.S., at age 85. Dr. Klassen was certified by the Royal College in Internal Medicine in 1962. His research interests centered on coronary circulation and bioethics in human research; early in his career, he was involved in the early transplantation of pacemakers in Canada. Read more about Dr. Klassen.

Michel Léveillé, MD, FRCSC, died on August 23, 2018, in Sainte-Marie-Salomé, Que., at age 81. Dr. Leveille was certified by the Royal College in General Surgery in 1968. For 20 years, he worked as a surgeon at the Hôpital de Joliette (CHRDL) and later did administrative tasks at the Centre hospitalier régional de Lanaudière (CHRDL). Read more about Dr. Léveillé.

Robert Harold (Bob) North, MD, FRCSC, died on August 15, 2018, in Brampton, Ont., at age 80. Dr. North was certified by the Royal College in Otolaryngology – Head and Neck Surgery in 1969. He practised in Brampton for over 50 years, and was well-loved by colleagues and patients of the Peel Memorial and Brampton Civic hospitals. Read more about Dr. North.

Heather Frances Penney, MD, FRCPC, died on August 18, 2018, in Camrose, Alta., at age 75. Dr. Penney was certified by the Royal College in Diagnostic Radiology in 1973. Passionate about her specialty; along with a colleague, she brought ultrasound to Western Canada in 1975. She never missed a Radiological Society of North America annual meeting. Read more about Dr. Penney.

Sheldon Hershl Rubin, MD, FRCPC, died on August 13, 2018, in Moncton, N.B., at age 75. Dr. Rubin was certified by the Royal College in Internal Medicine (1973) and Hematology (1974). He was the first oncologist and second hematologist to practice in New Brunswick. Among other firsts, he started the province’s first comprehensive Hemophiliac Clinic in 1988. Read more about Dr. Rubin.

Muriel Florence Smith, MD, FRCPC, died on August 6, 2018, in Fredericton, N.B., at age 74. Dr. Smith was certified by the Royal College in General Pathology (1980) and Anatomical Pathology (1980). Dr. Smith practised as a pathologist in Fredericton.


 

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