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10% effective? No – the flu vaccine is an EXCELLENT match!!

According to recent data from the Public Agency of Canada, 583 influenza viruses have been identified. The quadivalent vaccine that we gave children last Fall (Flulaval Tetra) covers 98.2% of these viruses.

The trivalent vaccine (Agriflu and Fluviral) covers 99.8% of the Influenza A viruses (including H3N2 and H1N1).

So why are so many people getting sick with the flu?

Regrettably, unlike the quadrivalent vaccine, the trivalent version does not vaccinate against the vast majority of the Influenza B viruses. Even so, the trivalent vaccine is a match against 62.3% of all indentified flu viruses this year.

Articles like the one below, published in December, warned about strains in Australia and Western Canada and speculated on their potential impact.

In reality, the flu vaccine is an excellent match – or in the words of the National Microbiology Laboratory – the circulating influenza viruses are “antigenically similar to components in the 2017-2018 Northern Hemisphere vaccine.”

The bottom line – get the Flu vaccine.

Health care with no heart

Sadly – these cuts will not be the exception – they will become the norm.

Please understand that this IS the Minister of Health’s plan. His focus is reorganization, cost-saving and “efficiency” – NOT care – and definitely not care for all.

Remember Bill 10? In its own words: “This bill modifies the organization and governance of the health and social services network…in order to facilitate and simplify public access to services, improve the quality and safety of health care and make the network more efficient and effective.”

“The bill establishes a new system of governance for the regional and supraregional institutions by specifying, among other elements, the composition of their boards of directors… appointed by the Minister of Health and Social Services.”

“The Minister is granted new powers…in particular the power to prescribe rules relating to their organizational structure and management and the power to work with the general management in cases of actions incompatible with the rules of sound management….”

Bill 10 passed in February 2015, abolishing the Board of Directors of individual health institutions and organizations (including the Jewish General, Mount Sinai, Mackay, etc). They were replaced by the CIUSSS, a supraregional agency, led by a team handpicked by the Minister of Health.

In the words of former Liberal MNA, Clifford Lincoln: “It’s such a huge reorganization of the health system that it buries the individual, it buries the client, it buries the patient, it buries the individual institutions and their boards into one, big, mega-reorganized system.”

This is why it should come as no surprise that Francine Dupuis, associate CEO of the CIUSSS West-Central Montreal, justifies the cuts because Miriam Home and Services has “not properly managing its day program for years.”

How has the Miriam Home failed? After all, its purpose is “to ensure that persons with intellectual disabilities be seen and treated as persons, experience love and friendship, experience continuity in their lives, be afforded personal security, be adaptively cared for, be treated with respect and dignity, have access to opportunities to make choices and exercise their rights, learn skills, be given means to compensate for their deficiencies and disabilities, have a decent and appropriate place to live, have a meaningful employment or occupation and have life-long opportunities for growth.”

Apparently not anymore. Dr. Barrette now determines every institution’s purpose – and to quote Francine Dupuis, the “Ministry of Health and Social Services has made it very clear it will no longer allow Miriam Home to provide rehabilitation services to clients whose condition can’t improve.”

The CIUSSS does NOT share the same vision as Miriam Home. The CIUSSS aims to “ensure real integration of services provided to the population.” Its “values” include: commitment to our clientele, collaboration, transparency, courage, respect and innovation.” The list does NOT include Miriam Home qualities like respect, dignity, access, meaning or growth.

Regrettably, we have a health system that promotes efficiency over care and selects services based on risk–return tradeoff. Today we are cutting services for apparently “babysitting” adults with intellectual and developmental deficits. After all, the CIUSSS had determined that they “take too many medications.” Apparently, quality of life, maintaining care, choices, personal security, don’t matter anymore.

Who can we cut next? Children with disabilities? Frail elderly? Palliative patients? Drug addicts? Alcoholics? Do they have good prospects for improvement? What is their cost-benefit?

We have a commitment to care for all. No one said health care was cheap – but common sense and dignity are still free!

 

New Flu Information for 2017-2018 from cdc

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New Flu Information for 2017-2018 from cdc.gov/flu

Getting an annual flu vaccine is the first and best way to protect yourself and your family from the flu. Flu vaccination can reduce flu illnesses, doctors’ visits, and missed work and school due to flu, as well as prevent flu-related hospitalizations.

What’s new this flu season?

A few things are new this season:

  • The recommendation to not use the nasal spray flu vaccine (LAIV) was renewed for the 2017-2018 season. Only injectable flu shots are recommended for use again this season.
  • Flu vaccines have been updated to better match circulating viruses (the influenza A(H1N1) component was updated).
  • Pregnant women may receive the flu vaccine

What flu vaccines are recommended this season?

This season, only injectable flu vaccines (flu shots) are recommended. Some flu shots protect against three flu viruses and some protect against four flu viruses.

Live attenuated influenza vaccine (LAIV) – or the nasal spray vaccine – is not recommended for use during the 2017-2018 season because of concerns about its effectiveness.

What viruses will the 2017-2018 flu vaccines protect against?

There are many different flu viruses and they are constantly changing. The composition of flu vaccines is reviewed annually and updated as needed to match circulating flu viruses. Flu vaccines protect against the three or four viruses (depending on vaccine) that research suggests will be most common. For 2017-2018, three-component vaccines are recommended to contain:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus (updated)
  • an A/Hong Kong/4801/2014 (H3N2)-like virus
  • a B/Brisbane/60/2008-like (B/Victoria lineage) virus

Quadrivalent (four-component) vaccines, which protect against a second lineage of B viruses, are recommended to be produced using the same viruses recommended for the trivalent vaccines, as well as a B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

When should I get vaccinated?

You should get a flu vaccine before flu begins spreading in your community. It takes about two weeks after vaccination for antibodies to develop in the body that protect against flu, so make plans to get vaccinated early in fall, before flu season begins. CDC recommends that people get a flu vaccine by the end of October, if possible. Getting vaccinated later, however, can still be beneficial and vaccination should continue to be offered throughout the flu season, even into January or later.

Children who need two doses of vaccine to be protected should start the vaccination process sooner, because the two doses must be given at least four weeks apart.

Can I get a flu vaccine if I am allergic to eggs?

The recommendations for people with egg allergies are the same as last season.

  • People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health.
  • People who have symptoms other than hives after exposure to eggs, such as swelling, respiratory distress, or vomiting; or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a health care provider.

Protective Actions

What should I do to protect myself from flu this season?

CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.

In addition to getting a seasonal flu vaccine, you can take everyday preventive actions like staying away from sick people and washing your hands to reduce the spread of germs. If you are sick with flu, stay home from work or school to prevent spreading flu to others. In addition, there are prescription medications called antiviral drugs that can be used to treat influenza illness.

What should I do to protect my loved ones from flu this season?

Encourage your loved ones to get vaccinated.

Do some children require two doses of flu vaccine?

Yes. Some children 6 months through 8 years of age will require two doses of flu vaccine for adequate protection from flu. Children in this age group who are getting vaccinated for the first time will need two doses of flu vaccine, spaced at least 28 days apart. Children who have only received one dose in their lifetime also need two doses.

What can I do to protect children who are too young to get vaccinated?

Children younger than 6 months old are at high risk of serious flu complications, but are too young to get a flu vaccine. Because of this, safeguarding them from flu is especially important. If you live with or care for an infant younger than 6 months old, you should get a flu vaccine to help protect them from flu.

How effective will flu vaccines be this season?

Influenza vaccine effectiveness (VE) can vary from year to year among different age and risk groups and even by vaccine type. How well the vaccine works can depend in part on the match between the vaccine virus used to produce the vaccine and the circulating viruses that season. It’s not possible to predict what viruses will be most predominant during the upcoming season.

Will this season’s flu vaccine be a good match for circulating viruses?

It’s not possible to predict with certainty if the flu vaccine will be a good match for circulating flu viruses. The flu vaccine is made to protect against the flu viruses that research and surveillance indicate will likely be most common during the season. However, experts must pick which flu viruses to include in the flu vaccine many months in advance in order for flu vaccines to be produced and delivered on time. Also flu viruses change constantly (called drift) – they can change from one season to the next or they can even change within the course of one flu season.

How long does a flu vaccine protect me from getting the flu?

Multiple studies conducted over different seasons and across flu vaccine types and influenza virus subtypes have shown that the body’s immunity to influenza viruses (acquired either through natural infection or vaccination) declines over time.

Can the flu vaccine provide protection even if the flu vaccine is not a “good” match?

Yes, antibodies made in response to vaccination with one flu virus can sometimes provide protection against different but related flu viruses. A less than ideal match may result in reduced vaccine effectiveness against the flu virus that is different from what is in the flu vaccine, but it can still provide some protection against flu illness.

In addition, it’s important to remember that the flu vaccine contains three or four flu viruses (depending on the type of vaccine you receive) so that even when there is a less than ideal match or lower effectiveness against one virus, the flu vaccine may protect against the other flu viruses.

Can I get vaccinated and still get the flu?

Yes. It’s possible to get sick with the flu even if you have been vaccinated (although you won’t know for sure unless you get a flu test). This is possible for the following reasons:

  • You may be exposed to a flu virus shortly before getting vaccinated or during the period that it takes the body to gain protection after getting vaccinated. This exposure may result in you becoming ill with flu before the vaccine begins to protect you.
  • You may be exposed to a flu virus that is not included in the seasonal flu vaccine.

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Recordings in the Office

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Recording doctor appointments can be beneficial – but certain rules need to be respected. Specifically, the recording’s location – public versus private – has certain implications.
The following are concerns and recommendations of the Canadian Medical Protective Association (CMPA):
Privacy issues in public areas
Patients recording in public areas of a doctor’s office, such as waiting rooms and other common spaces, could possibly capture other people who are not involved in the patient’s healthcare encounter. The recordings could include identifiable information about another patient or staff which could breach a person’s privacy.
Impact on the doctor-patient relationship
A patient may have valid reasons for wanting to record a clinical encounter in a private area such as an examination room. They may want to have an accurate record of the physician’s advice, or to share the information with a family member. However, the recording of a clinical encounter by a patient without the physician’s knowledge can be perceived as reflecting a lack of confidence in the relationship on the part of the patient.
Impact on the medical record
Any recording made at the time of the clinical encounter (i.e. contemporaneously) could be considered part of the medical record.

 

Our Policy
Recordings should only be made in private areas. Patients should avoid taking photos and making video and audio recordings in the waiting room or other public areas in order to protect the privacy of other patients and staff members.
Recordings in private locations should be transparent and obtained with the mutual consent of the patient and physician. A copy should be provided and added to official patient health record. The recorded conversations should never be posted on public websites or on social media without the knowledge and approval of all affected parties. the absence of trust and openness may negatively impact the doctor-patient relationship.

 

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Nurse Practitioners: What’s the deal?

Many of you may have noticed nurse practitioners popping up in your family medicine clinics lately. If you haven’t noticed them yet, you are very likely going to notice more of them soon. The Quebec government has invested $25 million dollars to help train new nurse practitioners in Quebec. Their goal is to have at least 2,000 primary care nurse practitioners trained in Quebec by 2025. We still have a long way to go to meet this goal; there are only 428 nurse practitioners in Quebec.

So what is a nurse practitioner? Simply, they are a family doctor for healthier people. Nurse practitioners are nurses who have gone back to school and received a Master’s degree and extra medical training. They are qualified to write prescriptions for certain medications, they can send you for blood tests, x-rays, ultrasounds, and other tests, and they can do procedures like stitches.

A nurse practitioner can follow healthy people from babies to older adults for their regular check ups. They can also follow healthy pregnant women until they are 32 weeks pregnant. You will also see them in walk-in clinics because they are able to manage most of the acute issues that bring people to a walk-in clinic.  If you are followed by a nurse practitioner all of your health needs are managed by the nurse practitioner much like if you had a family doctor.

Nurse practitioners are not completely alone. They work in partnership with family doctors who are there to act as the nurse practitioner’s specialist. Much like your doctor may send you to see a specialist, like a cardiologist, a nurse practitioner can “refer” to their partner physician. The nurse practitioner may discuss your case with their partner physician or, if needed, the doctor may see you for a visit.

The goal of the nurse practitioner is to help improve access to primary care. Nurse practitioners are able to help relieve the burden of the family doctors by following their own caseload. This increases the number of Quebecers who have a family doctor and it also allows family doctors to follow more complex cases.

 

https://www.oiiq.org/sites/default/files/rapport-statistique-2014-2015.pdf

http://www.cbc.ca/news/canada/montreal/quebec-super-nurses-1.4041873

Jennifer Reoch

Santé Kildare Nurse Practitioner Candidate

No need to worry…Casino Montreal still has unlimited free parking!

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The running meter is a distraction that interferes with medical appointments.”
Dr. Rajendra Kale, former editor CMAJ

Our Facebook post last week on plans to reduce parking fees at Quebec hospitals was our most popular yet. Parking fees can be excessive and their appropriateness has been extensively debated.

In the March 6, 2012 issue of the Canadian Medical Journal (CMAJ), doctors debated the merit and necessity of charging patients for parking. Dr. Tom Closson, President and CEO of the Ontario Hospital Association, argued that parking fees are one of the most common ways of making up the deficit of hospital operating budgets. He stresses that provincial government cutbacks to hospitals eliminate “crucial revenues that hospitals use to fund clinical research and front-line patient care.” He admonishes the Journal’s editorial board, “surely CMAJ has something to say about these and other more relevant issues, instead of banging away on the populist drum about parking fees.

Dr. Tim Meagher of the MUHC takes the opposing position, “I support free hospital parking for patients. I would probably also support free transport to and from hospital visits, reimbursement for time lost from work due to hospital visits, and reimbursement for myriad of ancillary costs that hospital visits generate.”

Dr. Rajendra Kale, editor in chief of the CMAJ, writes “”Parking fees amount to a user fee in disguise.” He urges Canadian hospitals to follow the example set in Scotland and Wales where hospital parking fees are abolished “because they burden (the) patient.” Dr. Kale concludes, “Those opposed to scrapping parking fees for patients need to recognize that such fees are, for all practical purposes, user fees and a barrier to health care. Using revenue generated from such surrogate user fees for health care is against the health policy objective of the Canada Health Act and could become the subject of a legal challenge.”

This opinion was supported by Dr. Brian Goldman, Host of CBC’s White Coat, Black Art, “I think hospital parking fees should be abolished because they punish patients.”
The highlights of the new hospital parking plan, starting April 1, are:
Hospital visitors will be able to park for free at hospitals in Quebec for the first 30 minutes, instead of paying as much as $10 for that first half hour.
• A flat daily rate will not be applied until a vehicle has been parked for more than four hours, a big change from the current practice of charging the maximum daily rate after 90 minutes.
• Health care institutions must offer weekly and monthly parking passes, as well as books of tickets, at reduced rates.
• Health care institutions must offer daily parking passes that allow motorists to come and go without penalty.

 

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Is it my turn yet?

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It is no secret that we are (extremely) frustrated with long waiting times. Consecutive governments repeatedly promise to fix this problem but wait times only seem to grow longer.
As noted by the Fraser Institute: “excessively long wait times remain a defining characteristic of Canada’s health-care system, but this year (2016) is the longest we’ve ever seen and that should trouble all Canadians.” Bacchus Barua, senior economist at the Institute, continues, “long wait times aren’t simply minor inconveniences, they can result in increased suffering for patients, lost productivity at work, a decreased quality of life, and in the worst cases, disability or death.”
http://globalnews.ca/news/3083826/medical-wait-times-in-canada-are-longer-than-ever-hitting-20-weeks-in-2016-fraser-institute/

 

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The Canadian Institute of Health Information (CIHI) released a report based on The Commonwealth Fund’s 2016 international survey that highlighted this continued issue. According to the survey, Canada scored the poorest of all 11 countries surveyed when it came to access to specialists.  Fifty-six percent of Canadians wait longer than a month to see a specialist—as compared to the international average of 36 percent.

Dr. Josh Tepper, CEO of Health Quality Ontario, along with Vanessa Milne and Sachin Pendharkar, published “Four ways Canada can shorten wait times for specialists” at Healthydebate.ca.  Their prescription for success focuses on simple, achievable concepts:

 

1.Do virtual consults, not visits

Not every patient needs to see a specialist.  Often the family physician needs some guidance and a virtual consult system can help.

The Rapid Access to Consultative Expertise (RACE) is a phone based system available in parts of British Columbia. Family physicians call a central phone number during business hours on weekdays, and a specialist calls back within a couple of hours.

The success of RACE in B.C. inspired a similar program in Ontario, called The Champlain BASE e-Consult service. In this system, primary care providers complete a form that includes patient information and the medical question. Test results and images can be attached. The information is then sent to a specialist.

From 2010 to 2015, the BASE service was used in over 10,000 consultations in the Champlain region. The average wait time for a response from the specialist was two days.  Most impressively, in 40% of cases the patient did not need to see the specialist.

 

2.Add physician directories and e-referrals

Alberta currently offers paperless referrals through e-Referrals. The system includes referrals to Oncologists and Orthopedics.  Family doctors get an idea of wait times BEFORE submitting the referral and can chose a specific specialist.

 

3.Try pre-assessment in specialized clinics

Another approach is adding an assessment step in between the referral and the specialist.  This method has been successfully introduced for patients with severe low back pain (Interprofessional Spine Assessment and Education Clinics (ISAEC)).

Known as CareAxis in B.C., Saskatchewan, Ontario and Quebec, wait times are reduced by training physiotherapists to triage potential surgical candidates.

 

4.Switch to central intake

Pooled referral systems (aka central intakes) allow family doctors to select a specific specialist or the first-available.  Newfoundland, Ontario, Saskatchewan and Calgary all use this model.  Quebec’s model, CRDS, launched in the Fall of 2016, offers central intake for 9 specialties: Cardiology, ENT, Gastroenterology, General Pediatrics, Nephrology, Neurology, Ophthalmology, Orthopedics, and Urology.

Information can be found at:

Tél. : 514-762-CRDS (2737)
Téléc.: 514-732-5121
Courriel: crdsmontreal.ccsmtl@ssss.gouv.qc.ca

https://www.santemontreal.qc.ca/professionnels/medecins/crds-centre-de-repartition-des-demandes-de-services-montrealais/

So…can wait times be fixed?

All four models can help reduce wait times and simplify the process.  However, the authors caution, “Canada is notorious for being a land of pilot projects in health care, where good ideas aren’t scaled well. For systems like this, where getting buy-in from many professionals is crucial, that problem is especially important to overcome.”

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The truth about GMF’s

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“Created to improve access, Montreal clinics often turn away patients,” published in the Gazette on February 15, 2017, is a misleading and misrepresentative article. It makes false assumptions and reaches incorrect conclusions.
The article states that “there are 86 family medicine groups in Montreal that rely on government funding to stay open longer than private doctors’ offices.” The author contends that “fewer than half the clinics are actually open seven days a week.”
The reality is GMFs are neither super-clinics nor general walk-ins. They are grouped, private, family medicine practices that offer care to a defined, registered patient population. Emphasis is placed on assiduité, fidélisation and prise en charge. In other words, GMFs prioritize their own patients while super-clinics or GMF-reseau (known previously as cliniques-reseau) are designed primarily for patients who do not have a family doctor.
These distinctions are available at: http://www.msss.gouv.qc.ca/professionnels/statistiques-donnees-services-sante-services-sociaux/acces-premiere-ligne/ and http://sante.gouv.qc.ca/systeme-sante-en-bref/groupe-de-medecine-de-famille-gmf/.
GMFs do not all receive the same funding and are not expected to maintain the same number of operating hours or days. While larger GMFs are open 68 hours/week, smaller GMFs only need to be open 5 or 6 days/week.
Yes – GMF walk-in clinics generally extend appointments to non-registered patients whenever possible. “All” patients can come irrespective of age, gender or medical history. Clinics, doctors, nurses are all working to improve access and help patients in need. But the GMF is not a “general” walk-in clinic – and hasn’t been since their inception in the early 2000s.
At the end of the day, the article should have asked – “can patients obtain timely appointments with their own family doctor?” Bottom line – register with a family doctor.

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Learning from Effective Primary Care Teams

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Santé Kildare was selected to participate in the University of Toronto Department of Family and Community Medicine Quality Improvement “teaming” project in 2016.  High functioning primary care teams were chosen across Canada with the goal of developing a blueprint and action plan to guide primary care teams to function effectively. The ultimate outcome leading to improved health of populations, improved and patient and provider experiences and improved value.  Santé Kildare was the only clinic studied from Quebec.

Launched in late 2014, the Quality Improvement (QI) Program set out to answer the question: What makes primary care teams effective or high-functioning?

“The evolution of health care provision in the community is moving from a single primary care provider (usually a family physician) providing health care patient by patient in a reactive context, to an organizational one – a primary care team proactively meeting the needs of a defined population. Teaming – a verb – refers to the collective actions or processes associated with a primary health care team performing optimally”.

In April 2016, the environmental scan for the teaming project was completed with case studies of nominated, high-functioning primary care teams. The case studies, representing teams from Alberta, Ontario and Quebec, marked the last element of the scan that included a robust literature review and a series of expert interviews.

Last Fall, the Quality Improvement (QI) Program published themes that were identified as attributes of high-functioning teams.  They include:

  1. A practice environment where members of an interprofessional team work in close proximity (co-location)
  2. Effective use of electronic medical records (EMRs)
  3. A focus on patient experience
  4. An effective communication culture
  5. Leadership
  6. Right skill mix
  7. A combination of clarity and flexibility around roles
  8. Ensuring that all team members work to their full scope of practice
  9. Professional development
  10. Collaboration with external partners and agencies

It was pleasure for Santé Kildare to participate in this project.  The full report can be found here.