Welcome to Postcall, the sickest newsletter for doctors since 14^th century town criers announced the Bubonic Plague! 🗞️📣

… Too soon? 😬

Did you know that new discoveries are still being made about the Black Death — the deadliest pandemic in recorded history, estimated to have wiped out half of the European population in seven years? Just last year, researchers found DNA evidence of Yersinia pestis in graves dated between 1338 and 1339 in modern-day Kyrgyzstan.

Stay tuned for the next 684 years — there could be more development on this (very, very) cold case!

Now time for some headlines!

• First episode of AF: to treat or not to treat 🤔

  ^{OACs… that is the question.}

• What patients might say this week 🙊 

  ^{“Man, Lyme disease really ticks me off.”}

• ER Ghosting 👻

  ^{A scary tale of vanishing patients.}

• A simple guide to Canadian home-buying

  ^{Brought to you by real estate maestro Vivian Yu!}

• Play: Postcall med-themed crossword puzzle vol. 3! ⛳️

  ^{This one’s a doozy.}

Driving these numbers: Stocks climbed this week, though analysts expect some market volatility related to the war in Israel (short-term impact is that oil is rallying). On the flip side, the major indexes have fallen 4%–6% since early September.

First ep AF: to treat or not to treat 🤔

A new study published at McMaster in the Annals of Internal Medicine has shown that 1 in 3 patients with transient, new-onset atrial fibrillation (AF) will have recurrent AF within 1 year.

What happened: It’s a common story: an elderly patient is admitted for pneumonia. An ECG is done and voilà, it’s a first-ever episode of AF in the absence of previous cardiac procedures — a.k.a. they’re cardiovirgins. As you whip out MDCalc to figure out their CHADSVASC score, you wonder: is this a one-off or the time to start oral anticoagulants (OACs)?

A matched cohort study from McMaster recruited patients from three academic hospitals in Ontario who had their first AF episode during a hospital admission for either non-cardiac surgery or medical illness. On average, patients were 71 with CHADSVASC score of 3. Patients were discharged home after a median duration of AF of 16 hours, followed by low-level monitoring consisting of 2x two-week monitoring and phone calls. One year later, AF was detected in 32% patients (vs. 3% in the controls).

Why it’s important: According to the Canadian Cardiovascular Society 2020 guidelines, OACs should be prescribed for most patients with AF and age 65+ or CHADS 2 score ≥ 1. But in practice, many first episodes of AF are self-terminating, not to mention that pill burden in elderly patients is on the rise. But now that we have smart-watch-capable ECG monitoring, perhaps it’s time to recharacterize baseline AF and the threshold to use OACs?

Postcall’s Take: This study may be a signal that perhaps we shouldn’t dismiss patients who have a bit of AF in the hospital. At the same time, we shouldn’t necessarily assume one hospital-based AF episode requires OACs for life. But the fact that researchers found 1 in 3 patients with recurrent AF with low-level monitoring is quite revealing — that’s a lot of AF recurrence. Bottom line is, we need more studies on first ep AF.

What patients might say this week 🙊 

1. “Is Pfizer approved yet?”

Health Canada has approved the Pfizer vaccine which targets the Omicron XBB.1.5 variant. Meanwhile, for the first time ever, doctors in BC can offer COVID-19 vaccines to their patients, along with influenza immunizations.

2. “I’m off to Mexico… for Lyme’s treatment.”

With cases of Lyme disease on the rise, some Canadians are travelling to Mexico to access treatments such as hyperthermia, stem cell therapy, extended antibiotic use, and plasmapheresis. Experts warn these are not evidence-based, despite patients dropping up to $30K to secure these therapies.

3. “I’m sick of waiting in the ED.”

See our feature on LWBS just below 👇

ER Ghosting 👻

Imagine waiting in the ER so long that you decide, “Eh, I’ll just go home and deal with my heart attack later.” 🤷‍♀️

What happened: New data by the Canadian Institute for Health Information (CIHI) reveals a 5x surge in Canadians leaving ERs without care due to long waits caused by overcrowding and staff shortages. The problem has a code: “LWBS” — Leave Without Being Seen.” To add to the chaos, from April 2022 to March 2023, ER visits soared to 15.1 million, from 14 million in 2021-22.

Why it’s interesting: Health issues wait for no one. Sadly, in some cases, patients who endured hours of waiting died in the ER or left, only to pass away at home. Dawn Peta, an ER nurse, says, "It worries me because some of the people who leave may not fully grasp the severity of their illness, and departing could be the wrong choice."

The influx in ER visits isn’t people being Karens about a minor cold. It underscores a nationwide scarcity of family doctors, primary care providers, and specialists. To many Canadians, the ER has become “the only default care space of all things,” including long stays. However, ERs aren’t designed for lengthy admissions; they rapidly assess patients for transfer to appropriate care. Yet, with bed shortages and numerous hospitals at full capacity, doctors have nowhere to admit ER patients, causing significant backups. Ideally, LWBS rates should be under 1%, but some hospitals have hit 40%.

Bottom line: Maybe the federal Health Minister office realizes Canada’s free healthcare bragging rights are at stake. They’re investing nearly $200 billion in Canadian healthcare over the next decade, allocating over $46 billion to provinces. Let’s hope they prioritize investments in ERs, so burnt-out doctors aren’t treating patients in waiting room chairs and washrooms, or resuscitating patients in EMS vans.

We’ve covered provincial solutions tackling Canada’s healthcare crisis, from SFU’s new medical school to BC’s move allowing PAs into the ER. Whether LWBS rates can be reduced is something to stay tuned for.

🍔 Quick Bites

1: 🇮🇱 In an unprecedented attack, an offensive by the Palestinian militant group Hamas has kicked off a war in which over 1000 (as well as 2 Canadians) have died. Israel has launched a “complete siege” of Gaza, cutting off their supplies and electricity. In Canada, pro-Palestinian and pro-Israeli rallies are being held at places like Nathan Philips Square. Protestors deny they glorify the violence, but some refuse to condemn the attacks. For up-to-date news, we recommend fact-checked sources like BBC or the Associated Press, and staying away from X.

2: 🚭️ New Zealand just banned cigarette sales to anyone born in 2009 or later, and the UK is looking at following suit. So at home, “I’m very interested in what they’re doing” says Adrian Dix, BC’s Minister of Health. It makes sense to us at Postcall: according to the ALA, “among adults who have ever smoked daily, 87% had tried their first cigarette by the time they were 18 years of age, and 95% had by age 21.”

3: 🤝 LinkedIn is gaining popularity among younger users, especially Gen Z. “‘It’s a place for connection and a place for celebration,’ says Zachary Clifton, a high-school senior and unabashed LinkedIn evangelist. He points out that in the deep-red county in Kentucky where he lives, Facebook is a swamp of election denial and buff Trump memes.” (Details at The Cut)

4: Wondering which is the right choice to start with — TFSA vs. RRSP vs. FHSA? At Postcall, we’re big fans of Wealthsimple’s decision flowchart! (Note that it’s not specifically for those in medicine. We have our own flowchart coming out next week, combining the best advice from the leading Canadian physicians).

Postcall Picks ✅ 

📖 Read: Dr. Abraham Verghese (Stanford Medicine professor) just published his first novel, Cutting for Stone. It’s the tale of Marion and Shiva Stone, two brothers whose bond is tested by a shared love interest. Marion flees to the US, where he becomes a surgeon. “When the past catches up to him—nearly destroying him—Marion must entrust his life to the two men he thought he trusted least in the world: the surgeon father who abandoned him and the brother who betrayed him.”

🧑‍🍳 Eat: Creamy au Gratin Potatoes - The creamy cheese sauce and tender potatoes in this classic French dish make a delicious flavour combination. Serve with a roast pork loin or beef tenderloin, alongside a green salad.

🛫 Travel tip: European cities are cracking down on over-tourism.

• Next year, Venice will become the first city to start charging a €5 entrance fee for day-tripping tourists to ease overcrowding during the city’s busiest days.

• Earlier this year, Amsterdam launched an ad campaign that was blunt about the type of tourists it wants, literally telling rowdy British lads to “stay away.”

• In 2022, Barcelona took steps to limit the number of visitors, cracking down on the size of tour groups and introducing noise restrictions.

• Not a crackdown, but you probably want to avoid Paris for now due to a bedbug rampage.

👀 Watch: A couple weeks ago we told you about how phenylephrine pills are ineffective at treating a stuffy nose. But why is it still being sold?

💳️ Buy: It’s once again Amazon’s Prime Day. Our favourite sale this year is the one on Kindles ($40 off the latest Paperwhite).

Presented by our partner Vivian Yu, PREC

A simple guide to Canadian home-buying 🏡 

Because they don’t teach real estate in medical school 🤷‍♀️

We’ve said it before and we’ll say it again — real estate is a great investment. About to buy the dip, and dip your toes into the market? Here’s our handy-dandy guide to buying a home, suitable for all audiences — beginners and intermediaries alike! 🏘️

🕹️ Game ⛳️

Presenting the third instalment of Postcall’s crossword puzzle — by doctors, for doctors! 🤗

First question: What gets point across and is also a canMEDS role?

If you struggled, get cracking on that textbook again. If you crushed it, share your time with your friends and see how fast they can do it ⏲️ .

Job Opportunities 💼 

Role: General Surgeon

• Location: Cape Breton Regional Hospital (Sydney, Nova Scotia)

• Compensation: $450,000 to $500,000

• Learn more

Role: Anesthesiologist

• Location: Personnel Management Consultants (Barrie, ON)

• Compensation: $400,000 to $600,000

• Learn more

Role: Medical Physicist

• Location: Allan Blair Cancer Center (Regina, SK)

• Compensation: $125,000 to $189,000

• Learn more

Role: Physician Assistant (Part-Time)

• Location: Garden Hill Nursing Station (St. Theresa Point, MB)

• Compensation: $123,187 to $196,042 (Rate will change with new agreement in near future)

• Learn more

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