Practice Change

Implementing Prescribing Portraits — Therapeutics Initiative

By Drs. Jill Norris and Jessica Otte on September 12, 2023

Primary care clinicians face an overwhelming volume of information to process and tasks to complete. There are new and sometimes conflicting guidelines and practice standards, forms to fill out, emails about meetings, and an inbox full of labs, documents to review, and messages to respond to. Now that I get Portraits in my email inbox from time to time, I schedule time to look at them, and focus on the listed recommendations and whether my pattern of practice is close to where it should be according to the evidence, and if not, why not.

Thromboprophylaxis in ambulatory cancer patients

By Drs. Domnick Manhas and Tony Wan on August 23, 2023

It is estimated that 15% of all cancer patients will develop VTE, resulting in significant morbidity and mortality. The cost of cancer-associated thrombosis is substantial to the healthcare system. Currently, routine thromboprophylaxis is not recommended given the fear of increased risk of bleeding, modest absolute risk reduction in VTE, and inconvenience. However, a selected group of cancer patients with very high VTE risk will benefit from thromboprophylaxis.

SGLT2i in patients with diabetes: translating an evolving body of evidence to the nuances of practice

By Jamison Falk, PharmD on June 19, 2023

While I’ve been hard on newer medications like SGLT2i for their relatively small benefit in lower-risk patients, recent systematic reviews show that our traditional interventions are no better, and may be worse, at reducing risks of outcomes. I now discuss the option of adding an SGLT2i with patients with diabetes and pre-existing cardiovascular or renal disease or with symptomatic hyperglycemia where blood glucose reduction would be expected to reduce day-to-day symptoms. I reduce or discontinue doses of other antihyperglycemic medications if possible when starting an SGLT2i and I educate patients about potential adverse events.

LNG-IUS (Mirena) IUD for emergency contraception

By Dr. Emma Coffey on April 3, 2023

Many patients don’t know that an IUD is a highly effective option for emergency contraception. We can offer patients either the 52mg LNG-IUS (up to 5 days) or the copper IUD (up to 7 days) for EC. Both options are highly effective at preventing pregnancy (>99%).

Pharmacotherapy for Tobacco Use Disorder

By Drs. Clara Lu and Renée Janssen on March 7, 2023

Since the publication of the 2020 ATS Clinical Practice Guideline on pharmacologic treatment in tobacco-dependent adults, I now explain the goals of pharmacotherapy for tobacco use disorder in terms of reducing the compulsion to smoke and increasing readiness to quit, rather than abstinence alone. If patients are open to the conversation, I will discuss and offer all pharmacotherapy options — but emphasize the efficacy and safety of varenicline as my preferred first-line agent.

Vaginal progesterone for the prevention of preterm birth

By Drs. Jennifer Kask and Kirsten Duckitt on January 25, 2023

Preterm birth is the leading cause of perinatal morbidity and mortality in British Columbia and worldwide. We now carefully elicit any history of previous preterm birth and offer vaginal progesterone therapy for ANY history of spontaneous preterm birth. We fill in the Special Authority Request and give out the patient handout even before the patient goes to the pharmacy. We also encourage women to continue the medications until 37 weeks of gestational age.

Diagnosis and treatment of polycystic ovary syndrome (PCOS) using virtual health

By Dr. Caitlin Dunne on November 30, 2022

Polycystic ovary syndrome is the most common endocrinopathy in women of reproductive age. It affects 8%–13% of young women and its symptoms are some of the most prevalent concerns that community physicians encounter. In many cases, diagnosis and management can be carried out in a virtual health setting using clinical criteria and judicious use of laboratory investigations.

Moving into the treatment phase of the COVID-19 pandemic

By Drs. Piszczek, Wright, and Grant on November 16, 2022

My approach now is to have the confidence to reassure patients who are low risk that SARS-CoV2 infection will most likely be mild for them and that no specific therapy is needed. Those who are of intermediate risk will also generally do well, but it is an opportunity to create a plan of what to do if they have flu-like symptoms, including their preferences should they test COVID positive. For those who are at high risk, especially CEV-1, I ensure them that there is a clear testing and treatment plan. Any physician can prescribe Nirmatrelvir/rt. A step-by-step instruction guide for prescribing is available on the BCCDC website.

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Offering CBT skills by group medical visits

By Drs. Fiona Petigara and Joanna Cheek on September 28, 2022

A large part of physician’s day is spent on mental health and wait times to see specialists can be very long. In 2022 the BC Government created “Group Medical Visit” (GMV) codes to promote physicians to deliver services to groups of patients as “an effective way of leveraging existing resources; simultaneously improving quality of care and health outcomes, increasing patient access to care and reducing costs” (BC Gov, 2022). Physicians can now refer their patients to the Group Cognitive Behavioral Therapy program via cbtskills.ca or through PathwaysBC fillable PDF and they can also train to facilitate group medical visits.

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Why I no longer prescribe weight loss, calculate BMI, or use the term “obesity”

By Dr. Katarina Wind on May 3, 2022

Medical school taught me that “obesity” is a cause of morbidity and mortality, and that weight loss is its cure. I recorded patients’ BMIs and counselled them on weight-loss strategies, believing that I was helping them.

Practice tip (for BC practitioners) utilizing PathwaysBC beyond specialist lookups — finding patient handouts, requisitions, point-of-care tools

By Drs. Tracy Monk, Nick Graham, Karin Kausky, Michele Thomasse, and Ryan Gallagher on March 22, 2022

We all used PathwaysBC.ca to help us find specialists for our patients, to look up wait times and what information to include in a referral, but we learned that Pathways could help streamline our clinical work in so many more ways.

Tokes in the throat: cannabis smoking-related harm in otolaryngology

By Brendan McNeely and Dr. Amanda Hu on February 9, 2022

Recent evidence has emerged that shows cannabis smoking is related to significant patient morbidity. Namely, cannabis smoke exposure increased the risk of oropharyngeal cancer in a dose-dependent manner. Cannabis use may also be associated with hearing loss, vestibular dysfunction, tinnitus, and sinusitis.

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Perioperative anticoagulation management in mechanical heart valves, the PERIOP2 trial

By Drs. Taylor Drury, Poupak Rahmani, and Tony Wan on January 26, 2022

We continue to use full dose therapeutic low molecular weight heparin (LMWH) for bridging in the pre-operative period. However, we now use post-operative prophylactic LMWH as an alternative bridging strategy in patients undergoing high-risk bleeding procedures. In patients at high risk of thromboembolism (including mechanical mitral valve and atrial fibrillation) undergoing a high-risk bleeding procedure, we are now less aggressive in resuming full dose therapeutic anticoagulation, as we feel comfortable using prophylactic LMWH for up to several days post-operatively before resuming therapeutic anticoagulation.

Advances in diabetes glucose monitoring

By Gerri Klein on January 12, 2022

For all my patients who are on hypoglycemic medications, oral or injectable, I suggest using rtCGM or isCGM. Even intermittent use or a short trial of 10 days to two weeks with either of these devices can be enlightening for patients. With the ongoing COVID restrictions, many of my patients have been unable (or unwilling) to obtain an A1C from a lab test. In my practice, I have found it helpful to use glucose TIR to assess glucose control as an adjunct measure to A1C results; when an A1C is not available; and to guide treatment recommendations.

Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 3: The Importance of Attachment Theory in Healthcare

By Dr. Linda Uyeda and Dr. Ashley Miller on July 7, 2021

The ingredients needed to create a happy workplace also largely reflect the principles of secure attachment. Across all levels within organizations, if people do not feel “safe, seen, soothed, and secure” they are more likely to make errors, breach safety protocols, and struggle working together as a team.

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Concussion rehabilitation update and a free self-management concussion tool

By Sue Barlow and Carolyn Rondeau on June 3, 2021

Concussions or mild traumatic brain injury are the most common type of traumatic brain injury. It is estimated that every year in British Columbia (BC), there are approximately 14,500 visits to the emergency department and that this number is most likely an underestimate of the “true burden of concussion”.

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Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 2: Parenting During a Pandemic

By Dr. Ashley Miller and Dr. Linda Uyeda on May 12, 2021

As I started to understand that this pandemic would wear on, I had to figure out how to help my patients’ families and my own family navigate our way through this totally new reality. I drew on the science of attachment, resilience and healthy relationships to make a plan. (Please stay tuned for Article #3!)

Rate versus Rhythm Control in Patients with Atrial Fibrillation: Time to Change the Paradigm?

By Drs. Christopher Cheung, Kenneth Gin, Jason Andrade on February 10, 2021

Patients with persistent AF, less symptomatic and/or older patients, and those with prior anti-arrhythmic failure are best managed with a rate control strategy. The EAST-AFNET 4 study is a practice-changing trial, and strongly supports the role of early rhythm control in patients with newly-diagnosed AF.

Psychological PPE during COVID-19

By Dr. Jennifer Russel & Françoise Mathieu MEd RP on November 18, 2020

A few weeks into the COVID-19 crisis and as a psychiatrist working in a tertiary care hospital, while homeschooling my two boys, I had a strong awareness that I needed to really work to keep myself healthy in a way that I have never felt before to make sure I was able to survive this crisis. I needed to grab my psychological PPE.

Portable ultrasound

By Drs. Philip Lee and Stefanie Falz Mclellan on September 30, 2020

The integration of point of care ultrasound (PoCUS) in the emergency department workflow is not always easy, and these challenges have been amplified in the time of COVID-19. The COVID-19 pandemic has led to an increased interest in the use of handheld ultrasound devices as they simplify infection control procedures and take up little space in emergency rooms crowded with critical care equipment.

Icosapent Ethyl to Reduce Atherosclerotic Events in Patients with Hypertriglyceridemia

By Omid Kiamanesh, MD, FRCPC on August 26, 2020

Despite intensive lowering of LDL-C using lipid-modifying therapy, residual ASCVD risk persists, particularly in those with hypertriglyceridemia. Icosapent ethyl has been shown to reduce residual ASCVD risk and cardiovascular death in select patients with hypertriglyceridemia while on statin therapy.

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Nash, W. P. (2011). US Marine Corps and Navy combat and operational stress continuum model: A tool for leaders. Combat and operational behavioral health, 107-119.

Stress First Aid as a form of Peer Support

By Dr. Joanna Cheek on August 5, 2020

It’s not easy to train in new skills to support our mental health when the race has already begun. We are all going to cycle out of the green zone many times, regardless of our practice of self-care. We need each other right now to provide peer support to help each of us notice when we’re moving to the right of the stress continuum and pause or pace ourselves so we can complete this marathon together.

Serious Illness Conversations in the Time of COVID-19

By Drs. Lawrence Chow and Rose Hatala on May 6, 2020

In the era of the COVID-19 pandemic, our most vulnerable patients (the elderly and those with chronic illnesses) are disproportionately at the highest risk of mortality. In this difficult and chaotic time, it’s more important than ever that we maintain a humanistic approach to care. This involves keeping the patient, and their values and preferences, front and center in our care.

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Taking care of each other during COVID-19 – peer support for physicians

By Tandi Wilkinson MD CCFP-EM on April 1, 2020

I conducted a study examining effective peer support in rural Canadian physicians. (Spoiler alert: those who have had good peer support say it is essential to their career in medicine.) Here is what I am doing now to ensure I, and my team, can manage through this unprecedented time at work.

Government Assistance Forms: Do they leave you bewildered?

By Dr. Janet McKeown on March 11, 2020

Government Assistance: Health Resources and Forms tool has helped me understand assistance with a more organized approach. It has helped me access information quickly and it has helped me be more knowledgeable about billing provincially, federally and privately. It is also an efficient tool to use in a teaching environment to help learners better understand government assistance.

Hiding in plain sight: men’s mental health

By Dr. Dan Bilsker on January 8, 2020

It is well-known that men die on average 3-4 years before women – but why? We identified three main factors contributing to Years of Life Lost by men compared to women: cardiovascular disease, suicide, and motor vehicle accidents. As a psychologist, I was intrigued by the substantial contribution of suicide.

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Use of endometrial aspirators as a uterine sound for IUD insertion

By Dr. Lisa Nakajima on December 4, 2019

One of the risks of IUD insertion includes perforation of the uterus. Although uterine perforation is relatively uncommon and often does not cause long-term harm, it does increase the risk of unplanned pregnancy and often requires surgery. I have chosen to use endometrial aspirators that are commonly used for endometrial biopsy sampling as a sound for IUD insertions, instead of the traditional metal sounds.

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.

Practice Change

Implementing Prescribing Portraits — Therapeutics Initiative

Thromboprophylaxis in ambulatory cancer patients

SGLT2i in patients with diabetes: translating an evolving body of evidence to the nuances of practice

LNG-IUS (Mirena) IUD for emergency contraception

Pharmacotherapy for Tobacco Use Disorder

Vaginal progesterone for the prevention of preterm birth

Diagnosis and treatment of polycystic ovary syndrome (PCOS) using virtual health

Moving into the treatment phase of the COVID-19 pandemic

Offering CBT skills by group medical visits

Why I no longer prescribe weight loss, calculate BMI, or use the term “obesity”

Practice tip (for BC practitioners) utilizing PathwaysBC beyond specialist lookups — finding patient handouts, requisitions, point-of-care tools

Tokes in the throat: cannabis smoking-related harm in otolaryngology

Perioperative anticoagulation management in mechanical heart valves, the PERIOP2 trial

Advances in diabetes glucose monitoring

Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 3: The Importance of Attachment Theory in Healthcare

Concussion rehabilitation update and a free self-management concussion tool

Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 2: Parenting During a Pandemic

Rate versus Rhythm Control in Patients with Atrial Fibrillation: Time to Change the Paradigm?

Psychological PPE during COVID-19

Portable ultrasound

Icosapent Ethyl to Reduce Atherosclerotic Events in Patients with Hypertriglyceridemia

Stress First Aid as a form of Peer Support

Serious Illness Conversations in the Time of COVID-19

Taking care of each other during COVID-19 – peer support for physicians

Government Assistance Forms: Do they leave you bewildered?

Hiding in plain sight: men’s mental health

Use of endometrial aspirators as a uterine sound for IUD insertion

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

Practice Tip: Cutaneous larva migrans

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

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