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April 2022: 64:3
Pages 97–144
Are miscarriages more
common during COVID-19?
An analysis of in vitro fertilization pregnancies in BC
In this issue:
In situ simulation training for
in-office anaphylaxis preparedness
Innovations in early interventions
for people with eating disorders
Global decline of male
fertility: Fact or fiction?
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April 2022
Volume 64 | No. 3
Pages 97– 144
Drs Bron Finkelstein (left) and Jodie Graham (right), from Chetwynd, population 3000, often use the Real-Time Virtual Support pathways for providers. Story begins on page 110.
102 Editorials n The current gender-affirming care 109 News
n Musings about the state of the world model in BC is unvalidated and n Book review: Patients at risk:
David R. Richardson, MD outdated, Joanne Sinai, MD Exposing Canada’s health-care crisis
n Quest for Superdoc, Version 2.0 n Re: The value of ancillary testing David Esler, MD
Jeevyn K. Chahal, MD in amniotic fluid infection/ n Real-Time Virtual Support:
inflammation-related early pregnancy Much-needed rural and remote
104 President’s Comment loss…, Andrew Kotaska, MD assistance during the pandemic
Prioritizing physician health and n Author replies, Jefferson Terry, MD n Prescribing nature to improve health
safety, Ramneek Dosanjh, MD n Improving planetary health in BC: n Physician health and wellness: Doctors
Taking small but important steps of BC 2021 Report to Members
105 Letters Eric M. Yoshida, MD, Alison n Free online mental health and
n Where have all the family doctors Harris, MBBCh, Ka Wai Cheung, substance use supports for your
gone? Suzanne Montemuro, MD MD, Michael Nimmo, MD, John patients
Ridley, MD, Hui-Min Yang, MD
n Editor replies Contents continued on page 100
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BC Medical Journal vol. 64 no. 3 | april 2022 99
ARE MISCARRIAGES MORE COMMON
DURING THE COVID-19 PANDEMIC?
We analyzed two cohorts of IVF pregnancies to
An analysis of IVF pregnancies assess whether miscarriages were more common
in British Columbia. during the pandemic.
Clinical pregnancy rates were similar during the pandemic compared to
prepandemic, as were the biochemical miscarriage rates per positive bHCG.
We sought to determine whether intangible factors* occurring during the
pandemic were associated with changes in IVF pregnancy and miscarriage rates.
On the cover
Clinical pregnancy rates and
miscarriage rates in IVF patients
do not appear to be affected
by the COVID-19 pandemic. *changes in *asymptomatic
*stress
disinfection protocols COVID infections
Women planning to conceive do not need to delay their plans as a result of the pandemic.
Pregnancy and miscarriage rates do not appear to be changed in IVF treatment outcomes.
ReadRahana
the full article
Harjee, by Harjee,
MD, Jason Au, MSc,Au,
MayTian, andCaitlin
Tian, MSc, Dunne, beginning
Dunne, MD, FRCSCon page 116.
The BCMJ is published by Doctors of BC. The BCMJ 2022;64:116-119.
journal provides peer-reviewed clinical and review
articles written primarily by BC physicians, for
BC physicians, along with debate on medicine
and medical politics in editorials, letters, and
Contents continued from page 99
essays; BC medical news; career and CME listings;
physician profiles; and regular columns.
113 Premise 126 BCMD2B
Print: The BCMJ is distributed monthly,
other than in January and August.
Innovations in early interventions for Global decline of male fertility: Fact
Web: Each issue is available at www.bcmj.org.
people with eating disorders, Karen or fiction? Nora Tong, BDSc, Luke
Subscribe to print: Email journal@doctorsofbc.ca.
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131 College Library
To receive the table of contents by email, visit 116 Are miscarriages more Three best point-of-care tools
www.bcmj.org and click on “Free e-subscription.” common during the COVID-19 available, Karen MacDonnell
Prospective authors: Consult the
“Guidelines for authors” at www.bcmj.org
pandemic? An analysis of in
for submission requirements. vitro fertilization pregnancies 132 Obituaries
in British Columbia, Rahana n Dr John O’Brien Bell
n Dr Peter Michael Rees
Harjee, MD, Jason Au, MSc, May
n Dr Barrie Humphrey
Tian, MSc, Caitlin Dunne, MD
Editor Proofreader
134 CME Calendar
David R. Richardson, MD Amy Haagsma
120 In situ simulation training
Editorial Board Web and social media
for in-office anaphylaxis
Jeevyn K. Chahal, MD coordinator 135 Classifieds
David B. Chapman, MBChB Amy Haagsma preparedness, Sean Duke, MD,
Brian Day, MB
Caitlin Dunne, MD
Cover concept and Victoria E. Cook, MD 138 Guidelines for Authors
art direction
David J. Esler, MD
Jerry Wong,
Yvonne Sin, MD
Cynthia Verchere, MD
Peaceful Warrior Arts 125 WorkSafeBC
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100 BC Medical Journal vol. 64 no. 3 | april 2022
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BC Medical Journal vol. 64 no. 3 | april 2022 101
Editorials
Musings about the state of
the world
A
s this editorial is being crafted, Russia part of Italy was liberated from the Germans can also be kind, caring, and generous. Focusing
has invaded Ukraine and we are into in World War II. It was as if this event had on people’s potential for goodness can help us
year 2 of a global pandemic. People happened recently and was fresh in the minds deal with the uncertainty and negativity found
are discouraged and tired. Public patience is of the local townspeople. I wonder how they in the world today.
being tried, as demonstrated by recent free- felt about the world during the worst of that By the time this editorial is in print, the
dom convoys and the occupation of Ottawa (as global conflict. pandemic may have subsided and the war in
an aside, it wouldn’t be possible to have such There are certainly other times in history Ukraine will likely have been decided. As trou-
demonstrations in a country that wasn’t free). when the future seemed bling as these events have
Public health guidance would seem to be dark and uncertain. Com- been, a great deal of good-
apolitical, but lines have been drawn between ing out of the Great War Disease, violence, and ness has also been demon-
right-leaning conservatives/republicans and (World War I) and being war have been a part of strated. There has been an
left-of-centre liberals/democrats. It amazes me struck by the deadly Span- the human condition outpouring of well-wishes
how polarizing mask and vaccine mandates ish flu pandemic would and support for the people
have become. Vitriol often spread by social me- have caused many to de-
since time began. of Ukraine from millions
dia is divisive and inflammatory. A crisis that spair. Living through the of regular citizens around
many would think should unite us has become bubonic plague during the 14th century, when the world. So many health care workers, neigh-
a lightning rod for vehement disagreements 100 million souls perished, would have been bors, family, and friends have lifted those around
even among family members. dark days indeed. I was born in 1963, shortly them during this tiresome pandemic. For a local
The current state of the world is discourag- before President John F. Kennedy was assassi- example of decency, look no further than to the
ing and brings up questions about the humanity nated. My parents likely questioned their deci- people of British Columbia, who mobilized to
of humankind and its future. sion to bring a new life into this troubled world. support the farmers affected by flooding and the
One month after 9/11, partly in defiance of Disease, violence, and war have been a residents devastated by fires in the recent past.
terrorism, I went to Europe on a long-planned part of the human condition since time be- Good and evil exist in each of us, but in
vacation. I distinctly remember strolling into gan. Charles Dickens started his novel A Tale the end, I have faith that our basic humanity
a small Tuscan village and noticing a war me- of Two Cities with the line: “It was the best of will triumph. n
morial in the central square with fresh flowers times, it was the worst of times.” While true —David R. Richardson, MD
on it. It was erected in honor of the day that that humans are capable of the despicable, they
Available for streaming on
all podcast platforms
BURNOUT AND COVID-19
Warning signs
and when to act
with guests
Dr Jennifer Russel
and Dr Lawrence Yang A Doctors of BC Podcast
102 BC Medical Journal vol. 64 no. 3 | april 2022
Editorials
Quest for Superdoc, Version 2.0
I
n 2016 I wrote an editorial titled “Quest living and community well-being in colleagues, and my cat (in that order), and the
for Superdoc.”1 During the past 5 years, addition to primary care. advice was the same: the benefits outweighed
I have been on the brink of burning out, 3. Community-governed: CHCs are the risks. They had seen through my “it’s all
so I decided to revisit my quest and see where governed by community members good” mask. They knew I was burning out.
it went sideways. and focused on community priorities. I joined STEPS on 1 September 2021, and
Even before COVID-19 reared its virulent 4. Working upstream: CHCs actively it has been a seamless transition. My EMR
spikes, I was feeling overwhelmed. Working address the “social determinants of was integrated with STEPS, allowing all of
as a solo family physician, I was on my EMR health,” like access to food, housing, the clinicians to access and make notes in the
for 12 hours a day, managing my office, and education, and the supports needed same EMR; therefore, the continuity of care
juggling spending time with my family, three to thrive. is amazing. We have monthly team meetings
dogs, cat, chickens, and friends (in that order). 5. Justice-based: CHCs demonstrate a that include the medical office assistants and
I told myself and everyone around me that “it’s commitment to fairness, and to the all the allied health care clinicians. Commu-
all good.” After all, wasn’t I just a family physi- values of health equity and social nication is key.
cian? I wasn’t an ER doc or an internist in the justice.2 My patients are thrilled. They have time-
ICU. And aren’t all docs supposed to be super The Canadian Association of Community ly and increased access to a variety of health
resilient? I just had to patch and dry-clean my Health Centres is working on initiatives such care services. The team-based care is amazing.
cape, and all would be well. as investing in CHCs, establishing universal Everyone on the team is genuinely interested
My family practice was so busy that on many Pharmacare, investing in oral health and dental in working together to provide the best out-
days I would have to send patients to the ur- health care, and investing in affordable housing comes for our patients. As part of this team,
gent care clinic or the ER because I couldn’t and ending homelessness.3 I feel supported, respected, and valued. “Just
see them in a timely manner. I felt like I was CHCs are funded by MSP, the Ministry of a family doctor” is becoming a phrase of the
failing them. My staff was working with their Health, municipalities, community fundraising, past. With CHCs, the province is moving to-
hair straight back. I felt like I was failing them. primary care networks, and health authori- ward allowing physicians to choose between
I wasn’t visiting my parents as much, and when ties. In exchange for a percentage of my MSP salaried and fee-for-service payment models.
I did visit, I was always rushing to get back earnings, my patients and I would be part of a The fee-for-service model that exists today for
home because I had “lots of work to finish.” I unique team-based care concept. family physicians needs to be modernized. Our
felt like I was failing them. Many of my col- The Supporting Team Excellence with Pa- governing bodies are well aware of this fact and
leagues were feeling the same way. We would tients Society (STEPS)4 is a Kamloops-based are starting to engage in conversations that will
chat on the phone, vent, and then carry on as not-for-profit CHC. The STEPS team consists help make these changes.
before. There were no obvious solutions. of a volunteer board of directors, a compassion- Joining the STEPS CHC has renewed my
Then one day I was introduced to the idea ate executive director, a diligent clinic manager, love for family medicine and is allowing me to
of the community health centre (CHC) model: caring medical office assistants, nurses, a social spend quality time with my patients, family,
Community Health Centres are cre- worker, a counselor, a pharmacist, an occupa- friends, and cat.
ated by not-for-profit organizations and tional therapist, a nurse practitioner, a diabetes My quest for Superdoc is finally becoming
co-operatives that are committed to pro- nurse educator, a women’s sexual health services a reality; it just needed a Superteam. n
viding comprehensive, accessible, afford- clinic, a transgender clinic, a respiratory thera- —Jeevyn K. Chahal, MD
able, and culturally-appropriate services pist, a dietitian, a billing clerk, and family phy-
through a collaborative team approach. sicians. There is increased access to locums and References
CHCs adhere to five key principles: “doctor of the day” physicians who are able to 1. Chahal JK. Quest for Superdoc. BCMJ 2016;58:495.
1. Interprofessional care: CHCs pro- accommodate the urgent needs of our patients 2. British Columbia Association of Community Health
Centres. About CHCs. Accessed 1 March 2022. https://
vide collaborative services through when our schedules are full. bcachc.org/about-chcs.
an integrated multidisciplinary I was apprehensive at first. Would I lose 3. Canadian Association of Community Health Centres.
team-based primary health care my autonomy? Would I lose the trusting rela- Policy and advocacy. Accessed 1 March 2022. www
team. tionships with my patients? Would I earn less? .cachc.ca/policy-advocacy.
4. Supporting Team Excellence with Patients Society.
2. Wrap-around approach: CHCs of- Was I giving up? I consulted with my fam- About STEPS. Accessed 1 March 2022. www.steps
fer programs and services for healthy ily, my friends, my accountant, my lawyer, my health.ca.
BC Medical Journal vol. 64 no. 3 | april 2022 103
president’s comment
Prioritizing physician
health and safety
S
ignificantly more influences our health peer support initiative that will train doctors to .ca/your-benefits/physician-health-safety/
than whether or not we are free of dis- deliver one-on-one emotional peer support to memorandum-agreement.
ease. Our holistic health—physical, their colleagues, and a physician wellness net-
mental, spiritual, and emotional—as individual work to bring together those of us who have Addressing physician burdens
physicians and the collective health of us as a leadership responsibilities for the health and To further support physician health and well-
profession is influenced by many internal and wellness of physicians. ness, we must address the challenges in the
external factors. Now more than ever we must health care system that are adding to physician
make our health and well-being a priority; with- Addressing physical and burdens and contributing to stress and burnout.
out it, our profession has no chance of healing psychological safety Doctors of BC recognizes that there are more
and promoting health in others. An increase in concerns around violence, demands on doctors than ever before in today’s
We can assert control over some of the fac- threats, and stressful work environments due increasingly complex health care system. The
tors immediately, while others come with sig- to the pandemic has highlighted the importance volume and pace of change is overwhelming and
nificant barriers or challenges that lead to issues of safe working environments for physicians is negatively impacting physician health and
such as burnout, an overwhelming workload, to be able to provide patient care. At the same wellness. We are advocating to the Ministry of
and a lack of physical and psychological safety. time, the support mechanisms to address these Health, health authorities, WorkSafeBC, ICBC,
The pandemic has only exacerbated experiences issues for both hospital and community-based the College of Physicians and Surgeons, and
of burnout, stress, and even violence and bul- physicians are far behind the supports available other health system partners to recognize and
lying, leading to increased mental and physical for nurses and other staff working in hospitals. reduce burdens on physicians. For more infor-
health concerns for physicians. Doctors of BC is taking significant action to mation, check out our Physician Burdens policy
So, how do we heal ourselves while also address this through a Memorandum of Agree- statement in the Policy Database section of our
healing the system in which we operate? Doc- ment on Physical/Psychological Safety in our website (www.doctorsofbc.ca/policy-database).
tors of BC is taking a leadership role to pro- Physician Master Agreement. Our health and safety matters. Our patients’
vide physicians with the programs, systems, and This agreement has created opportuni- health depends on the health and well-being of
supports to address concerns about physician ties at the provincial level and in every health our profession and our health care system. If we
health and safety. authority for Doctors of BC to discuss phy- want to foster a culture that promotes health, we
sician safety, influence policy and programs, need to scrutinize the profession’s structures and
Physician Health Program’s expanded and undertake projects and efforts to improve clinical environments and be aware of the po-
mandate working conditions for physicians. Working tential implications to our health. It will take a
Our Physician Health Program, which provides with medical affairs departments and occupa- multifaceted approach to confront the systemic
confidential advocacy, support, and referral as- tional health and safety departments within barriers that challenge our health; however, we
sistance for physicians, physicians in training, health authorities, for the first time Doctors owe it to ourselves to recognize the problem
and their families, is expanding its programs of BC is able to engage on these matters and areas and commit to finding solutions. n
and services to better address challenges before influence policy and decision making. These —Ramneek Dosanjh, MD
they become crises. Members will soon learn efforts have already delivered programs related Doctors of BC President
about new initiatives, including a program to to COVID-19 support, improvements in vio-
help attach physicians to their own family doc- lence prevention, respectful workplace incidents,
tors, a cognitive behavioral therapy skills train- and blood and body fluid exposure support.
ing program to support doctors with mild to This is just the beginning of this important
moderate mental health challenges, a physician work. You can learn more at www.doctorsofbc
104 BC Medical Journal vol. 64 no. 3 | april 2022
Letters to the editor We welcome
original letters of less than 300 words; we may edit them for clarity
and length. Letters may be emailed to journal@doctorsofbc.ca, submitted
online at bcmj.org/submit-letter, or sent through the post and must include
your mailing address, telephone number, and email address. Please disclose any
competing interests.
Where have all the family Consider a young man who injured his neck Some are moving to other provinces. The
doctors gone? and back in a motor vehicle accident. He waited average remuneration for family doctors in On-
at walk-in clinics and looked on Medimap for tario is $300 000; in Alberta it is $250 000 to
Try to find a family doctor in BC and you will
4 days. No access. He eventually went to emer- $300 000. BC lags far behind.
be sadly disappointed. Patients are now asking
gency and waited there for hours. The first step our government needs to take
any specialist they see to help them with general
To emergency they go, for minor as well is to settle the unequal payments physicians
medical issues, but specialists have neither the
as major health issues. As a result, emergency receive, and they need to do it now.5-7 The in-
time nor the training to help. Nurse practitio-
rooms are overloaded. A Kamloops woman died equities in the medical funding model need to
ners have a completely different skill set; they
in the waiting room of Royal Inland Hospital’s be addressed.6 Only our provincial government
are not equipped to take over the role of a fam-
emergency department last September.3 can do this. The rest of Canada has tackled this
ily physician. Where are the family doctors we
In the past, the health care system worked problem with some success. BC needs to get
were promised in the “A GP for Me” initiative?
because family physicians kept patients with on board.
It hasn’t happened.
minor ailments out of hospital emergency —Suzanne Montemuro, MD, CCFP
The following are but a few examples of
rooms. Serious medical issues were attended Clinical Instructor, Faculty of Medicine, UBC
the problem.
to expeditiously. What has happened? This letter endorsed by:
Linda Swain from Malahat wrote to the
Look no further than physician remu- Darlene Hammell, MD, CCFP
Times Colonist about access to urgent and pri-
neration. Why do ophthalmologists make Past President, College of Physicians and
mary care centres:
$1 000 000 per year and family physicians make Surgeons of BC
“Each UPCC is geographically based. To
$163 000 per year? Most other specialists make Assistant Dean, Island Medical Program
even apply to become a patient, two pieces of
over $500 000 per year. Consider that overhead Clinical Professor, Faculty of Medicine, UBC
ID are required to prove residency within the
for a family physician’s office is 35% to 40% of Lorelei Johnson, MD, CCFP
established boundaries of each UPCC. And
gross income. Their net income is in the range Family Physician, Victoria
if the Westshore UPCC is anything to go by,
of less than $100 000.4
this taxpayer-funded system is a dismal failure.
Where can a family doctor make a better References
I needed an X-ray requisition and dutifully ar- 1. Swain L. A dismal failure of the medical system. Times
living? As a hospitalist. In the past 10 years,
rived at 7:15 a.m. and lined up with 20 other Colonist [letters]. 24 July 2021. Accessed 7 March 2022.
hospitals have been hiring family physicians to
people to wait for the 8 a.m. opening, only to www.timescolonist.com/opinion/letters/letters-july
take care of complicated patients in the hospital. -24-pros-and-cons-of-urgent-care-clinics-virus-puts
be told at 8 a.m. that the facility was ‘at capac-
They are paid $240 000 to $280 000 per year, -health-dollars-at-risk-4690889.
ity’ because only one doctor had shown up for 2. Palmer V. NDP politicians yawn as doctors call it quits.
with no overhead costs. In Victoria, 72 family
work that day! How can a sick person get the Vancouver Sun. 27 January 2022. Accessed 7 March
doctors have recently become hospitalists. In
care they need when no one seems to care?”1 2022. https://vancouversun.com/opinion/columnists/
the Fraser Health region that number is 110. vaughn-palmer-ndp-politicians-yawn-as-doctors-call
Since Swain wrote this letter, three more
The population in Victoria, especially in the -it-quits.
clinics in Victoria have closed. My own family 3. Brend Y. Death of 70-year-old waiting for care in BC
western communities, continues to grow but
physician, Dr G. Zabakolas, an excellent doc- emergency room to be reviewed, minister says. CBC
family doctors are getting out of the business
tor, has quit.2 News. 9 September 2021. Accessed 7 March 2022. www
as fast as they can. .cbc.ca/news/canada/british-columbia/70-year-old
Consider a 93-year-old friend of mine who
Other family physicians are leaving practice -patient-in-kamloops-emergency-room-1.6169654.
signed up to become a patient of the James Bay
to become surgical assistants or to practise vir- 4. BC Ministry of Health, Health Sector Information, Anal-
Urgent and Primary Care Centre 2 years ago. ysis and Reporting Division. Physician resource report
tual medicine. Others are taking early retire-
She still has no family physician. She never 2011/2012–2020/2021. October 2021. Accessed 7 March
ment or simply quitting from stress.2 2022. www2.gov.bc.ca/assets/gov/health/practitioner
received an intake call.
-pro/medical-services-plan/msp_physician_resource
_report_20112012_to_20202021.pdf.
BC Medical Journal vol. 64 no. 3 | april 2022 105
letters
5. Corbella L. Canada’s health care system overrun by WPATH have gone on record stating their 3. Society for Evidence-Based Gender Medicine. The
administrators and lacks doctors. Calgary Herald. 24 concerns. Dr Marci Bowers, a trans wom- signal—and the noise—in the field of gender medicine.
January 2022. Accessed 7 March 2022. https://calgary 31 January 2022. Accessed 17 February 2022. https://
herald.com/opinion/columnists/corbella-canadas
an surgeon, publicly disclosed her concerns segm.org/flawed_systematic_review_puberty
-health-care-system-overrun-by-administrators-and about puberty blockers, particularly the age _blockers.
-lacks-doctors. at which they are started.4 Psychologists Drs 4. Shrier A. Top trans doctors blow the whistle on “slop-
6. CBC News. Fee-for-service model is deterring as- Laura Edwards-Leeper and Erica Anderson py” care. Common Sense. 4 October 2021. Accessed
piring family doctors from setting up practice: Re- 17 February 2022. https://bariweiss.substack.com/p/
port. 12 November 2021. Accessed 7 March 2022.
(a trans woman), have raised questions about top-trans-doctors-blow-the-whistle.
w w w.cbc.ca/news/canada/british-columbia/ the significant rise of gender-dysphoric youth, 5. Edwards-Leeper L, Anderson E. The mental health es-
fee-for-service-model-family-doctors-1.6247049. particularly adolescent girls. They have advo- tablishment is failing trans kids: Gender-exploratory
7. Change.org. Bring back our family doctors and our cated for thorough psychological assessment therapy is a key step. Why aren’t therapists providing
walk-in clinics [petition]. Accessed 7 March 2022. www it? Washington Post. 24 November 2021. Accessed 17
and questioned the potential harm of not pro-
.change.org/p/bring-back-our-family-doctors-and February 2022. www.washingtonpost.com/outlook/
-our-walk-in-clinics. viding exploratory therapy.5 2021/11/24/trans-kids-therapy-psychologist.
While WPATH SOC8 may provide an
The current gender-affirming opportunity for evidence-based guidelines, a Re: The value of ancillary testing
review of the draft raises concerns. For example,
care model in BC is unvalidated the section on “eunuchs,” presented as a unique
in amniotic fluid infection/
and outdated gender identity, was bewildering. I question the inflammation-related early
As a psychiatrist, I have seen an explosion of evidence for this category, and particularly the pregnancy loss and perinatal
gender-dysphoric youth and young adults in recommendation to “affirm” and refer for surgi- death in British Columbia
recent years. These vulnerable groups deserve cal castration lest they attempt self-castration. I thank Dr Terry for his informative article
compassionate, evidence-based care. I am con- For those hesitant to agree, I urge you to [BCMJ 2021;63:383-387]. Of the many causes
cerned that the recent BCMJ content on gender watch the Swedish Trans Train documentaries of preterm birth, finding an infectious agent
dysphoria presents gender-affirming care as (part 1: https://youtu.be/sJGAoNbHYzk). Ca- gives hope that treatment might prevent re-
evidence-based1 and as the only appropriate nadian physicians should not ignore the poten- currence. However, most bacteria identified
model of care. This premise forms the basis for tial risks of the affirmation model when there during autopsies are commonly found in the
the three articles that follow on the medicalized is international evidence of harm to vulnerable lower female genital tract. Their culture from
treatment of gender dysphoria. youth. Distressed youth deserve diligent, nu- fetal surfaces, lung, and stomach may repre-
The World Professional Association for anced care favoring psychological assessment sent colonization during transit through the
Transgender Health (WPATH) Standards of and care over medical harm. Concerningly, Bill maternal vagina rather than pathogenicity. The
Care Version 7 (SOC7) are not evidence-based. C-4 (banning conversion therapy) was recently most common bacteria cultured was Group B
The WPATH website clearly states that SOC8 passed by the Senate. Without a clear definition Streptococcus, a commensal found in the lower
is the first version being developed using an of what constitutes exploratory therapy versus genital tract of 20% of women. The second was
evidence-based approach. In addition, a sys- conversion therapy, therapists risk being charged E. coli, which is ubiquitous. Although occasion-
tematic review of its clinical practice guidelines under this bill and may be dissuaded from treat- ally pathogenic, sometimes aggressively so, we
states that SOC7 “contains no list of key rec- ing people with gender dysphoria at all. cannot eradicate either from a woman’s gut and
ommendations or auditable quality standards.”2 We are in a unique position to rethink the vaginal flora for the duration of a future preg-
Furthermore, “many recommendations are flex- treatment model for gender dysphoria. I hope nancy. How helpful are these culture results?
ible, disconnected from evidence and could not we can begin a dialogue, so that our youth can Do they explain the index preterm birth? Can
be used by individuals or services to benchmark get the treatment they need and deserve. Gen- they help prevent a future one?
practice.”2 der affirmation is not a one-size-fits-all model. Why do commensal organisms some-
Finland, Sweden, Norway, and the UK are To allow ideology to prevail over sound medi- times become pathogenic? The relationship
re-evaluating care of gender-dysphoric youth cine is negligent at best. between bacteria, fetal membranes, and the
due to concerns about medical harm and the —Joanne Sinai, MD, MEd, FRCPC intra-amniotic cavity is dynamic and poorly
uncertainty of benefit.3 Victoria understood, as is the maternal immune response
I find it disconcerting that the validity of to those organisms.1 Amniocentesis during pre-
SOC7 and the gender-affirming model are References term labor frequently detects inflammatory
wholeheartedly accepted and promoted by 1. Knudson G. Gender-affirming care in British Columbia, cytokines without a positive culture, meaning
these articles. There is no balanced discourse Part 1. BCMJ 2022;64:18-19.
invasion of the amniotic cavity is not required
2. Dahlen S, Connolly D, Arif I, et al. International clinical
of reported negative outcomes or alternative to cause inflammation and preterm birth. Of
practice guidelines for gender minority/trans people:
approaches. Systematic review and quality assessment. BMJ Open all the commensal organisms suspected to play
Further, some high-profile members of 2021;11:e048943. an etiological role in infectious/inflammatory
106 BC Medical Journal vol. 64 no. 3 | april 2022letters
preterm birth and bacterial vaginosis, Urea- The practice at BC Children’s and BC Wom- for molecular testing. The genomes of Myco-
plasma and Mycoplasma species are perhaps en’s Hospitals is to sample for bacteria from plasma and Ureaplasma may also be visualized
the most amenable to treatment.2 Identifying areas that are unlikely to be artifactually con- fluorescently in the cytoplasm of infected cells,
them during a preterm loss may help direct care: taminated at or after delivery, such as the lung although this approach is more suitable to a
screening and treatment for bacterial vaginosis and stomach contents. This study was not in- research environment.
early in a future pregnancy and eradication of tended to assess the sensitivity and specificity —Jefferson Terry, MD, PhD, FRCPC
Ureaplasma and/or Mycoplasma in a woman and of bacterial culture in the setting of AFII and Vancouver
her partner before or early in a future pregnancy. as such a non-AFII cohort was not included
Treatment of atypical bacteria to decrease for comparison; anecdotally, however, bacterial Improving planetary health in
preterm birth has not been adequately studied.3 cultures from non-AFII cases at BC Chil- BC: Taking small but important
Treatment of bacterial vaginosis with clindamy- dren’s and BC Women’s Hospitals are mostly
steps
cin appears to have better preventive effect than negative, which demonstrates the low level of
metronidazole, perhaps because clindamycin detectable delivery and tissue sampling–related It is becoming increasingly clear that our fu-
also covers Ureaplasma and Mycoplasma, whereas contamination. ture health, as well as the health of future gen-
metronidazole does not.2,4 We have not typi- Dr Kotaska makes the excellent point that erations, is linked to global planetary health,
cally performed fetal cultures for Ureaplasma the relationship between microbes, inflam- including the preservation of the natural en-
and Mycoplasma, and they require Universal mation, and delivery continues to be poorly vironment, appropriate use of resources, and
Transport Medium for identification. Can Dr understood. A robust relationship between engagement of sustainable systems.1 The Board
Terry comment on whether Ureaplasma and intra-amniotic microbes and AFII has been of the Vancouver Medical, Dental, and Allied
Mycoplasma cultures were done in any of the established; however, the recent application Staff Association/Vancouver Physician Staff
included autopsies? Might he suggest a suitable of highly sensitive molecular techniques for Association is very supportive of Vancouver
fetal site if a clinician were to test for them? bacterial detection has failed to demonstrate Coastal Health’s formal adoption of planetary
detectable microbial DNA in all AFII cas- health as a strategic priority via the creation of
—Andrew Kotaska, MD, FRCSC
es; conversely, the presence of intra-amniotic an official planetary health portfolio, with Dr
Obstetrician and Gynecologist, Stanton
Territorial Hospital microbes (particularly Mycoplasma and Urea-
Assistant Professor, Department of Obstetrics plasma) without any appreciable maternal in-
and Gynecology, University of Manitoba flammatory response has been convincingly
Adjunct Professor, School of Population and shown. Thus, bacterial culture by itself is a poor
Public Health, University of BC
diagnostic test for AFII but can be diagnosti-
Adjunct Professor, Department of Obstetrics
cally useful in the context of histological AFII Secure cloud-based clinical
and Gynecology, University of Toronto
Yellowknife, NT
where bacteria are not seen microscopically. Dr speech recognition
Kotaska also makes the important practical
References
point that bacterial culture presently has no Dictate into your EMR from
1. Combs CA, Gravett M, Garite TJ, et al. Amniotic fluid predictive value as there is no robust data to almost anywhere
infection, inflammation, and colonization in preterm support treatment to decrease preterm birth,
labor with intact membranes. Am J Obstet Gynecol although this is also not well studied. Install within minutes across
2014;210:125.e1-125.e15.
2. Morency A-M, Bujold E. The effect of second-trimester
Testing for Mycoplasma and Ureaplasma is unlimited computers
antibiotic therapy on the rate of preterm birth. J Ob- difficult as these obligate intracellular micro-
stet Gynaecol Can 2007;29:35-44. organisms are fastidious and require special One synchronized user
3. Kotaska A, Paulette L. Genital mycoplasma and pre- handling, as Dr Kotaska points out. Myco- profile
term birth: A difficult puzzle to solve. BJOG 2022. doi:
plasma and Ureaplasma culture is presently
10.1111/1471-0528.17069.
not performed in British Columbia and the Stunningly accurate with
4. Donders G, Van Calsteren K, Bellen G, et al. Predictive
value for preterm birth of abnormal vaginal flora, bac- only locally available Mycoplasma/Ureaplasma accents
terial vaginosis, and aerobic vaginitis during the first testing is molecular based and not validated
trimester of pregnancy. BJOG 2009;116:1315-1324. on placental tissue, so testing for Mycoplasma Contact us today for a free trial!
and Ureaplasma in the setting of AFII, or preg-
Author replies 604-264-9109 | 1-888-964-9109
nancy loss in general, is not routinely done at
I appreciate Dr Kotaska’s comments on the our centre. If I were to test a clinical sample speakeasysolutions.com SY SOLU
EA
amniotic fluid infection/inflammation (AFII) for Mycoplasma or Ureaplasma I would submit
T
21
K
IO
SPEA
Professional Speech
NS
autopsy quality assurance study recently pub- lung and stomach contents for culture-based
studies or lung and stomach contents and tissue
Technology Specialists YEARS OF EXCELLENCE
lished in the journal [BCMJ 2021;63:383-387].
2000 - 2021
BC Medical Journal vol. 64 no. 3 | april 2022 107letters
Andrea MacNeill leading the clinical services role on this issue, we suspect that other associa- • Working with an environmentally advanced
component. Dr MacNeill has given outstand- tion journals (e.g., CMAJ) may follow. printer, Mitchell Press, certified by www
ing lectures on the subject to our membership —Eric M. Yoshida, OBC, MD, FRCPC .canopy.org.
at our annual general meeting in December, Past President, VMDAS/VPSA • Printing with vegetable-based inks.
and more recently to our Board. It is clear that —Alison Harris, MBBCh, FRCPC • Using FSC-certified paper.
what may be perceived as small steps locally President, VMDAS/VPSA • Printing locally.
can lead to long-lasting positive consequences. —Ka Wai Cheung, MD, FRCPC Our recently completed member survey
With this in mind, we strongly recommend Vice President, VMDAS/VPSA ( January 2022) again asked about members’
that the BC Medical Journal consider publishing —Michael Nimmo, MD, FRCPC attitudes toward print versus online. As in previ-
only online and cease publishing in print. Given Secretary, VMDAS/VPSA ous years, a strong majority of members asked
the popularity and convenience of online medi- —John Ridley, MD, CCFP that we continue with print, and this prefer-
cal journals in general, and the fact that Doctors Treasurer, VMDAS/VPSA ence holds when stratified for age and other
of BC’s services and communications have long —Hui-Min Yang, MD, FRCPC demographic factors. The number of readers
been conducted electronically, we suspect that Member at Large, VMDAS/VPSA who favor print has diminished somewhat since
the Doctors of BC membership will quickly the previous survey in 2016; this trend seems
adapt to accessing and reading the BCMJ on- Reference likely to continue, and perhaps in the future the
line. Reducing the carbon footprint associated 1. Whitmee S, Haines A, Beyrer C, et al. Safeguarding hu- BCMJ will become an online-only publication.
with printing the journal (i.e., saving paper, ink, man health in the Anthropocene epoch: Report of the The BCMJ’s mission is to provide a forum
Rockefeller Foundation–Lancet Commission on plan-
metal staples, and plastic wrappers, not to men- for clinical education, medical news, opinion,
etary health. Lancet 2015;386(10007):1973-2028.
tion the production and distribution resources) and resources for BC physicians, and we—along
will contribute positively to planetary health. with the majority of our colleagues from around
It will also most likely result in cost savings to
Editor replies BC—believe that this mission is best accom-
Doctors of BC. If the BCMJ takes a leadership Thank you for your letter. We agree with the plished with a combination of print and online
small-steps approach and have been working to formats.
lessen our environmental impact for many years. To cease your subscription to the paper
The small steps that we have taken include: edition, please email your request to journal@
• Supporting doctors who wish to read online- doctorsofbc.ca. To remain informed about
only by canceling their paper subscrip- new BC-relevant medical content, subscribe
tion and encouraging them to subscribe to BCMJ Headlines, a notification emailed when
British Columbia
to BCMJ Headlines, a notification emailed a new issue is posted on our website, by going
Medical Journal
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when a new issue is posted on www.bcmj to www.bcmj.org and clicking on the “Free
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British Columbia Medical Journal number of copies we print. provide only your name and email address.
@BCMedicalJournal • Avoiding bag use, and using recyclable paper
—Ed
Community-based specialists: No-cost access to envelopes when needed.
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108 BC Medical Journal vol. 64 no. 3 | april 2022News We welcome news items of less than 300 words; we
may edit them for clarity and length. News items should be emailed to
journal@doctorsofbc.ca and must include your mailing address, telephone
number, and email address. All writers should disclose any competing interests.
Book review: Patients at risk: Act in 1984 (public administration, comprehen-
siveness, universality, portability, and accessibili-
Exposing Canada’s health-care ty) represent tragic myths when viewed from the
crisis patient’s perspective. She touches on the history
By Susan D. Martinuk. Winnipeg: Frontier of publicly funded health care in Canada, then
Centre for Public Policy, 2021. ISBN: 978-1- reviews two legal challenges to medicare, be-
7776577-4-1. Paperback, 264 pages. ginning with the successful Chaoulli v. Quebec
Susan Martinuk is a Vancouver-based jour- decision (Supreme Court of Canada, 2005). She
nalist and research fellow in health care for then proceeds to an in-depth analysis of the
the Frontier Centre for Public Policy, an in- ongoing case of Cambie Surgeries Corporation
dependent Winnipeg-based think tank. This v. BC, initially unsuccessful in the BC Supreme
book, published by the Frontier Centre in 2021, Court in 2020, currently awaiting a decision by
begins with the stories of five patients who the BC Court of Appeal, and expected by all
endured prolonged suffering and poor out- players to be ultimately decided by the Supreme
comes while waiting for specialized medical Court of Canada. Martinuk is uncompromising
care, and lays blame squarely at the feet of a in her support for Cambie surgeon Dr Brian
“‘system’ that has lost sight of its raison d’etre Day and condemns what she sees as the mis-
and now functions more to constrain medical guided role played by the government of BC,
care than provide it.” the defendant in this ongoing litigation; hence
The author argues that the tenets of Cana- the title of Chapter 20: “The BC Government
dian medicare enshrined in the Canada Health v. Common Sense.”
Available for streaming on
all podcast platforms
PUTTING INDIGENOUS
CULTURAL SAFETY
INTO PRACTICE
with guests
Dr Terri Aldred and Len Pierre
A Doctors of BC Podcast
BC Medical Journal vol. 64 no. 3 | april 2022 109NEWS
Martinuk’s two final chapters, “How to those who fear that any venture into hybrid vaccination rates lower than in other areas of
Make Health Care Better” and “Where Do public/private care will lead to the extinction the province, a higher percentage of the popu-
We Go from Here,” detail in broad strokes of a system that represents the very cornerstone lation is at risk of getting critically ill from the
her prescription for reform, which involves of the Canadian identity. fifth wave.
acknowledging medicare’s failings; abandon- —David Esler, MD, CCFP(EM) The impact on health care workers in a
ing rigid ideology; and separating politics Dr Esler has practised emergency medicine in and remote community like Chetwynd (popula-
from health, care, and planning for the long around Vancouver for 34 years. He is also a clinical tion just over 3000) is far-reaching. The help
term, including the establishment of a Cana- associate professor of emergency medicine at the being offered by Real-Time Virtual Support
dian hybrid public/private system embraced University of British Columbia and a member of the (RTVS) physicians, who are available 24/7 over
by other countries with better-ranked health BCMJ Editorial Board. Zoom, has been welcomed with open arms. And
care systems. physicians are reporting that RTVS is having
Patients at Risk is eloquently written, moves an impact on outcomes and helping alleviate
along quickly, and is carefully referenced by an Real-Time Virtual Support: the challenges of rural medicine during the
experienced journalist who presents a compel- Much-needed rural and pandemic.
ling argument for a major refit in Canadian RTVS virtual providers are physicians with
medicare. The patient anecdotes are especially
remote assistance during the experience in rural medicine and are dedicated
poignant, and while necessarily subjective, they pandemic to offering shoulder-to-shoulder support to
continually remind the reader that health care The COVID-19 pandemic continues to impact physicians, residents, nurse practitioners, and
exists to serve patients, and that a system that rural and remote regions in Northern BC at a nurses—any rural health care worker—over
places ideology ahead of patient care is destined disproportionate rate compared with the rest Zoom. The RTVS physicians, who are based
for failure. of the province. More than 100 patients have throughout the province, can help with urgent
Martinuk’s book is a concise and worthwhile had to be transferred out of Northern Health and non-urgent cases and questions, including
read. It will elicit applause from readers frustrat- since the start of the fourth wave to hospitals case consultations, second opinions, ongoing
ed by their experience with Canadian medicare with more ICU capacity. The vast majority of patient support, point-of-care ultrasound, and
and eager for change, and condemnation from those have been COVID-positive. And with simulations.
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110 BC Medical Journal vol. 64 no. 3 | april 2022NEWS
Drs Bron Finkelstein (left) and Jodie Graham (right), from Chetwynd, are frequent users of the Real-Time Virtual Support pathways for providers.
When a critically ill patient cannot be man- Alberta, the Northwest Territories, and Yukon, encountered someone who was unwilling or
aged at a rural site, RTVS physicians can also and agrees that RTVS is the best thing to hap- unhappy to talk. Providers throughout the prov-
step in to coordinate their transfer to a larger pen to rural medicine. ince are encouraged to reach out for support.
centre through the Patient Transfer Network Dr Matt Petrie is an RTVS physician who For more information on how to get start-
run by BC Emergency Health Services. The has helped coordinate patient transfers for ed with RTVS, visit https://rccbc.ca/rtvs/
transfer is made to a centre with available ICU the Chetwynd team, pointing out that it is getting-started.
capacity. In recent months, due to critically ill sometimes difficult for doctors in urban cen-
COVID-19 patients, patient transfer has be- tres to understand the situation on the ground Prescribing nature to improve
come more common. in a rural centre. As a member of the RUDi health
Dr Bron Finkelstein, a new-to-practice doc- (emergency) team in RTVS, he understands PaRx is Canada’s first national, evidence-based
tor in Chetwynd, where the hospital has just five that part of his job is to advocate for rural nature prescription program, an initiative of the
beds, says RTVS physicians have been instru- providers who may not be able to advocate BC Parks Foundation driven by health care
mental in making stressful situations manage- for themselves and their community during professionals. Each prescriber who registers
able with advice, guidance when a colleague is a stressful situation. with PaRx receives a nature prescription file
needed, and taking on patient transfers during customized with a unique provider code, and
the depths of a difficult situation. With RTVS Call early and call often instructions for how to prescribe and log na-
support, the patient can be stabilized while a Dr Finkelstein urges health care providers to ture prescriptions. Doctors and other licensed
transfer is being arranged. call RTVS early—before they get too busy to health care professionals in BC can now pre-
Dr Jodie Graham, chief of staff at Chet- call—and to call often—when they have a sig- scribe Parks Canada Discovery Passes to pa-
wynd Hospital, has trained and worked in rural nificant case, a challenging case, a case where a tients through PaRx. For more information,
medicine for over a decade, including in rural second opinion would be beneficial. He’s never visit www.parkprescriptions.ca/en/prescribers.
BC Medical Journal vol. 64 no. 3 | april 2022 111NEWS
Physician health and wellness:
Doctors of BC 2021 Report to
Members
Doctors of BC has released its 2021 Report to
Members, with a focus on physician health and
wellness. To illustrate some of the ways the as-
sociation has been working to support physi-
cians throughout the pandemic, the report looks
at health and wellness advances made by the
Physician Health Program, by the Rural Coor-
2021 REPORT TO MEMBERS
dination Centre of BC, and through divisions of
family practice, the Joint Collaborative Commit-
tees, and the Council on Health Economics and
Policy. The report also contains:
• A summary of the year from 2021 President
Dr Matthew Chow, Chair of the Board
Dr Adam Thompson, Speaker of the Rep-
1 2021 REPORT TO MEMBERS
resentative Assembly Dr Eric Cadesky, and
Acting CEO Mr Jim Aikman.
• Reports from committees, sections, societies, A fresh take on physician wellness: New leadership Grassroots physician wellness solutions
and funding for the Physician Health Program from divisions and MSAs
councils, coordinating and working groups,
and external committees and aff iliated
organizations.
• A full list of all the doctors who served on the
association’s many committees in the year.
The report is available now at www.doctorsofbc
.ca/about-us/report-members.
READ MORE READ MORE
7 Back to Main Table of Contents 2021 REPORT TO MEMBERS 30 Back to Main Table of Contents 2021 REPORT TO MEMBERS
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112 BC Medical Journal vol. 64 no. 3 | april 2022You can also read
