Christmas Message 2010
Poverty affects us all - lets work to eliminate poverty - 'feel good' giving is a symptom, not a cure.
The need for charity is something that makes me very angry. It reminds me that our society is unjust. The poor continue to be poor, while the rich get richer. Rich people 'feeling good' about giving a few dollars or a few hours of their time to the 'deserving poor' is something I would love to see the end of.
In a fair society, the rich would pay more in tax and that money would go to raising the poor out of poverty.
In their book The Spirit Level, Richard Wilkinson and Kate Picket argue that everyone - rich and poor - is more happy in societies where the gap between rich and poor is less*. Money can't buy you happiness if it makes someone else poorer. We certainly see that every day in our medical practice. Patients who are sick and dying because they can't afford basic medications. They don't need charity, they need free prescriptions funded by taxpayers. Not only will the poor be happier then (they won't die as young), but the rich will be happier too (their tax money won't be wasted on unnecessary hospital admissions). I regularly waste tens of thousands of dollars of tax payers money admitting patients to hospital because they could not afford a $60 prescription. I'm tired of seeing legions of patients who are not poor, but are stressed and miserable because of the fear of losing money and becoming poor. If we had a proper social safety net, that fear would be less and they would be happier.
And don't waste time on the kind of ignorant narcissism displayed by far too many successful people that the poor are poor because of their own choices. We are all the product of our genes and our environment. The rich stack the table against the poor from before conception (leverage) and then add insult to injury by blaming the poor for being poor. 'Feel-good' giving to charity based on that view is like running someone down with your car and then feeling good about yourself because you gave them a band-aid.
A recent report by PEI MLAs recommends that our Social Assistance programs need an overhaul and more money. This, they say, is a matter of social justice not charity.
This Christmas season lets do some real good. Lets express some justified anger. Lets push for a future in which charity 'turkey drives' are just a memory of a dark and unfair past.
December 4, 2010
November 29, 2010
New Walk In Clinic Thursday mornings 10 to 12
Following on from the success of our Rapid Access Clinics (which have been running weekdays 10am to 11am), we've decided to trial a Walk In Clinic on Thursday mornings. This will replace the Thursday morning Rapid Access Clinic and will run from 10am to 12am.
It will be open to everyone, even if they are not our patient. Patients attending the Sherwood Medical Center walk in clinic on Thursday mornings will be re-directed to our practice upstairs*. There should be space for up to 60 patients each morning, with the doctor being assisted by a Practice Nurse, a Pharmacy Technician, and three Health Care Technicians. We are hoping to keep waiting times short.
If it proves successful, we may add a second Walk In Clinic earlier in the week.
* And on the weeks that we are closed, our patients can attend the Sherwood Medical Practice walk in clinic downstairs instead.
It will be open to everyone, even if they are not our patient. Patients attending the Sherwood Medical Center walk in clinic on Thursday mornings will be re-directed to our practice upstairs*. There should be space for up to 60 patients each morning, with the doctor being assisted by a Practice Nurse, a Pharmacy Technician, and three Health Care Technicians. We are hoping to keep waiting times short.
If it proves successful, we may add a second Walk In Clinic earlier in the week.
* And on the weeks that we are closed, our patients can attend the Sherwood Medical Practice walk in clinic downstairs instead.
November 22, 2010
GPAQ Questionnaire Week
This week is Questionnaire week at the practice. Once a year we distribute questionnaires to patients visiting the practice. We use the answers to help us find ways to provide better care.If you have an appointment at the practice this week, you may be given a questionnaire when you check in. Please read the questionnaire carefully. Don't fill it in until after you have been seen by the doctor or nurse. Once you have filled it in, you can drop it back into reception. If you would prefer, we will give you an envelope so you can take the questionnaire home and mail it back to us later.
The questionnaire we use is the GPAQ questionnaire. It is specially designed by Manchester University in England for family practices. It is used by most NHS family physicians in the UK. We have been running it for several years.
The questionnaire is given to 60 consecutive patients for each doctor and nurse in the practice over the week. It is anonymous. Staff will not know who has filled in each questionnaire.
The questions relate to how easily you can access care at the practice, waiting times, and how helpful you found your visit to the doctor/nurse. We use these answers to look for areas where we can improve what we are doing.
Thank you for helping us to help you.
October 29, 2010
Far too many patients still at risk from influenza - Scottish practice showing us up!
 |
| Our computer system speeds up the flu clinic and improves safety |
We have a lot of work to do after a disappointing start to our free flu clinics for our at-risk patients . Only
This is shockingly bad. Strachur Medical Practice, our Scottish sister practice is miles better at this with 95% of their Heart Disease, 100% of their Chronic Bronchitis and 100% of their Diabetic patients vaccinated in 2009.
It means that the great majority of our elderly and chronic illness patients are at higher risk of catching influenza and dying this year. This is just not good enough.
We want to vaccinate at least 75% of our at-risk patients. This is based on the World Health Organization recommendations. You can watch how we are doing via this page and the tracker on our home page. They update with live data every 60 seconds.
We're now going to extend our access to free flu shots:
- To avoid confusion, flu shots are now free for all patients.
- We are going to run a drop in flu shot clinic every weekday from 10am to 2pm
- We are going to run an evening flu shot clinic from 2pm-6pm every Thursday.
- Our nursing team are going to be chasing up our at-risk patients.
Our Scottish sister practice is way ahead of us. Come on Canadians! Don't let the Scots show you up. You can do better!
October 10, 2010
New Schedule
 |
| Our new schedule is now up and running. |
We've moved the appointments around to reduce the waiting times. We've spaced out the medical appointments because they had the longest waits on the day, and we've started our Rapid Access Clinics for people who just need two or three minutes with the doctor. The Rapid Access Clinic runs weekdays from 10am till 11am.
Reduced waiting times
We trialled the new schedule last week, and on Friday (when most of the bumps had been ironed out!) the average waiting time for patients was down to 17 minutes. That's a great improvement from the average of around 1 hour that we had before we moved to the new premises, and the average of 35 minutes that we had with the old schedule. We continue to be able to offer appointments usually within a few days.
Our waiting times (both on the day, and for booking ahead) are displayed on our home page.
New opening hours - evening clinic on Thursdays
A couple of changes to hours as well. This is mainly due to the fact that we have had to postpone having a second doctor. The front desk will be open only from 10am until 2pm daily. We will also only be answering the phones between these hours.
We will now be offering appointments every weekday, but only between 10am and 2pm (except the Treatment Room Nurse who will remain open from 8.20am until 4pm). For patients who find it hard to take time off work, we will be starting an evening clinic running to 6pm on Thursdays from next month.
We're really pleased with this new schedule, and we hope it will make accessing care even easier for our patients.
September 26, 2010
Practice Nurses Tackling Obesity Epidemic
Canada is in the middle of a deadly obesity epidemic.
Which life do you want future generations of Canadians to have?
Obesity is classed as a Body Mass Index (BMI) of over 30. BMI is the ratio of your weight to your height.
The Pheonix Medical Practice computer system contains the height and weight of all of our patients who have been for their initial visit with our clinical team. Each night our computer re-calculates every patient's BMI and works out what percentage of our patients have a BMI over 30.
Today, the computer says 28% of patients at the Phoenix Medical Practice are classed as obese. In 1980 that figure would have been around 10%.
Obesity is a very serious medical condition.
Obesity is a killer. It puts a strain on your heart, lungs, blood vessels, and joints. Your risk of getting diabetes goes up with your weight. The World Health Organisation (WHO) suggests that 58% of diabetes, 21% of heart disease, and up to 42% of certain cancers are caused by higher weight (BMI above 21).
Condemning our children to a life of sickness and early death
Basically, your chances of being sick and dying young go up with your weight. As obesity rates rise, our children face a life of ill health and short lifespan unknown since the rise of modern medicine.
It's a nightmare that is unfolding so slowly that few are noticing it even happening. Combined with the body image problems of a size zero obsessed fashion industry, we have a society that has a terminal weight problem.
What can we do about it?
The solutions are actually quite simple in theory. We build roads that give priority to cyclists and walkers, we force the food industry to reduce hidden sugar and fat, and we tax sugary and fatty foods. Of course, none of these things are going to happen any time soon in a capitalist economic system addicted to unhealthy food and big cars. That's a discussion for you to have with your politicians. Dr Jenni Zelin is hard at work doing a great job pushing for more cycle lanes in PEI
In the mean time, our Practice Nursing Team will be following the WHO advice. The WHO is urging family physician teams to intervene with healthy eating and lifestyle advice. Our team of nurses are already doing that. They have lists of patients who are obese, and they will be working through the list calling them to offer them support and advice. Our Practice Nurses can run a very successful weight management program with these patients.
The WHO wants to see this introduced nationally. It thinks 40,000 Canadians will be saved if it is. We agree. Our team is already hard at work doing this.
 |  |
| Fast food, slow death (North America) | Healthy for life (Denmark) |
Obesity is classed as a Body Mass Index (BMI) of over 30. BMI is the ratio of your weight to your height.
The Pheonix Medical Practice computer system contains the height and weight of all of our patients who have been for their initial visit with our clinical team. Each night our computer re-calculates every patient's BMI and works out what percentage of our patients have a BMI over 30.
Today, the computer says 28% of patients at the Phoenix Medical Practice are classed as obese. In 1980 that figure would have been around 10%.
Obesity is a very serious medical condition.
Obesity is a killer. It puts a strain on your heart, lungs, blood vessels, and joints. Your risk of getting diabetes goes up with your weight. The World Health Organisation (WHO) suggests that 58% of diabetes, 21% of heart disease, and up to 42% of certain cancers are caused by higher weight (BMI above 21).
Condemning our children to a life of sickness and early death
Basically, your chances of being sick and dying young go up with your weight. As obesity rates rise, our children face a life of ill health and short lifespan unknown since the rise of modern medicine.
It's a nightmare that is unfolding so slowly that few are noticing it even happening. Combined with the body image problems of a size zero obsessed fashion industry, we have a society that has a terminal weight problem.
What can we do about it?
The solutions are actually quite simple in theory. We build roads that give priority to cyclists and walkers, we force the food industry to reduce hidden sugar and fat, and we tax sugary and fatty foods. Of course, none of these things are going to happen any time soon in a capitalist economic system addicted to unhealthy food and big cars. That's a discussion for you to have with your politicians. Dr Jenni Zelin is hard at work doing a great job pushing for more cycle lanes in PEI
In the mean time, our Practice Nursing Team will be following the WHO advice. The WHO is urging family physician teams to intervene with healthy eating and lifestyle advice. Our team of nurses are already doing that. They have lists of patients who are obese, and they will be working through the list calling them to offer them support and advice. Our Practice Nurses can run a very successful weight management program with these patients.
The WHO wants to see this introduced nationally. It thinks 40,000 Canadians will be saved if it is. We agree. Our team is already hard at work doing this.
September 22, 2010
The Phoenix Medical Practice - our new name!
The Phoenix Medical Practice is the new name of our medical practice.
We chose the name for several reasons. The phoenix is the mythical bird that rises from the ashes.
Lots of professionals work in a modern Medical Practice as part of the team, and our new name reflects this.
We will be updating our letterheads, signage, and painting a mural in the children's play area over the next few weeks to represent our new name.
We chose the name for several reasons. The phoenix is the mythical bird that rises from the ashes.
- The Phoenix Medical Practice has been set up as a response to Dr Coull's failed attempt to set up a collaborative model of care in the Four Neighbourhoods Community Health Center between October 2008 and February 2009. Four Neighbourhoods has since closed its family physician service.
- The Phoenix Medical Practice offices literally rose from the ashes of the old Maid Marion diner, which burnt to the ground in 2009.
- We - along with some of our clinical team and lots of our patients - are incomers making a new life in a new land.
Lots of professionals work in a modern Medical Practice as part of the team, and our new name reflects this.
We will be updating our letterheads, signage, and painting a mural in the children's play area over the next few weeks to represent our new name.
September 11, 2010
Update: new doctor pulls out of coming to PEI
**UPDATE**
Sadly, Dr Rawal has informed us that she has decided not to come to PEI. We have been talking to her about her move here for over two years, and we are terribly disappointed that she has decided against coming.
This is a terrrible blow to our plans for the medical practice. We have been working hard over the last few months planning for the expansion of the practice, and we are very disappointed by this news.
It means that we will not be able to provide the level of service to our patients that we would like. We won't yet be able to provide the extended opening hours that we were planning. We won't yet be able to stay open during the doctor's vacations. We won't yet be able to provide the stability and sustainability that comes with a group practice.
We are actively looking for more doctors, and so we are hopeful that this is just a temporary setback.
Original post:
Our goal is to make sure that every patient in PEI has easy access to a family physician. To do this we plan to keep our doors open to new patients. Instead of closing our doors, as we register more patients we plan to add more doctors to our medical practice to meet demand.
As part of this plan, we have now appointed our second doctor. Dr Susan Rawal is a GP (family physician) in England. She is currently a partner in a medical practice with 21,000 patients. However, her husband has taken a job as a radiologist at the QEH hospital in Charlottetown and they will be moving to PEI this year with their three young children. Dr Rawal has kindly asked Health PEI if she can join our practice when she arrives and Health PEI have agreed to this.
The addition of a second doctor will make us a 'group practice'. This means that all of our patients will have access to both doctors. Patients will be able to book an appointment with the doctor of their choice.
We plan to continue to add more doctors to the practice as we grow over the next two to three years, and have a capacity in our current premises for up to 4 doctors and 12,000 patients. We have also been approached about the possibility of opening a branch practice in the future in Prince County to tackle the physician shortage there.
This is fantastic news for the residents of Queens County who have struggled with a shortage of family physicians for so long. Once up and running our medical practice will have the following advantages:
We are delighted to be able to continue our work to improve access to high quality care and I'm sure all our patients will be as excited as we are about Dr Rawal coming to join us in January.
Sadly, Dr Rawal has informed us that she has decided not to come to PEI. We have been talking to her about her move here for over two years, and we are terribly disappointed that she has decided against coming.
This is a terrrible blow to our plans for the medical practice. We have been working hard over the last few months planning for the expansion of the practice, and we are very disappointed by this news.
It means that we will not be able to provide the level of service to our patients that we would like. We won't yet be able to provide the extended opening hours that we were planning. We won't yet be able to stay open during the doctor's vacations. We won't yet be able to provide the stability and sustainability that comes with a group practice.
We are actively looking for more doctors, and so we are hopeful that this is just a temporary setback.
Original post:
Our goal is to make sure that every patient in PEI has easy access to a family physician. To do this we plan to keep our doors open to new patients. Instead of closing our doors, as we register more patients we plan to add more doctors to our medical practice to meet demand.
As part of this plan, we have now appointed our second doctor. Dr Susan Rawal is a GP (family physician) in England. She is currently a partner in a medical practice with 21,000 patients. However, her husband has taken a job as a radiologist at the QEH hospital in Charlottetown and they will be moving to PEI this year with their three young children. Dr Rawal has kindly asked Health PEI if she can join our practice when she arrives and Health PEI have agreed to this.
The addition of a second doctor will make us a 'group practice'. This means that all of our patients will have access to both doctors. Patients will be able to book an appointment with the doctor of their choice.
We plan to continue to add more doctors to the practice as we grow over the next two to three years, and have a capacity in our current premises for up to 4 doctors and 12,000 patients. We have also been approached about the possibility of opening a branch practice in the future in Prince County to tackle the physician shortage there.
This is fantastic news for the residents of Queens County who have struggled with a shortage of family physicians for so long. Once up and running our medical practice will have the following advantages:
- A choice of which doctor you see when booking in advance.
- A choice of a female or male doctor depending on your needs.
- A medical practice that is never closed for vacations.
- A new 'Rapid Access Clinic' which will allow patients to see a doctor within 48hours for urgent conditions.
- A planned joint injection clinic.
- Patients will not 'lose' their family physician if one doctor leaves. Even if one doctor leaves the group practice, the other doctors can carry on until a replacement is found. This will hopefully mean an end to thousands of patients suddenly finding themselves without a family doctor.
- We operate the style of medical practice that modern family physicians are used to elsewhere.
- We have already been contacted by several Canadian doctors who have seen us on the internet and are interested in moving to PEI.
- Our Health Care Technicians will be taking their Canadian exams over the next couple of years and may be able to become physicians within the practice once they obtain Canadian licenses.
- One of our Health Care Technicians, Shirin Majdi Zadeh, will be leaving us to start her Family Practice intern training in the US in November. We would be delighted if she chose to return to work with us in three years time when she is a fully qualified family doctor.
- Every month we are visited by doctors and people in health-related fields from around Canada interested in how we have set up our medical practice.
We are delighted to be able to continue our work to improve access to high quality care and I'm sure all our patients will be as excited as we are about Dr Rawal coming to join us in January.
August 14, 2010
Dr Fox - Cognitive Behavioural Therapy (CBT)
 |
| Dr Declan Fox, Family Physician |
Dr Fox is a Northern Irish GP (Family Physician) who is experienced in Cognitive Behavioural Therapy (CBT). CBT is commonly called "talking therapy". It is very effective for patients with anxiety, depression, stress, insomnia, post-traumatic stress disorder, chronic pain, and panic attacks.
Dr Fox has been coming to work in PEI for around 10 years now - mainly over in West Prince. He is completing his diploma in CBT, and will be returning to visit our practice again next year. On his next visit, as well as seeing patients, he will be training our nursing staff in how to support patients who are using self-directed CBT. That is, CBT using the excellent self-help website Living Life to the Full and the self-help books written by Professor Chris Williams of Glasgow University. We have several copies of Dr Williams' books Overcoming Depression and Overcoming Anxiety in our medical library. These books are available to our patients to take out on loan.
If you would like more information about CBT, please book an appointment with one of our Practice Nurses.
CBT practitioners are sadly quite rare, and we'd like to thank Dr Fox for taking the time to help out our patients and staff. We are sure that the patients who meet him will find him as thoughtful, helpful and caring as we do.
August 7, 2010
Colour coded staff uniforms
We are a large medical practice with a large team. It's important that patients, staff and visitors can easily and quickly identify different staff groups. This improves safety and efficiency.
That is why we have standardised staff uniforms that are colour coded.
Registered Nurses wear navy blue tunics. Licensed Practical Nurses (LPNs) wear 'hospital blue' tunics. Health Care/Pharmacy Technicians wear white tunics.
Receptionists wear a black and white pattern tunic.
The licensed physicians, our Practice Pharmacist, and the management team will continue to wear street-clothes ('civvies').
The staff uniform color coding for our Sherwood practice and our Strachur practice are based on the Scottish National Health Service (NHS Scotland) national uniforms (although we are still using the 'old' uniform style which is more appropriate for primary care) and the NHS Scotland staff dress code.
That is why we have standardised staff uniforms that are colour coded.
Registered Nurses wear navy blue tunics. Licensed Practical Nurses (LPNs) wear 'hospital blue' tunics. Health Care/Pharmacy Technicians wear white tunics.
 Registered Nurses (RNs) wear navy blue tunics |  Licensed Practical Nurses (LPNs) wear 'hospital blue' tunics |
 Health Care Technicians and our Pharmacy Technician wear white tunics |  |
Receptionists wear a black and white pattern tunic.
The licensed physicians, our Practice Pharmacist, and the management team will continue to wear street-clothes ('civvies').
The staff uniform color coding for our Sherwood practice and our Strachur practice are based on the Scottish National Health Service (NHS Scotland) national uniforms (although we are still using the 'old' uniform style which is more appropriate for primary care) and the NHS Scotland staff dress code.
July 23, 2010
Practice reopening
**UPDATE**
The practice is reopening today (Monday) at 1pm.
Apologies to any patients for any disruption.
__________________________
The practice staff have received a telephone call from a known violent offender which could be construed as posing a threat of serious violence involving the use of a firearm.
As a result the medical practice is currently locked down. Police officers are in attendance at this time.
Patients are advised not to attend the practice which will remain closed at least until Monday afternoon.
We will update this site with more details as they become available.
The practice is reopening today (Monday) at 1pm.
Apologies to any patients for any disruption.
__________________________
The practice staff have received a telephone call from a known violent offender which could be construed as posing a threat of serious violence involving the use of a firearm.
As a result the medical practice is currently locked down. Police officers are in attendance at this time.
Patients are advised not to attend the practice which will remain closed at least until Monday afternoon.
We will update this site with more details as they become available.
Collaborative care will not mean less doctors on PEI
CBC ran a story yesterday about a leaked copy of the draft Hay report into the future of health care on PEI.
I've not read the report, but they make reference to a suggestion that the number of doctors in PEI may be cut. This could obviously cause concern for patients and doctors who might be worried about the effect this might have on their care.
No matter what the report contains, the changes in health care will not reduce the need for doctors in the province. Improvements in health care delivery will mean better care for patients. However, there are lots of reasons why the number of doctors won't be able to be safely reduced in the foreseeable future:
1. There is a huge unmet health need. Better working will help meet, but will not exceed this need.
2. The population is aging.
3. As care improves, people need more care for the complex chronic illnesses that they are living longer with.
4. It will take 15 years to introduce changes across the health care system.
5. As the use of nurses and technicians increases, they will become an increasingly valuable resource, slowing the rate of change and increasing costs.
I'm looking forward to reading the final report when it is published.
I've not read the report, but they make reference to a suggestion that the number of doctors in PEI may be cut. This could obviously cause concern for patients and doctors who might be worried about the effect this might have on their care.
No matter what the report contains, the changes in health care will not reduce the need for doctors in the province. Improvements in health care delivery will mean better care for patients. However, there are lots of reasons why the number of doctors won't be able to be safely reduced in the foreseeable future:
1. There is a huge unmet health need. Better working will help meet, but will not exceed this need.
2. The population is aging.
3. As care improves, people need more care for the complex chronic illnesses that they are living longer with.
4. It will take 15 years to introduce changes across the health care system.
5. As the use of nurses and technicians increases, they will become an increasingly valuable resource, slowing the rate of change and increasing costs.
I'm looking forward to reading the final report when it is published.
July 11, 2010
Updated Practice Leaflet and website
The leaflet was last updated in January, and we've moved offices and had several new members of staff join us since then. The leaflet has also had it's information about our services updated, and has up to date opening hours included in it.
Please download a copy of the new patient leaflet, print it out, and keep it by your phone. Or pick up a fresh copy from the practice when you are next in.
July 4, 2010
SIGN Rockets - Aiming for Best Practice
If you are a hockey fan googling for 'PEI Rockets Sign' and you ended up here a little confused, I apologise.
SIGN guidelines have revolutionised the standard of medical care over the last fifteen years. They are a series of guidelines produced by the Scottish Intercollegiate Guideline Network and are arguably the best guideline network in the world. The fact that they are made in Scotland - like so many other wonderful inventions - helps, of course. The key thing is that they are unbiased. Vitally, the are completely independent of any pharmaceutical industry influence. This is because they are funded centrally by the National Health Service in Scotland (they are part of NHS Quality Improvement Scotland) and don't have to rely on any outside industry funding*.
The national guidelines are now an established part of all family practice in Scotland. Many of our patients with chronic issues will have come across them already as our Practice Nurses use them in both of our clinics as the basis for our Chronic Issues Reviews. So, if you have higher blood pressure, or diabetes, or chronic bronchitis, our nurses will use the SIGN guidelines for those conditions as part of your review. (Specialists may also have noticed that our referral letters to them are based on SIGN Guideline 31: Report on a Recommended Referral Document.)
Basically, the guidelines tell us what we should be doing to provide the best care possible to our patients. This is called Best Practice. They do this by evaluating all the available evidence and then grading their advice based on how good the evidence is. They do this using the Canadian ABCD system - each point has a letter next to it to show how good the evidence is for that advice/treatment. A is the highest quality, D is the lowest quality. Often, low quality evidence is because something is very hard to measure, and so is very hard to prove.
Now, SIGN is moving from simply telling us what the evidence is to helping us to actually put that in to practice. One part of that move is the introduction of SIGN Rockets. Rockets stands for Recommendations Online: Clinical Knowledge Evidence Translation. I prefer to think of them as a fast vehicle which takes us (including the patient) on a journey of best care. (There are other vehicles that we use for this too - such as the excellent 'best BETs' evidence based medical care website or the English National Health Service's Clinical Knowledge Summaries, although sadly you need access to an NHS Proxy Server to use the later).
So, if you come to us with a breast lump, don't be alarmed if we start to talk to each other about putting you on a rocket! The medical team will simply be making sure that we get you on the path to the best possible care. This will involve the medical and nursing teams working together using the appropriate SIGN Rocket.
Anyone can read and/or download the SIGN guidelines that we use. They are available on the SIGN website.
* In my medical practices I have a have a near-total ban on any information leaflets, guidelines, or equipment that has been funded - even in part - by the pharmaceutical industry. SIGN are therefore a 'trusted' source of information for us that makes it much quicker and easier to implement good care. We know straight away that the guidelines are free of outside bias. In fact, they even have a guideline for the creation of guidelines! We use other guidelines but - of course - that takes much longer as we need to research the guideline before we can be sure we can trust it.
June 18, 2010
Chronic Issue Registers and Disease Prevalence
We updated the title of this post to reflect the fact that our aim is to promote healthy living - physically, psychologically, and socially - and not just to diagnose and treat illness. Thanks to Anonymous for pointing this out to us in the comments section.
Many of our patients will already have noticed that we are constantly talking about 'registers'. One of the first things I look at when I open a patient's chart is the box in the top left of the screen. It's the 'disease register' list (Chronic Issues Registers). These are chronic issues that we want to prevent, screen for, and treat aggressively when we find them. For example, diabetes and asthma. Some registers are supportive - for example the Carers' Register is a list of patients who care for relatives or friends with serious health problems.
We use these registers to call patients back - usually to see our Practice Nurses for review on a regular basis. We have guidelines for each one - a series of questions, tests, or goals which will help keep our patients healthy (and, hopefully, out of the emergency department!).
The registers also help us track the quality of the care we provide to our patients. In fact, setting up chronic issues registers is the first step in any quality system. Unless we know how many diabetics we have and who they are, we can't check if we are getting their care right.
Knowing what percentage of patients we have with a disease also helps us plan our care. This is called 'prevalence data'. Every night, our computer system (EMR) counts up how many patients we have in each register and divides it by our total number of patients.
Here are our current prevalence figures for Sherwood:
You can compare them with the prevalence of illnesses in our Scottish practice here.
In Scotland, you will see from the link that you are able to compare our prevalence with that of our neighboring practices and a national average. Unfortunately, we can't show you any comparison data for our Canadian practice because we can't find any. Either no-one else is collecting this data in Canada, or they are not publishing it online. (If you know where we can get hold of this data, let us know.)
When comparing prevalences between our Canadian and Scottish patients, some points should be borne in mind. 1. The average age in our Scottish practice is unusually high. 2. We have not reviewed all of our Canadian patients yet, and in many cases are relying on self-reporting on the online registration form. For example, we only have recorded weights in our database from just over half of our patients. So the actual rate of obesity is likely to be around 25% once all our patients have been weighed.
Many of our patients will already have noticed that we are constantly talking about 'registers'. One of the first things I look at when I open a patient's chart is the box in the top left of the screen. It's the 'disease register' list (Chronic Issues Registers). These are chronic issues that we want to prevent, screen for, and treat aggressively when we find them. For example, diabetes and asthma. Some registers are supportive - for example the Carers' Register is a list of patients who care for relatives or friends with serious health problems.
We use these registers to call patients back - usually to see our Practice Nurses for review on a regular basis. We have guidelines for each one - a series of questions, tests, or goals which will help keep our patients healthy (and, hopefully, out of the emergency department!).
The registers also help us track the quality of the care we provide to our patients. In fact, setting up chronic issues registers is the first step in any quality system. Unless we know how many diabetics we have and who they are, we can't check if we are getting their care right.
Knowing what percentage of patients we have with a disease also helps us plan our care. This is called 'prevalence data'. Every night, our computer system (EMR) counts up how many patients we have in each register and divides it by our total number of patients.
Here are our current prevalence figures for Sherwood:
You can compare them with the prevalence of illnesses in our Scottish practice here.
In Scotland, you will see from the link that you are able to compare our prevalence with that of our neighboring practices and a national average. Unfortunately, we can't show you any comparison data for our Canadian practice because we can't find any. Either no-one else is collecting this data in Canada, or they are not publishing it online. (If you know where we can get hold of this data, let us know.)
When comparing prevalences between our Canadian and Scottish patients, some points should be borne in mind. 1. The average age in our Scottish practice is unusually high. 2. We have not reviewed all of our Canadian patients yet, and in many cases are relying on self-reporting on the online registration form. For example, we only have recorded weights in our database from just over half of our patients. So the actual rate of obesity is likely to be around 25% once all our patients have been weighed.
June 12, 2010
Access, Equality, Quality, Economy: Good quality primary care for all without bankrupting the province?
The Guardian ran an article on access to family physicians in PEI.
This is part of a wider debate about the rising costs of health care, particularly as the population ages and their medical care becomes ever more complex (and costly).
There are four features of an ideal primary health care system: access, quality, equality, and economy.
In other words, we need a system that patient have easy access to, that provides good quality care, that is available equally to all, and that is affordable.
Lets look at those four topics in more detail.
Access
Unless a primary care service is accessible, it will not meet the needs of patients.
There are three parts to access:
1. how long patients wait to get on a family physician's list of patients
2. how long patients have to wait for an appointment with their family physician.
3. how long patients wait to be seen on the day of their appointment.
These three barriers to access are like a pyramid (see Figure 1 below).
You have to get past each barrier in turn.
If you don't have a family physician, then short waiting times for patients that do have one are no use to you.
Once you have a family physician, then unless you can get an appointment with your family physician, short waiting times on the day are of no use to you.
We'll look at ways to improve access in a moment, but first we need to look at our other aims to make sure these are met too.
Equality
Access to quality health care is a basic right of citizens in a civilized society. For society to be fair, access to basic rights must be equal.
It is not acceptable for people to be denied access to quality health care because of where they live, or the level of their income, or the type of job they have, or the colour of their skin, or because they don't know the right people.
Everyone should have equal, fair access to quality health care provision.
So whatever we do to improve our health care system, must met the equality test: Does this make provision of health care more or less fair?
Quality
Health care provision needs to be of high quality to be effective.
It is easy to improve access to health care cheaply by simply providing poor health care. In fact, this is exactly what New Labour in Britain did to the National Health Service over the last 15 years: they brought waiting times for specialist treatment down dramatically, but the quality of hospital care suffered as a result. This technique was referred to in the UK press as 'never mind the quality, feel the width'.
It is vital as we look at how to improve provision of health care that we look at ways that also improve - or, at the very least, maintain - quality of care.
Economy
As you might expect, over the years in my discussions with health service managers and politicians, the topic of money causes the biggest disagreements.
There are few problems with the current health care system that could not be solved with an unlimited amount of money. But sadly, there is not enough money in the world to make this a viable solution. No-one - not even the richest countries - have access to unlimited amounts of money. Canada is a rich country, but even Canada could literally spend all of it's GDP (money) on health and still not meet all possible health needs of its citizens.
Secondly, even if we had the money we don't have the doctors. The shortage of family doctors in rural areas is a world-wide problem that is getting worse. This is partly due to changes in society - the reduction in the hours doctors are willing to work, the increase in family/work balance, the increase in patient expectations - and partly due to changes in the job - medicine is much more complex and stressful than it used to be.
This is only going to get worse as the population ages.
It is important to make sure that everything we do is cost effective. The more cost effective we are, the more quality care we can provide with the money that we have.
Thankfully, this is not as difficult as it sounds, because there are lots of things we do currently that are not of any benefit to patients or may even be harmful. There are lots of cost savings to be made from better prescribing of cheaper medicines that are just as effective. There are lots of efficiency savings that can be made by making sure we have the right mix of team members doing the right jobs.
Table 1. Comparison of various models of care.
Back to Access
Which brings us back to the main point of this post: improving access.
We must solve the first access barrier - lack of access to a family physician. Until that is solved, our system will always be unfair and unequal.
We can solve that by simply increasing the number of patients that each doctor has. That is the most equitable solution as it means everyone will have access to a family physician. It is also cost effective. This has been tried in other places, but without other changes this will lead to longer waits to see a family doctor for all patients and/or a decline in quality of care. It will likely also lead to more doctor burnout, which will reduce access further in the future.
One change we can make is to differentiate more between acute illness and chronic illness. Acute (short term) illness ranges from simple coughs and colds to medical emergencies like heart attacks. Chronic (long term) illnesses are things like diabetes, chronic bronchitis, asthma and so on.
Acute illnesses can be dealt with quite effectively without having to see your own family doctor. The emergency department is the best place for medical emergencies, while the walk-in-clinic system works well for coughs and colds and other minor illness.
It is chronic illnesses (and their prevention) that can only be managed properly by your family practitioner. Or more correctly, by your family practice team. Because, the research is that patients do far better when their chronic illnesses are looked after by a good team: usually family practice nurses working with a family physician. This team is best placed to co-ordinate all the care that is needed for patients with these complex conditions.
The Solution?
So our proposed solution is:
1. Register a lot more patients so everyone has access to a family doctor.
2. Set up computerised 'registers' of patients with chronic illnesses. These patients are the ones that need access to their own family doctor's team.
3. Use computerised appointment systems to 'time limit' a certain proportion of appointments to improve access (for example, a third of appointments can't be booked until a week in advance).
4. If waiting times for appointments build up, divert acute illness (coughs and colds) to walk in clinics (emergency departments should be seeing all medical emergencies such as heart attacks and strokes).
5. Use Practice Nurses to screen for chronic diseases, look after patients with chronic illness, and educate patients on how to stay well.
6. Use computer systems to communicate and co-ordinate care better with other health care providers.
7. Computerised prescribing of medication refills to make medication reviews safer and more efficient.
8. Focus the doctors' time on what they do best: diagnosing illnesses and advising on medical treatment.
Hopefully this will come as close as is possible to meet our aims: access, equality, quality, economy.
This is part of a wider debate about the rising costs of health care, particularly as the population ages and their medical care becomes ever more complex (and costly).
There are four features of an ideal primary health care system: access, quality, equality, and economy.
In other words, we need a system that patient have easy access to, that provides good quality care, that is available equally to all, and that is affordable.
Lets look at those four topics in more detail.
Access
Unless a primary care service is accessible, it will not meet the needs of patients.
There are three parts to access:
1. how long patients wait to get on a family physician's list of patients
2. how long patients have to wait for an appointment with their family physician.
3. how long patients wait to be seen on the day of their appointment.
These three barriers to access are like a pyramid (see Figure 1 below).
If you don't have a family physician, then short waiting times for patients that do have one are no use to you.
Once you have a family physician, then unless you can get an appointment with your family physician, short waiting times on the day are of no use to you.
We'll look at ways to improve access in a moment, but first we need to look at our other aims to make sure these are met too.
Equality
Access to quality health care is a basic right of citizens in a civilized society. For society to be fair, access to basic rights must be equal.
It is not acceptable for people to be denied access to quality health care because of where they live, or the level of their income, or the type of job they have, or the colour of their skin, or because they don't know the right people.
Everyone should have equal, fair access to quality health care provision.
So whatever we do to improve our health care system, must met the equality test: Does this make provision of health care more or less fair?
Quality
Health care provision needs to be of high quality to be effective.
It is easy to improve access to health care cheaply by simply providing poor health care. In fact, this is exactly what New Labour in Britain did to the National Health Service over the last 15 years: they brought waiting times for specialist treatment down dramatically, but the quality of hospital care suffered as a result. This technique was referred to in the UK press as 'never mind the quality, feel the width'.
It is vital as we look at how to improve provision of health care that we look at ways that also improve - or, at the very least, maintain - quality of care.
Economy
As you might expect, over the years in my discussions with health service managers and politicians, the topic of money causes the biggest disagreements.
There are few problems with the current health care system that could not be solved with an unlimited amount of money. But sadly, there is not enough money in the world to make this a viable solution. No-one - not even the richest countries - have access to unlimited amounts of money. Canada is a rich country, but even Canada could literally spend all of it's GDP (money) on health and still not meet all possible health needs of its citizens.
Secondly, even if we had the money we don't have the doctors. The shortage of family doctors in rural areas is a world-wide problem that is getting worse. This is partly due to changes in society - the reduction in the hours doctors are willing to work, the increase in family/work balance, the increase in patient expectations - and partly due to changes in the job - medicine is much more complex and stressful than it used to be.
This is only going to get worse as the population ages.
It is important to make sure that everything we do is cost effective. The more cost effective we are, the more quality care we can provide with the money that we have.
Thankfully, this is not as difficult as it sounds, because there are lots of things we do currently that are not of any benefit to patients or may even be harmful. There are lots of cost savings to be made from better prescribing of cheaper medicines that are just as effective. There are lots of efficiency savings that can be made by making sure we have the right mix of team members doing the right jobs.
Table 1. Comparison of various models of care.
| Model of care | Number of patients | Appointments per week | Ratio appts/wk/patient | Cost per patient/year |
| Fee for Service | 1,500 to 2,000 | 100 to 150 | 5% to 10% | $140 |
| Salaried | 1,200 | 100 | 8% | $180 |
| Multi-disciplinary Team | 3,000 to 5,000 | 300 to 450 | 8% to 10% | $130 |
Back to Access
Which brings us back to the main point of this post: improving access.
We must solve the first access barrier - lack of access to a family physician. Until that is solved, our system will always be unfair and unequal.
We can solve that by simply increasing the number of patients that each doctor has. That is the most equitable solution as it means everyone will have access to a family physician. It is also cost effective. This has been tried in other places, but without other changes this will lead to longer waits to see a family doctor for all patients and/or a decline in quality of care. It will likely also lead to more doctor burnout, which will reduce access further in the future.
One change we can make is to differentiate more between acute illness and chronic illness. Acute (short term) illness ranges from simple coughs and colds to medical emergencies like heart attacks. Chronic (long term) illnesses are things like diabetes, chronic bronchitis, asthma and so on.
Acute illnesses can be dealt with quite effectively without having to see your own family doctor. The emergency department is the best place for medical emergencies, while the walk-in-clinic system works well for coughs and colds and other minor illness.
It is chronic illnesses (and their prevention) that can only be managed properly by your family practitioner. Or more correctly, by your family practice team. Because, the research is that patients do far better when their chronic illnesses are looked after by a good team: usually family practice nurses working with a family physician. This team is best placed to co-ordinate all the care that is needed for patients with these complex conditions.
The Solution?
So our proposed solution is:
1. Register a lot more patients so everyone has access to a family doctor.
2. Set up computerised 'registers' of patients with chronic illnesses. These patients are the ones that need access to their own family doctor's team.
3. Use computerised appointment systems to 'time limit' a certain proportion of appointments to improve access (for example, a third of appointments can't be booked until a week in advance).
4. If waiting times for appointments build up, divert acute illness (coughs and colds) to walk in clinics (emergency departments should be seeing all medical emergencies such as heart attacks and strokes).
5. Use Practice Nurses to screen for chronic diseases, look after patients with chronic illness, and educate patients on how to stay well.
6. Use computer systems to communicate and co-ordinate care better with other health care providers.
7. Computerised prescribing of medication refills to make medication reviews safer and more efficient.
8. Focus the doctors' time on what they do best: diagnosing illnesses and advising on medical treatment.
Hopefully this will come as close as is possible to meet our aims: access, equality, quality, economy.
June 9, 2010
Open Doors: a family physician for every patient in PEI?
Access. Quality. Equality. Economy. Those are our four aims in providing health care.
Now that our new offices are open, our multi-disciplinary team (four nurses, three technicians, and one doctor) is working at close to full speed.
This means that we can now see between 350 and 450 patients per week. On paper, this means we should be able to provide quality care to over 5,000 patients. We currently have just over 3,000 and we can usually see patients in 1 to 2 weeks (urgent patients within 1 to 2 days).
So we have opened our doors to new patients again. Some patients have commented that the 'number of spaces left' section is now missing from the website. This is because we've not set an upper limit on the spaces available, but instead will aim to add more staff and doctors to our 'group medical practice' as it grows over the next few years.
This is an aspiration. On paper we can move closer to it. Of course, planning and aspirations are not the same as reality. There is the risk that we will fail before we are fully 'developed' - due to illness, funding problems, etc.. However, as long as our doors stay open, everyone in PEI has access to a family physician. (Although, clearly, many are some distance from us!)
That's a fantastic situation for PEI patients.
We're going to try our best to maintain it.
Now that our new offices are open, our multi-disciplinary team (four nurses, three technicians, and one doctor) is working at close to full speed.
This means that we can now see between 350 and 450 patients per week. On paper, this means we should be able to provide quality care to over 5,000 patients. We currently have just over 3,000 and we can usually see patients in 1 to 2 weeks (urgent patients within 1 to 2 days).
So we have opened our doors to new patients again. Some patients have commented that the 'number of spaces left' section is now missing from the website. This is because we've not set an upper limit on the spaces available, but instead will aim to add more staff and doctors to our 'group medical practice' as it grows over the next few years.
This is an aspiration. On paper we can move closer to it. Of course, planning and aspirations are not the same as reality. There is the risk that we will fail before we are fully 'developed' - due to illness, funding problems, etc.. However, as long as our doors stay open, everyone in PEI has access to a family physician. (Although, clearly, many are some distance from us!)
That's a fantastic situation for PEI patients.
We're going to try our best to maintain it.
May 27, 2010
We're Hiring! Full Time Receptionist Post Available
This post is now closed to applications - thank you to all that applied.
We are expanding and we are looking to hire a second full time receptionist.
We have a very busy, exciting, paperless practice with over 3,000 patients in brand new premises in the Sherwood Medical Center in Charlottetown.
The successful candidate will have excellent people skills, a positive outlook, good computer skills, a love of learning, a desire to embrace positive change, and a personality that will fit in well with our close, informal team.
The rate of pay is $16.00/hr
If you are interested in this post, or you know someone who might be, then download an application form and job description using the links below.
The closing date for applications is June 7th.
Receptionist / Secretary job description
Receptionist / Secretary application form
We are expanding and we are looking to hire a second full time receptionist.
We have a very busy, exciting, paperless practice with over 3,000 patients in brand new premises in the Sherwood Medical Center in Charlottetown.
The successful candidate will have excellent people skills, a positive outlook, good computer skills, a love of learning, a desire to embrace positive change, and a personality that will fit in well with our close, informal team.
The rate of pay is $16.00/hr
If you are interested in this post, or you know someone who might be, then download an application form and job description using the links below.
The closing date for applications is June 7th.
Receptionist / Secretary job description
Receptionist / Secretary application form
May 22, 2010
New telephone switchboard - no more busy tones!
We are a very busy, large medical practice. As a result, our telephone line was often busy and patients complained it was difficult to get through to us.
Now we are in our new offices, we have installed a new telephone switchboard just for our office. It has five lines, three of which are dedicated incoming lines. We also now have a dedicated receptionist who will be manning the switchboard full time.
So when you call, you will be placed in a queue and your call will be answered in turn by the switchboard receptionist. No more busy tones. (We hope!)
Now we are in our new offices, we have installed a new telephone switchboard just for our office. It has five lines, three of which are dedicated incoming lines. We also now have a dedicated receptionist who will be manning the switchboard full time.
So when you call, you will be placed in a queue and your call will be answered in turn by the switchboard receptionist. No more busy tones. (We hope!)
Treatment Room Nurse - get your tests done locally, even if you are not our patient.
Dawn Rodd, L.P.N, is our full time Treatment Room Nurse*.
The Treatment Room Nurse is able to provide a wide range of service to everyone - even if they are not our patient.
Services provided include:
Medicare services (no charge to patients - tests in bold require a requisition from a doctor, tests marked ** require to be booked in advance):
- PAP tests
- Blood tests
- Intramuscular injections (requires prescription medication in original container)
- Cardiograms (12 lead ECG/EKG)
- Cardiac event monitoring
- Mini-spirometry (breathing test)
- 24 hour Blood Pressure monitoring**
- Overnight oximetry** (sleep studies)
- Ear syringing
- Wart care
- Wound care
- Post-op staples removal
Private services: (fees apply)
- Travel advice
Coming soon:
- Audiometry
You don't have to be one of our patients to see our Treatment Room Nurse, but some medicare items require a requisition from a doctor (marked in bold above). For blood tests simply bring the normal requisition that you would take to the hospital. For other services, ask your doctor to fill out one of our special requisition forms (which can be downloaded here), or to write the request on a prescription pad. If in doubt call us on 894 7369 for advice or visit our reception desk.
You can either walk in any weekday between 10am and 4pm (1pm on Fridays), or you can call and make an appointment in advance. Don't forget, you must bring your Health Card with you.
Call us on 894 7369 if you would like to make an appointment to see our Treatment Room Nurse.
* The Treatment Room Nurse used to be called our Walk In Nurse, but we have changed the name because (1) patients were getting confused with the Walk In Clinic doctor downstairs, (2) you can now book appointments with the nurse and saying 'book an appointment with the Walk In Nurse' sounded silly, and (3) Treatment Room nurse is the British name for it and we aiming for a British-style medical practice.
The Treatment Room Nurse is able to provide a wide range of service to everyone - even if they are not our patient.
Services provided include:
Medicare services (no charge to patients - tests in bold require a requisition from a doctor, tests marked ** require to be booked in advance):
- PAP tests
- Blood tests
- Intramuscular injections (requires prescription medication in original container)
- Cardiograms (12 lead ECG/EKG)
- Cardiac event monitoring
- Mini-spirometry (breathing test)
- 24 hour Blood Pressure monitoring**
- Overnight oximetry** (sleep studies)
- Ear syringing
- Wart care
- Wound care
- Post-op staples removal
Private services: (fees apply)
- Travel advice
Coming soon:
- Audiometry
You don't have to be one of our patients to see our Treatment Room Nurse, but some medicare items require a requisition from a doctor (marked in bold above). For blood tests simply bring the normal requisition that you would take to the hospital. For other services, ask your doctor to fill out one of our special requisition forms (which can be downloaded here), or to write the request on a prescription pad. If in doubt call us on 894 7369 for advice or visit our reception desk.
You can either walk in any weekday between 10am and 4pm (1pm on Fridays), or you can call and make an appointment in advance. Don't forget, you must bring your Health Card with you.
Call us on 894 7369 if you would like to make an appointment to see our Treatment Room Nurse.
* The Treatment Room Nurse used to be called our Walk In Nurse, but we have changed the name because (1) patients were getting confused with the Walk In Clinic doctor downstairs, (2) you can now book appointments with the nurse and saying 'book an appointment with the Walk In Nurse' sounded silly, and (3) Treatment Room nurse is the British name for it and we aiming for a British-style medical practice.
May 19, 2010
Oxycodone prescribing
The serious topic of oxycodone and hydromorphone prescribing has been in the news again. Some of our patients may have concerns about the issues raised in the CBC stories. Some may be affected by oxycodone addiction, or may have relatives that are affected by it, now or in the past. On the other hand, some patients may be concerned that they will be left in pain because of under use of these drugs.
The first thing to point out is that our prescribing policy on oxycodone and hydromorphone has not changed. We have not stopped prescribing oxycodone, because we never have prescribed oxycodone. We have only ever prescribed oxycodone to patients as part of terminal care. The Strachur Medical Practice, our Scottish branch, had only one patient taking the drug when I last checked with them.
The second thing is to reassure patients that we will be very aggressive in treating their pain. We are very experienced in treating chronic pain using a wide range of medications. We take chronic pain very seriously. We look at the patient as a whole, and we use lots of different medications to treat pain. This includes opiates such as tramadol, codeine, morphine and fentanyl where necessary. We have been able to control pain in vast majority of patients using this strategy for years. We are very experienced in terminal care, including palliative care at home. We are also experienced in dealing with drug addiction and how to support patients who are trying to overcome their addictions.
Finally, with regard to oxycodone/hyrdomorphone we have only asked patients to find another doctor if they have been dishonest or abusive. Some patients have chosen to go to other doctors who have different prescribing policies, and that is entirely up to them. Hopefully, the great majority of patients who have joined our practice who are on these drugs have understood our reasons for our policy and that we have their best interests at heart.
Not prescribing oxycodone is not news to us. It is the norm. I have not been prescribing these drugs for my 13 years as a family doctor.
I hope this information is reassuring to our patients. If anyone has any concerns or questions about oxycodone prescribing please let us know.
The first thing to point out is that our prescribing policy on oxycodone and hydromorphone has not changed. We have not stopped prescribing oxycodone, because we never have prescribed oxycodone. We have only ever prescribed oxycodone to patients as part of terminal care. The Strachur Medical Practice, our Scottish branch, had only one patient taking the drug when I last checked with them.
The second thing is to reassure patients that we will be very aggressive in treating their pain. We are very experienced in treating chronic pain using a wide range of medications. We take chronic pain very seriously. We look at the patient as a whole, and we use lots of different medications to treat pain. This includes opiates such as tramadol, codeine, morphine and fentanyl where necessary. We have been able to control pain in vast majority of patients using this strategy for years. We are very experienced in terminal care, including palliative care at home. We are also experienced in dealing with drug addiction and how to support patients who are trying to overcome their addictions.
Finally, with regard to oxycodone/hyrdomorphone we have only asked patients to find another doctor if they have been dishonest or abusive. Some patients have chosen to go to other doctors who have different prescribing policies, and that is entirely up to them. Hopefully, the great majority of patients who have joined our practice who are on these drugs have understood our reasons for our policy and that we have their best interests at heart.
Not prescribing oxycodone is not news to us. It is the norm. I have not been prescribing these drugs for my 13 years as a family doctor.
I hope this information is reassuring to our patients. If anyone has any concerns or questions about oxycodone prescribing please let us know.
May 5, 2010
New Office Now Open!
Well we are finally in our new offices! (We've been dreaming about them for months.)
We are now upstairs on the second floor above the new Sherwood Drug Mart.
All the team worked incredibly hard over a long weekend (Friday to Tuesday). I'd like to thank everyone for there dedication and effort - including all the spouses, children, and friends who came in to help too. The Marathon Saturday Ikea Furniture Buildathon went very well. Special thanks to our Practice Manager, Joanne, who will probably be dizzy for weeks after four solid days of being spun from problem to problem. Thanks also to Rob MacLellan our landlord who managed to get us in on schedule (I know it was touch and go!), Barry at Sherwood Drug Mart for his tireless help with the heavy lifiting and other jobs, and Jason at Tech Guru and Les for getting our network and servers up and running.
All the furniture for the office comes from Ikea - Ellie, the children, and I spent four days in February in the Ikeas in Elizabeth New Jersey, New Haven Connecticut, and Boston Mass. filling a 12x6 trailer and the back of the truck with tables, chairs, office supplies, and leather sofas.
I think it was all totally worth it - the new waiting rooms are fantastic with comfortable sofas and chairs, racks of subscription magazine and daily newspapers (including the Sunday New York Times which delighted one patient recently!), a large childrens' play area, and free WiFi. And the offices are spacious and light which makes providing health care much less stressful to both patients and staff. We now have eight clinical rooms and three offices rather than the three clinical rooms and one office we had before.
The move was not without glitches - the blinds were the wrong size, so we have no blinds at present, and our wonderful new electric exam tables did not arrive as planned (they won't be here now until mid June). Also, some of the nurses new uniforms (more on that later) were the wrong sizes. (That's the last time I place the uniform order!)
We hope all our staff, patients, and visitors will enjoy and the new space.
We are now upstairs on the second floor above the new Sherwood Drug Mart.
All the team worked incredibly hard over a long weekend (Friday to Tuesday). I'd like to thank everyone for there dedication and effort - including all the spouses, children, and friends who came in to help too. The Marathon Saturday Ikea Furniture Buildathon went very well. Special thanks to our Practice Manager, Joanne, who will probably be dizzy for weeks after four solid days of being spun from problem to problem. Thanks also to Rob MacLellan our landlord who managed to get us in on schedule (I know it was touch and go!), Barry at Sherwood Drug Mart for his tireless help with the heavy lifiting and other jobs, and Jason at Tech Guru and Les for getting our network and servers up and running.
All the furniture for the office comes from Ikea - Ellie, the children, and I spent four days in February in the Ikeas in Elizabeth New Jersey, New Haven Connecticut, and Boston Mass. filling a 12x6 trailer and the back of the truck with tables, chairs, office supplies, and leather sofas.
I think it was all totally worth it - the new waiting rooms are fantastic with comfortable sofas and chairs, racks of subscription magazine and daily newspapers (including the Sunday New York Times which delighted one patient recently!), a large childrens' play area, and free WiFi. And the offices are spacious and light which makes providing health care much less stressful to both patients and staff. We now have eight clinical rooms and three offices rather than the three clinical rooms and one office we had before.
The move was not without glitches - the blinds were the wrong size, so we have no blinds at present, and our wonderful new electric exam tables did not arrive as planned (they won't be here now until mid June). Also, some of the nurses new uniforms (more on that later) were the wrong sizes. (That's the last time I place the uniform order!)
We hope all our staff, patients, and visitors will enjoy and the new space.
May 1, 2010
Pharmacy Technician to help with cost of medications
Patients can now book an appointment with our Pharmacy Technician, Melissa Murphy.
Melissa can help if you are having problems meeting the cost of of your medications. For example, there may be a cheaper equivalent drug. Or you may be able to obtain a Drug Exemption from Medicare. Or you may be able to obtain the drugs free from the manufacturer on a compassionate basis.
There is no charge for this service.
We are also developing a Pharmacy Adviser service. This will be a pharmacist who will advise us on our prescribing. For example, if there is new evidence about the effectiveness or safety of medications. Or if a medication is withdrawn, the Pharmacy Adviser can recommend the best alternative.
Also, the Pharmacy Adviser will be able to help us draw up and monitor our Practice Formulary. This is the list of medications that we will be recommending as being the best choice for various conditions. At the same time, the Pharmacy Adviser can monitor the level of prescribing of various types of drugs via our computer system and advise us of any areas where we might be prescribing too few or too many medications.
This will help us provide a better and safer service to our patients.
Melissa can help if you are having problems meeting the cost of of your medications. For example, there may be a cheaper equivalent drug. Or you may be able to obtain a Drug Exemption from Medicare. Or you may be able to obtain the drugs free from the manufacturer on a compassionate basis.
There is no charge for this service.
We are also developing a Pharmacy Adviser service. This will be a pharmacist who will advise us on our prescribing. For example, if there is new evidence about the effectiveness or safety of medications. Or if a medication is withdrawn, the Pharmacy Adviser can recommend the best alternative.
Also, the Pharmacy Adviser will be able to help us draw up and monitor our Practice Formulary. This is the list of medications that we will be recommending as being the best choice for various conditions. At the same time, the Pharmacy Adviser can monitor the level of prescribing of various types of drugs via our computer system and advise us of any areas where we might be prescribing too few or too many medications.
This will help us provide a better and safer service to our patients.
April 26, 2010
Prostate Cancer: to Screen or Not to Screen
One of the areas in which our medical practice aims to excel is in screening and prevention.
Having a computer system as sophisticated as ours and having a large team of Practice Nurses makes us uniquely suited to screening for preventable diseases. The Practice Nurses will be actively inviting and recalling patients for screening tests and health advice each year.
So it has come as a bit of a shock to some of our male patients to find that we are not routinely screening for prostate cancer. So much so, that I thought it would be a good idea to look at the pros and cons of screening in general, and the specific problems with prostate screening.
The perfect screening test will be (1) safe, and (2) reliable and will look for a disease that is (1) serious and (2) is either preventable or treatable.
Unfortunately, there is no such screening test in existence. Let's take prostate cancer. The test itself (called the PSA test) is safe - it's just a blood test - but it is very far from reliable. Having a high PSA does not mean you have cancer, and having a low PSA does not mean you do not have cancer.
Then there is the question of how serious prostate cancer is. Everyone is afraid of the 'C' word, so anything that is cancer must always be bad. Not so. The great majority of men who get prostate cancer will not suffer any real harm from it. However, a small number of men with prostate cancer will die from it. It's not possible to tell the 'indolent' cancer from the dangerous one.
This means that you have to 'treat' a lot of men who have nothing serious wrong with them in order to catch the small number who do have a serious cancer. And the treatment is not safe and simple - it is a biopsy or an operation can lead to incontinence and sexual dysfunction.
In fact, to treat a single man with a serious cancer you have to screen around 1,400 men and you will end up 'treating' around 48 men who had nothing serious wrong with them. So only around 2% of men who think they have had treatment for prostate cancer actually had serious prostate cancer. The other 98% had nothing serious wrong with them. Except, now they think they have a cancer. Worse, we will likely never know which patient is which.
Patient's don't believe me when I tell them that the evidence is that if you have a PSA test your chances of being harmed can go up. ("Just from a blood test!? Are you sure you're a real doctor?")
Ironically, this is because of what is called the Popularity Paradox. This is what happens:
Worse still, the side effects of treatment are all 'front-loaded' - they happen at the time of treatment - but the possible benefits (if any) are all 'tail-loaded' - they don't happen for decades (if ever).
And yet, prostate cancer kills over 4,000 men a year in Canada (around 11% of all cancer deaths in men).
So this gives us a real dilemma. If the evidence is that your chances of being harmed go up or stay the same when you get a PSA test, then should we be doing PSA's at all?
Well, that depends on a lot of things. Do you have a family history of prostate cancer (in a first degree relative at a young age)? Do you have symptoms? (Our nurses will give you a questionnaire to fill out.) What are you more afraid of personally? What is your attitude towards risk?
That's why we won't be performing routine PSA screening at present. As recommended by Health Canada, the NHS in the UK, and the US Preventive Task Force We'll want to go over the risks and benefits with each patient carefully before they decide whether to have the test or not.
Research continues in this area, and as any fresh information comes to light we will review our advice.
Links:
Health Canada Prostate Cancer page
New England Journal of Medicine Perspective Roundtable: Screening for Prostate Cancer
(Any patient interested in prostate screening should call to make an appointment with one of our Practice Nurses to discuss the test.)
Having a computer system as sophisticated as ours and having a large team of Practice Nurses makes us uniquely suited to screening for preventable diseases. The Practice Nurses will be actively inviting and recalling patients for screening tests and health advice each year.
So it has come as a bit of a shock to some of our male patients to find that we are not routinely screening for prostate cancer. So much so, that I thought it would be a good idea to look at the pros and cons of screening in general, and the specific problems with prostate screening.
The perfect screening test will be (1) safe, and (2) reliable and will look for a disease that is (1) serious and (2) is either preventable or treatable.
Unfortunately, there is no such screening test in existence. Let's take prostate cancer. The test itself (called the PSA test) is safe - it's just a blood test - but it is very far from reliable. Having a high PSA does not mean you have cancer, and having a low PSA does not mean you do not have cancer.
Then there is the question of how serious prostate cancer is. Everyone is afraid of the 'C' word, so anything that is cancer must always be bad. Not so. The great majority of men who get prostate cancer will not suffer any real harm from it. However, a small number of men with prostate cancer will die from it. It's not possible to tell the 'indolent' cancer from the dangerous one.
This means that you have to 'treat' a lot of men who have nothing serious wrong with them in order to catch the small number who do have a serious cancer. And the treatment is not safe and simple - it is a biopsy or an operation can lead to incontinence and sexual dysfunction.
In fact, to treat a single man with a serious cancer you have to screen around 1,400 men and you will end up 'treating' around 48 men who had nothing serious wrong with them. So only around 2% of men who think they have had treatment for prostate cancer actually had serious prostate cancer. The other 98% had nothing serious wrong with them. Except, now they think they have a cancer. Worse, we will likely never know which patient is which.
Patient's don't believe me when I tell them that the evidence is that if you have a PSA test your chances of being harmed can go up. ("Just from a blood test!? Are you sure you're a real doctor?")
Ironically, this is because of what is called the Popularity Paradox. This is what happens:
- A healthy 45 year old man with nothing wrong with him takes a PSA test.
- The PSA comes back falsely high.
- The man (and his doctor) think he has prostate cancer because of the high PSA.
- The man has a biopsy, which is inconclusive.
- The man has prostate surgery which results in life-long incontinence and impotence.
- The man thinks his life has been saved by the surgery and tells all his friends and relatives that they must have the test too.
Worse still, the side effects of treatment are all 'front-loaded' - they happen at the time of treatment - but the possible benefits (if any) are all 'tail-loaded' - they don't happen for decades (if ever).
And yet, prostate cancer kills over 4,000 men a year in Canada (around 11% of all cancer deaths in men).
So this gives us a real dilemma. If the evidence is that your chances of being harmed go up or stay the same when you get a PSA test, then should we be doing PSA's at all?
Well, that depends on a lot of things. Do you have a family history of prostate cancer (in a first degree relative at a young age)? Do you have symptoms? (Our nurses will give you a questionnaire to fill out.) What are you more afraid of personally? What is your attitude towards risk?
That's why we won't be performing routine PSA screening at present. As recommended by Health Canada, the NHS in the UK, and the US Preventive Task Force We'll want to go over the risks and benefits with each patient carefully before they decide whether to have the test or not.
Research continues in this area, and as any fresh information comes to light we will review our advice.
Links:
Health Canada Prostate Cancer page
New England Journal of Medicine Perspective Roundtable: Screening for Prostate Cancer
(Any patient interested in prostate screening should call to make an appointment with one of our Practice Nurses to discuss the test.)
March 24, 2010
Congratulations!
We would like to congratulate our practice nurse, Alicia MacEachern, and her husband Winston on the arrival of their beautiful, healthy baby girl Jovi Sophia. She was born on Monday March 8th, weight 7lbs 8oz.Alicia is now on maternity leave, but she has visited as a couple of times with Jovi and we call all report that Jovi is a beautiful, happy baby.
Jovi Sophia
March 9, 2010
New Health Care Technician: Sarath Ekanayake
We'd like to welcome the newest member of our clinical team, Sarath Ekanayake.
Sarath is a physician who moved to Canada last year from Sri Lanka with his wife and children. He is an experienced General Practitioner (Family Physician) who also worked as a Health Care Manager in Sri Lanka before moving to PEI. Sri Lanka is a Commonwealth country which used to be called Ceylon until 1972. It's health care training is based on the British model and physicians such as Sarath trained entirely in English.
Sarath will be starting today as one of our Health Care Technicians.
Although Sarath would be most likely be eligible for immediate medical licensing in the United Kingdom (and possibly some Canadian Provinces), due to the licensing requirements in PEI for doctors, Sarath needs to take three licensing exams before he is able to practice as a physician in PEI.
This will take him about two years. Sarath is an experienced and capable physician who will be a significant asset to the Island when he has his license. Thousands of very talented and highly experienced doctors and nurses in this situation in Canada are working as taxi drivers and in fast food outlets, which is a disaster for them and for our health care system. (It's not as if we have too many doctors and short waiting times for patients!)
We created the Health Care Technician posts specifically to allow doctors and nurses in this position to:
- continue to contribute to patients in the community
- earn a decent income while they wait for their license
- keep their skills fresh
- learn about the Canadian medical system.
- make our medical practice more efficient and allow us to see more patients in the same amount of time, which means we can take on more patients who do not currently have a family doctor.
Although Sarath is a physician, because he is not currently licensed in PEI, he is not allowed to:
- make diagnoses
- give medical advice
- sign prescriptions
However, he will be able to:
- perform simple technical procedures under the supervision* of a physician, such as taking blood pressures or doing simple blood tests.
- enter medical data into our computer system.
- prepare referral letters, medication data at the instruction of the physician.
- organize medical data, such as test results, for the physician.
I'm sure all of our patients will join me in welcoming Sarath to the practice and will wish him good luck in his new post.
* Supervision means that he has been assessed by the physician as being competent, has been given a protocol and guideline to follow strictly for the procedure, and has access to the physician in person, by telephone, or electronically, during the procedure.
Sarath is a physician who moved to Canada last year from Sri Lanka with his wife and children. He is an experienced General Practitioner (Family Physician) who also worked as a Health Care Manager in Sri Lanka before moving to PEI. Sri Lanka is a Commonwealth country which used to be called Ceylon until 1972. It's health care training is based on the British model and physicians such as Sarath trained entirely in English.
Sarath will be starting today as one of our Health Care Technicians.
Although Sarath would be most likely be eligible for immediate medical licensing in the United Kingdom (and possibly some Canadian Provinces), due to the licensing requirements in PEI for doctors, Sarath needs to take three licensing exams before he is able to practice as a physician in PEI.
This will take him about two years. Sarath is an experienced and capable physician who will be a significant asset to the Island when he has his license. Thousands of very talented and highly experienced doctors and nurses in this situation in Canada are working as taxi drivers and in fast food outlets, which is a disaster for them and for our health care system. (It's not as if we have too many doctors and short waiting times for patients!)
We created the Health Care Technician posts specifically to allow doctors and nurses in this position to:
- continue to contribute to patients in the community
- earn a decent income while they wait for their license
- keep their skills fresh
- learn about the Canadian medical system.
- make our medical practice more efficient and allow us to see more patients in the same amount of time, which means we can take on more patients who do not currently have a family doctor.
Although Sarath is a physician, because he is not currently licensed in PEI, he is not allowed to:
- make diagnoses
- give medical advice
- sign prescriptions
However, he will be able to:
- perform simple technical procedures under the supervision* of a physician, such as taking blood pressures or doing simple blood tests.
- enter medical data into our computer system.
- prepare referral letters, medication data at the instruction of the physician.
- organize medical data, such as test results, for the physician.
I'm sure all of our patients will join me in welcoming Sarath to the practice and will wish him good luck in his new post.
* Supervision means that he has been assessed by the physician as being competent, has been given a protocol and guideline to follow strictly for the procedure, and has access to the physician in person, by telephone, or electronically, during the procedure.
January 29, 2010
We're Hiring! Third LPN post now open to applications
We are looking for a dynamic Licensed Practical Nurse to join our Primary Care Team as a Practice Nurse.
We have a busy, exciting, paperless practice with over 3,000 patients in brand new premises in the Sherwood Medical Center in Charlottetown. The three Practice Nurses have their own clinics seeing patients in conjunction with or under the supervision of the Family Physician. They also implement our computerized Annual Health Checks, run Initial Appointment clinics for new patients, and staff a daily Walk In Nurse Clinic for procedures and investigations.
Duties include:
- General measurements
- Use of electronic medical record
- Spirometry
- 12 lead ECGs
- Chronic disease monitoring
- Overnight oximetry
- Health screening
- 24 hour BP machine
- Taking blood
- INR near patient testing
- i.m. injections
- Audiometry
- Syringing ears
- PAP smear tests
- Travel advice
- Wound care
- Preparing investigations and organizing referrals
- Health promotion
The Practice Nurse will work within her or his scope of practice to the protocols in our Practice Nurse Procedures manual and will receive in-house training and competencies certification where appropriate from the R.N. and Family Physician.
The rate of pay is $22.50 per hour with excellent contract terms including an annual study budget and generous paid vacation time. The post is initially for 9 months with the possibility of permanent employment after that. The start date is March 2010.
The successful candidate will have excellent people skills, a positive outlook, good computer skills, a love of learning, a desire to embrace positive change, and a personality that will fit in well with our close, informal team.
Please download an application form and job description and return your completed application by email, fax, or post. The closing date for applications is 1st March 2010.
New Members of Staff
We'd like to welcome our new Practice Nurse, Dawn Rodd, and our new receptionist, Margaret Pippy, who have recently joined the practice. They are an excellent addition to our growing team, and we are delighted to have them in the team.
January 26, 2010
Oxycodone and Hydromorphone
We don't prescribe oxycodone and hydromorphone.
Virtually all the patients who have joined the clinic taking one of these drugs will be moved over to safer alternatives over the next six months.
Chronic pain is a common problem for primary care doctors - disabling arthritis, back pain, nerve pain. When choosing a medication that will treat long term pain, it is important to choose ones that are effective and continue to work over long periods of time.
The best choices are a combination of acetaminophen, anti-inflammatories, gabapentin (an anti-epileptic), and amitriptylline (an antidepressant). It is also very important to treat depression in chronic pain patients, as virtually all such patients will become depressed over time which makes their pain worse.
The worst choices are hydromorphone and oxycodone. These are extremely dangerous drugs, and a very poor choice for long term pain. The reasons are 1. they produce a 'buzz' or 'high' which is extremely addictive, and 2. patients become rapidly tolerant to them and need higher and higher doses for the same effect.
The street value for these drugs is very high as a result, and they are now the most common drug of addiction in Canada. They now cause far more damage than heroin or cocain and because the dangers are not widely known they are addicting a wide range of people who would not normally be exposed to dangerous drugs. Once exposed to these drugs, the less dangerous drugs are less effective because the 'buzz' is missing.
It is rare to see oxycodone prescribed in Scotland. I've only seen them used in terminal care of dying patients. There are two reasons for this: 1. the heavy marketing of the drug in the US by the manufacturers, and 2. the widespread use of pharmacy advisors who monitor the prescribing of drugs in the UK. Yet, I see far more chronic pain problems here than I do in Scotland. It could be that the use of these drugs is actually increasing the chronic pain problem by addicting patients rather than treating them.
If an opiate drug is required, then it is vital to use one that produces less 'buzz' or 'high' as these are less addictive. For example, tramadol.
Sadly, PEI Medicare currently covers the dangerous opiates but does not cover the less dangerous ones, although the prices are similar. I would encourage the PEI Department of Health to review this decision.
For terminal care patients addiction is obviously not an issue and we will continue to use all the drugs available to us to relieve pain in these patients.
Virtually all the patients who have joined the clinic taking one of these drugs will be moved over to safer alternatives over the next six months.
Chronic pain is a common problem for primary care doctors - disabling arthritis, back pain, nerve pain. When choosing a medication that will treat long term pain, it is important to choose ones that are effective and continue to work over long periods of time.
The best choices are a combination of acetaminophen, anti-inflammatories, gabapentin (an anti-epileptic), and amitriptylline (an antidepressant). It is also very important to treat depression in chronic pain patients, as virtually all such patients will become depressed over time which makes their pain worse.
The worst choices are hydromorphone and oxycodone. These are extremely dangerous drugs, and a very poor choice for long term pain. The reasons are 1. they produce a 'buzz' or 'high' which is extremely addictive, and 2. patients become rapidly tolerant to them and need higher and higher doses for the same effect.
The street value for these drugs is very high as a result, and they are now the most common drug of addiction in Canada. They now cause far more damage than heroin or cocain and because the dangers are not widely known they are addicting a wide range of people who would not normally be exposed to dangerous drugs. Once exposed to these drugs, the less dangerous drugs are less effective because the 'buzz' is missing.
It is rare to see oxycodone prescribed in Scotland. I've only seen them used in terminal care of dying patients. There are two reasons for this: 1. the heavy marketing of the drug in the US by the manufacturers, and 2. the widespread use of pharmacy advisors who monitor the prescribing of drugs in the UK. Yet, I see far more chronic pain problems here than I do in Scotland. It could be that the use of these drugs is actually increasing the chronic pain problem by addicting patients rather than treating them.
If an opiate drug is required, then it is vital to use one that produces less 'buzz' or 'high' as these are less addictive. For example, tramadol.
Sadly, PEI Medicare currently covers the dangerous opiates but does not cover the less dangerous ones, although the prices are similar. I would encourage the PEI Department of Health to review this decision.
For terminal care patients addiction is obviously not an issue and we will continue to use all the drugs available to us to relieve pain in these patients.
January 9, 2010
Patients bringing lists of problems to the clinic
We have been experiencing long waits in our clinics recently, which have been running over an hour behind frequently.
There are lots of reasons why doctors run behind - for example, they may receive an urgent phone call, an emergency may occur, or a patient may be much sicker than they realised and may require a lot of time.
However, the main cause of our clinics running late just now is patients bringing long lists of problems with them to their appointments. Quite a few patients have been attending with lists of between 5 and 10 problems that they want to discuss!
This is understandable - many of our patients have been without a family doctor for years. They have many issues they wish to discuss. We are very busy, and they may not want to wait again to discuss those issues.
We don't want to impose a 'one visit, one problem' limit on our patients. And we have several nurses/technicians helping with each clinic to make sure we deal with as much as possible in the time available.
But, we only have between 5 and 20 minutes per patient, and it really just is not possible to deal with more than one or two problems in that time.
To avoid long waits, and to provide safe care, we will now be prioritizing the problems when there is more than one. Patients bringing long lists will find that simply organizing the list will take up the first appointment, and they will then be advised how many appointments we think will be required to work through their list.
There are lots of reasons why doctors run behind - for example, they may receive an urgent phone call, an emergency may occur, or a patient may be much sicker than they realised and may require a lot of time.
However, the main cause of our clinics running late just now is patients bringing long lists of problems with them to their appointments. Quite a few patients have been attending with lists of between 5 and 10 problems that they want to discuss!
This is understandable - many of our patients have been without a family doctor for years. They have many issues they wish to discuss. We are very busy, and they may not want to wait again to discuss those issues.
We don't want to impose a 'one visit, one problem' limit on our patients. And we have several nurses/technicians helping with each clinic to make sure we deal with as much as possible in the time available.
But, we only have between 5 and 20 minutes per patient, and it really just is not possible to deal with more than one or two problems in that time.
To avoid long waits, and to provide safe care, we will now be prioritizing the problems when there is more than one. Patients bringing long lists will find that simply organizing the list will take up the first appointment, and they will then be advised how many appointments we think will be required to work through their list.
Subscribe to:
Posts (Atom)