Practice Change

ACEs (Adverse Childhood Experiences): One Family Physician’s Experience

By Dr. Tahmeena Ali on August 21, 2019

I now ask all patients, young and old, new to my practice and established for years, male and female, to complete an ACEs questionnaire in my clinic. I garner a new level of respect for my patients’ resilience and for the ongoing turmoil many of my young patients face. I make finding supports for these young vulnerable patients one of my top priorities—as important as a referral to a specialist or for diagnostic imaging.

Practice Tip: Cutaneous larva migrans

By Dr. Miguel Imperial on July 30, 2019

Once I diagnose a patient with CLM based on a compatible travel history and characteristic serpiginous rash, I continue to treat the itch and inflammatory symptoms symptomatically if indicated, but I am able to much more readily offer systemic therapy with ivermectin since it no longer requires a Health Canada Special Access application.

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Facing a College Physician Practice Enhancement Program Assessment? What you need to know in 2019?

By Dr. Daniel Ngui on June 12, 2019

The Physician Practice Enhancement Program Assessment is highly educational and it helps physicians enhance the quality of their patient care through a peer review. It provides valuable feedback and creates opportunities to guide professional development and lifelong learning.

The myth of the “Manipulative Personality Disorder”: taking the blame out of the illness

By Dr. Joanna Cheek on May 8, 2019

View personality disorder symptoms as important treatment targets in themselves. Be curious about each patient’s story, validate PD symptoms as coping mechanisms, focus on collaborative problem solving, set proactive regular visits, and also be mindful of your own emotional reactions providing compassion and empathy while setting clear boundaries.

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Parkinson’s disease: burden of non-motor problems

By Dr. Darly Wile on April 3, 2019

What I have found is that while it can sometimes be assumed that motor problems are the patient’s “biggest problem”, this is often not the case; instead, I now make a point of asking the patient, and their family directly: “What is the biggest problem for you right now?”

Decreasing pain of osteoarthritic knees

By Dr. Muxin (Max) Sun on March 6, 2019

I have decreased my frequency of giving steroid injections for decreasing pain of osteoarthritic knees. I educate patients on evidence, placebo effects and risks. I recommend less invasive therapies including physiotherapy, exercise (quadriceps and hip abductor strengthening, Tai Chi), hot compress, antiinflammatory creams, weight loss, TENS machine, orthopedic & orthotic devices, etc.

HIV pre-exposure prophylaxis (PrEP) for individuals at risk for HIV infection

By Mark W. Hull MD MHSc on November 13, 2018

Over the last five years, on an ongoing basis, we have seen new HIV infections occurring in young gay, bisexual and other men who have sex with men (MSM). The majority of these individuals had had a prior negative HIV test within the last year, or were presenting with signs or symptoms supportive of an acute HIV infection, suggesting recent exposure and transmission of HIV infection, highlighting the need for novel HIV prevention strategies.

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Learning to meet my patient where they are at – how letting go changed my practice

By Michelle C. Danda, RN, BN on October 10, 2018

I realized that engagement is paramount when working with an ambivalent patient, because the change that they want to make is often important in their life, even if the clinician views it as a problem behavior. Motivational interviewing education has been shown to improve patient alliance and treatment adherence.

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Trauma Informed Practice (TIP) makes perfect (or at least it is a good start)

By Dr. Carol-Ann Saari on September 5, 2018

In the general population, approximately 75% of Canadians will report having experienced an adverse and potentially traumatic experience in their lifetime, with 9.2% meeting criteria for PTSD. We have to become trauma informed. Trauma informed practice (TIP) is a way of providing services that recognizes the need for physical and emotional safety, choice and control in decisions affecting one’s treatment and an environment where patients do not experience further traumatization.

Equity-oriented health care

By Dr. Colleen Varcoe and Dr. Heather Smith on August 15, 2018

Health equity-oriented care is now part of my daily practice; the tools created with, and provided by, the EQUIP study have helped to make health care inequity an issue that I can screen for and offer options for management.

Baby aspirin for extended DVT prophylaxis after elective hip and knee arthroplasty

By Drs. Terence Yung and Tony Wan on July 24, 2018

For those who had an elective hip or knee arthroplasty who have no other risk factors for VTE, after initial 5 days of DVT prophylaxis with rivaroxaban 10mg a day, I complete the remaining DVT prophylaxis with aspirin 81mg once daily for an additional 30 days for hip arthroplasty and 9 days for knee arthroplasty. Those who already were on once-daily 81mg aspirin prior to surgery will receive 162mg aspirin once daily instead in this period.

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Hip surveillance in children with cerebral palsy

By Dr. Min S. Phang, MRCP, FRCPC on June 13, 2018

I now refer all children with cerebral palsy, or suspected cerebral palsy, to the Child Health BC Hip Surveillance Program. Information about the program is available at www.childhealthbc.ca/hips, including a referral form for physicians. The incidence of hip dislocations can be significantly reduced!

Trauma as a determinant of health

By Dr. Vanessa Brcic and Dr. Devon Christie on April 18, 2018

What changed our practice was a fundamental recognition of trauma as a determinant of health, and furthermore, that PTSD is only the tip of the iceberg when it comes to trauma. Much lies under the surface for our patients.

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The practice of mindfulness

By Dr. Vincent Hanlon on March 14, 2018

Mindfulness is the awareness that emerges through paying attention to the unfolding of experience moment by moment. This paying attention is done on purpose, in the present moment, and it’s non-judgmental.

Guidelines

By Dr. Duncan Etches on February 21, 2018

In summary, in place of pattern or algorithm driven medicine, clinical experience and ability to determine what is best for our patient lies at the heart of the art of medicine.

Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure with Reduced Ejection Fraction (HFrEF): Sacubiltril/Valsartan and the PARADIGM HF Trial

By Doson Chua, PharmD, FCSHP, BCPS(AQ) and Dr. Mustafa Toma on January 10, 2018

Sacubitril/valsartan is the first in class of ARNI and has proven its superiority in reducing mortality and morbidity in HFrEF as compared to the use of ACEI. Sacubitril/valsartan should be considered in patients who are symptomatic despite optimal or maximally tolerated guideline-driven HF therapies consisting of a beta blocker, ACEI/ARB and MRA. Monitoring of patients on sacubitril/valsartan is similar to ACEI.

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Managing your passwords

By Dr. David Topps on November 29, 2017

Ever been frustrated by the number of passwords you have to keep track of in your daily life as a professional? At one time, you might have only a few – some simple ones for unimportant sites, some stronger ones and perhaps a really good one for your most important data.

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Managing opioid use disorder: buprenorphine/naloxone opioid agonist treatment

By By Dr. Christy Sutherland and Emily Wagner on November 15, 2017

I no longer offer rapid methadone tapers to my patients. Buprenorphine/naloxone is now recommended as the first-line opioid agonist treatment for opioid use disorder in British Columbia. This is because of its superior safety profile when compared with methadone as well as an easier transition to take home dosing.

Indications and value of self-administered vaginal swabs for STIs and vaginitis

By Dr. Roberto Leon on November 1, 2017

I came across a publication in the British Medical Journal by Sarah A. Schoeman: Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. Participants took a vaginal swab before a routine gynecological exam, and clinicians then took an endocervical swab during examination.

MOVE an injury not RICE

By Dr. Jennifer Robinson on October 18, 2017

MOVE an injury: Movement, not rest. Options: offer other options for cross training. Vary rehabilitation with strength, balance and agility drills. Ease back to activity early for emotional strength.

Whether or not to use systemic corticosteroids to treat a skin disease

By Dr. Eileen Murray on October 3, 2017

When I started out in dermatology, corticosteroids were the only systemic drug available to treat patients with severe allergic contact dermatitis (ACD), atopic dermatitis (AD), drug reactions and those with bullous diseases. Corticosteroids are potent and excellent immunosuppressive agents. The main problem with systemic use is the high risk of drug interactions, as well as multiple serious acute and long-term side effects.

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The risks of worklessness

By Dr. Taryl Felhaber on September 20, 2017

Why should physicians encourage early and ultimate return to work whenever they can? In a nutshell, because it is usually in the patient’s best interest to remain in the workforce.

Evaluation of penicillin allergy

By Dr. Jennifer Grant on September 6, 2017

Recent data show that up to 90% of patients with a reported penicillin allergy are mislabelled and of those who are allergic, many beta-lactams can still be safely prescribed due to low risk of cross-reactivity. Mislabelling of penicillin allergy is due to many things including misdiagnosis (confusing a viral exanthema for allergy), purer formulations of antibiotics, loss of allergy and differences in side-chain structure.

Management of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

By Drs. Christopher Cheung and Kenneth Gin on August 9, 2017

Perioperative management of anticoagulation is challenging as physicians must consider the risks of stroke, systemic embolism, and perioperative bleeding.

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Review of the topic of Autism Spectrum Disorder

By Dr. Anne Antrim on July 18, 2017

The current definition of Autism Spectrum Disorder has 2 criteria: “persistent impairment in reciprocal social communication and social interactions” AND “restricted, repetitive patterns of behavior”. The symptoms must be present from early childhood, but may not manifest till the social demands exceed the capacity of the child to respond.

Step by step approach to determine the safety of prescribing Hormone Replacement Therapy

By Dr. Roberto Leon on June 20, 2017

One of the most complex decisions that women (and their physicians) occasionally need to take in mid-life is whether to use prescription medications for their menopausal symptoms. Previously known as Hormone Replacement Therapy (HRT), Menopause Hormone Therapy (MHT) is an effective and evidence based treatment for moderate to severe hot flashes and/or night sweats (defined as bothersome enough to interfere with daily activities, impair quality of life and/or interrupt sleep).

Seeking collateral information when clinical practice guidelines deliver strong recommendations for drug therapies on the basis of a single clinical trial

By Cait O'Sullivan on May 31, 2017

When I identify strong drug therapy recommendations of particular relevance to my practice scope, I seek collateral information and there are two resources I routinely incorporate into my literature search. I start with the Cochrane Library and then check to see whether a FDA advisory committee has weighed in on key issues.

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Long-term benzodiazepine use is associated with increased mortality in people with schizophrenia

By Dr. Randall White on May 10, 2017

When psychiatric patients are treated in an emergency department, they are often hypervigilant, manic, or otherwise in an excited, agitated state. The current standard of care to manage acute agitation in adults is using an antipsychotic medication and a benzodiazepine, often loxapine or haloperidol and lorazepam.

Elevated Lipoprotein (a) is a common reason for unexplained premature or recurrent coronary heart disease and stroke

By Dr. Gordon Francis on April 26, 2017

High Lp(a) is a major CVD risk factor that should be measured and acted upon in patients and families where there is history of premature CV events but lack of clear risk factors, and in patients with known CVD and recurrent events despite treatment to LDL-C target.

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Serious illness conversations and capturing advance care planning

By Drs. Charlie Chen and Hayden Rubensohn on April 12, 2017

What is the patient willing to consent to as treatment if his/her condition were to seriously deteriorate? The Serious Illness Conversation Guide developed by Ariadne Labs provides a framework for physicians to engage in care planning with patients in a manner acceptable to the patient.

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