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Treating Chronic Pain…Who you gonna call?

As family physicians we really do see everything when it comes to our patients.  From prenatal to palliative care, our patients trust that we will help them through all their medical complexities.  In turn, we put pressure on ourselves and our teams to meet their expectations.

A couple of months ago my colleague, the shared care psychiatrist who travels to Pincher Creek to see patients with us, told me that the hardest thing he sees family doctors deal with is chronic pain.  Initially this comment surprised me, but on further reflection, and a review of my next day’s patient list I realized he was absolutely correct.

The increase of opioid use disorder in my practice, the lack of supports for alternatives to medication for pain relief in my area and the new guidelines for pain management and opioid use have led to increased stress and frustration for patients, families, and health care providers.

Like most family doctors, I have relied on my “go to” people to consult with when my patients and I are struggling to manage chronic pain or addiction, including opioid use disorder.  These relationships have helped me to build my capacity to manage increasingly complex issues.

I’m pleased to be the Medical Director for the ACFP’s new Collaborative Mentorship Network for Chronic Pain and Addiction which aims to provide the infrastructure for a more formal mentorship relationship so that all family physicians can feel confident in treating their patients with pain and addiction.

About the Author

Cathy Scrimshaw, BSc (Hons), MD, CCFP, FCFP

Cathy is a fulltime family doctor in Pincher Creek, where she has been doing comprehensive care for over 25 years.  She works with members of the Piikani First Nation and the residents of Pincher Creek.  Last year Cathy was recognized for her continued active involvement in the work of the ACFP by receiving the ACFP Long -term Service Award.  Currently, Cathy is the Medical Director for the Collaborative Mentorship Networks for Chronic Pain and Addiction initiated by Primary Health Care Opioid Response Initiative.

Making “Cents” of Travel Vaccines

Oral Cholera Vaccine for Traveler’s Diarrhea Prophylaxis

While we might be through the worst of winter, many Albertans still have vacations planned for the upcoming months. What do you do when patients ask what vaccines they should get prior to traveling, and should you recommend the oral cholera vaccine to prevent traveler’s diarrhea?

Though diarrhea affects up to 50% of travelers to developing countries, most cases of traveler’s diarrhea (TD) happen because of consumption of contaminated food and water and are caused by organisms not prevented by the vaccine. TD usually resolves spontaneously in 3-4 days, but cure rates can be improved by taking antibiotics at onset. Travelers to high-risk areas can be prescribed antibiotics to self-administer should they develop diarrhea. Azithromycin 500mg twice daily for two doses is equivalent to longer courses of antibiotics, costs less than $20, and is covered by many drug plans. The oral cholera vaccine, on the other hand, is not recommended by North American guidelines, costs approximately $90, and is not covered by any provincial health care plans.

If you have a proactive traveler in the office, encourage vaccinations for other infectious diseases with high prevalence or potential morbidity, like Hepatitis A. You can also consider referring travelers to local clinics, public health units or pharmacies that specializes in travel medicine consultations.

About the Author

Tony Nickonchuk, BSc Pharm
Clinical Pharmacist, Alberta Health Services

Tony practices pharmacy in Peace River as a clinical pharmacist at the Peace River Hospital. He rotates with one other pharmacist between direct clinical care on the acute care ward and remote support for regional facilities. He is also site lead for the pharmacy team there.

Tony is a member of the Practical Evidence for Informed Practice (PEIP) Conference Planning Committee, is a contributor to Tools for Practice and the Best Science Medicine Podcast, and is a co-author of the popular Price Comparison of Commonly Prescribed Pharmaceuticals in Alberta document.

Outside of work he is a busy dad of three kids under 12, all three being active in swimming, gymnastics, and drums. In his infinitesimal free time, he’s an avid follower of politics.

Motivating Patients to Move—What can you do?

Many people look at the new year as a chance to reset their behaviours by making health-oriented resolutions. A quick look at Google Trends shows marked increases in search terms like “get fit” and “lose weight” around January 1. With patients already motivated to get up and get moving, how do you encourage their continued participation in regular physical activity after the excitement of the new year (and its resolutions) has passed?

What can you do to help them stay on both the figurative and literal track? Turns out, it may be as simple as writing a “prescription” to track their activity with a pedometer. In particular, in patients with chronic disease, the most successful interventions to increase physical activity are those that involve specific behavioural strategies and encourage self-monitoring. And using a pedometer fulfills both of these.

Providing patients with a written, goal-oriented exercise program has been previously demonstrated to increase physical activity levels. A sample “prescription” for activity with a pedometer might look like:

  1. Wear your pedometer every day for one week
  2. Calculate your daily steps (feel free to average to the closest 1,000-step increment)
  3. Add 500 steps per day to your daily average; walk that each day for the next week
  4. Repeat Step 3, adding 500 steps to last week’s daily goal and walk that each day for the next week
  5. Continue to your target of 10,000 steps per day

About the Author

Tina Korownyk, MD CCFP
Associate Professor, Family Medicine, University of Alberta
Assistant Director, Evidence and CPD Program, Alberta College of Family Physicians

Tina is an Associate Professor in the Department of Family Medicine at the University of Alberta. She has worked as a Family Physician for the past 12 years, primarily in Edmonton at the Northeast Community Health Centre.

Tina is a founding member of PEER, an evidence based medicine organization that seeks to improve patient care in the community through evidence synthesis and knowledge translation in the context of primary care. She is actively involved in the development of Tools for Practice and Continuing Professional Development programs within Alberta and nationally. She has many research interests, most of which include practical questions relating to the improvement of primary care and is also involved in the Pragmatic Trials Collaborative, which engages community physicians in clinical trials that seek to answer pivotal questions relating to improved patient outcomes.

August – Message From the President

Read the full August eNews & President’s Message.

Advanced Care Planning – A Personal Perspective

Having an advanced care plan easily available to any health care professional—be it home care nurses, paramedics with EMS or nurses on an active care unit in hospital—is very useful. In our own clinic, we discuss a personal directive with every patient who has a review of their complex care plan. It would be good to include follow-up and incorporate a Green Sleeve to ensure completion of a personal directive. On reflection, why only during review of a complex care plan; why not incorporate this into an annual review with any patient?

I’ve recently had a very personal brush with legal documents such as Power of Attorney and Personal Directive. I was recognizing signs of illness in my own father and had embarked on obtaining these documents in a proactive manner. However, it may not have been truly proactive when one sees a family member deteriorating as proactive means doing this before something happens. My father then became seriously ill and was hospitalized quite suddenly before I had these documents ready. In the weeks following, I had to have documents transferred from my lawyer in Red Deer to a lawyer in Calgary, then have that lawyer meet with my father in hospital to get a Power of Attorney and Personal Directive in place. My father had the capacity to remain his own agent while this was being pursued, however, it could just as easily not have been the case. And, in all honesty, it was truly the Power of Attorney that was most important to my father. He was bedridden in hospital and could not look after his affairs (even though he knows the value of his bank accounts better than I know mine). Since having the Power of Attorney, I have looked after a tax installment, insurance payments and other bills, and my father is very relieved.

Is having the Green Sleeve on the refrigerator door the best place? I’m not sure. It needs be with the patient in question. I know of one case in which the family had done all the right things for a member of the family receiving palliative care. The Green Sleeve was on the door of the fridge, but this patient rapidly deteriorated, paramedics were called, but the Green Sleeve had disappeared (no one knows to where) and, as a result, there was no personal directive. A husband had to watch his terminally ill wife receive CPR when this was explicitly not her wish, yet there was nothing he could do.

The bottom line is to advocate with your patients to be proactive and explicit about advanced care planning and to have those plans readily available for when and where they are needed. It truly does provide a much higher quality of care for your patient.


Ankle Swelling in the Summer?

Seasonality of Ankle Swelling
Population Symptom Reporting Using Google Trends

You might expect to see an increase in sprains, strains, and fractures in the winter when patients are navigating icy sidewalks and shoveling loads of snow. What problems cross our path more in summer?

In my practice, complaints of ankle swelling are more common in the summer and are usually brought to clinic by injury-free and otherwise healthy patients. We established this phenomenon in our 2016 publication, Seasonality of Ankle Swelling.

“Each summer we encounter an increased volume of patients complaining of ankle swelling—patients who do not go on to develop cardiovascular, venous, or lymphatic disease … we looked for seasonal modulation in the public’s interest in ankle swelling as measured by the volume of Google Internet searches related to ankle swelling.”

While clinicians can expect to see an increase of swelling related complaints in office, many such patients will not seek medical advice. Whereas Internet searches for ankle swelling (or related terms) are highest in the summer, hospital admission for heart failure exhibit the opposite trend and peak in the winter. So, rest assured, your patients are certainly not alone—and probably in good health.

About the author

Scott Garrison, MD PhD
Associate Professor, Department of Family Medicine, University of Alberta
Director, Pragmatic Trials Collaborative

Scott spent the first 20 years of his professional career as a full time fee-for-service family physician. He has a passion for evidence-based medicine and left full time clinical practice in 2013 intent on pursuing clinical trials that address important, as yet unaddressed, primary care questions. He is working to build a platform for large primary care trials in both BC and Alberta.

Prevention and Management of Cardiovascular Disease Risk in Primary Care

Toward Optimized Practice (TOP) introduces a new clinical practice guideline (CPG): Prevention and Management of Cardiovascular Disease Risk in Primary Care.

By removing lipid targets and associated monitoring of lipid levels, as well as other streamlining measures, the management of lipids and cardiovascular disease risk has been significantly simplified. Additionally, by targeting risk, clinicians can identify patients most likely to benefit while actively involving these patients in their care.

The collaboration between the ACFP’s Evidence and CPD program team  and TOP has created a guideline and recommendations based on the most recent and highest quality of evidence. The background evidence to create the guideline included a review of more than two hundred articles. Authors for the Evidence Review include: Drs. Adrienne Lindblad, Mike Kolber, Scott Garrison, Mike Allan, and Ms. Candra Cotton.

This Prevention and Management of Cardiovascular Disease Risk in Primary Care guideline balances evidence, simplification/efficiency, and patient involvement. Related files are available from the TOP website:

The Prevention and Management of Cardiovascular Disease Risk in Primary Care CPG recently received an endorsement from the College of Family Physicians of Canada.

Welcome to the Doc Blog

Physician-Led Practice Improvement

This blog is managed by the ACFP and aims to share with you relevant topics of discussion, information, and stories and experiences. Contributions are driven by your peers and physician-led. This recent post includes additions from the Communications Committee.

The main motivation is to aggregate interesting and relevant articles that will save you time and improve your practice. Here are some articles your peers found interesting: