Sheehan H Chowdhury-Essentials for the Canadian Medical Licensing Exam_ Review and Prep for McCqe,...

8/17/2019 Sheehan H Chowdhury-Essentials for the Canadian Medical Licensing Exam_ Review and Prep for McCqe, Part I-W…

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Essentials for theCanadian MedicalLicensing Exam

SHEEHAN H. CHOWDHURY, BSc, MD

Resident PhysicianUniversity of British ColumbiaVancouver, British Columbia, Ca nada

ADRIAN I. COZMA, MSc

Medical StudentUniversity of TorontoToronto, Ontario, Canada

JEESHAN H. CHOWDHURY, DPhil, MD

CEO of ListRunner San Francisco, California, USA

REVIEW AND PREP FOR MCCQE PART I

SECOND EDITION


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Acquisition s Edit or: Matt H auber Prod uct D evelop m ent E di to r: Ch ristine Fahey M ark eting M anager: M ichael McMahon Prod uctio n Pro ject M anager: M arian Bellus Design Co ord inator: H olly McLaughlin Art ist /I llustrato r: Jennifer Clements M anufacturing Coo rdin ato r: Ma rgie Or zech Prepress V endo r: S4Ca rlisle Publishing Services

Second ed ition

Copyright © 2017 Wolters Kluwer.

Copyright © 2010 Lippincott Williams & Wilkins, a Wolters Kluwer business.

Permission to reprint por tions of the M edical Cou ncil of Canada (MCC) O bjectives for the Q ualifying Examination (www.mcc.ca) has beengranted by MC C. T his permission does not constitute an endor sement by MC C or its employees of the textbook a nd/or its contents. The MCCObjectives Online Web Service and all copyrighted & trademark information contained t herein ar e the exclusive property of t he MC C an d itscontributors.

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or tra nsmitted in any form or by any means,including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written per mission fro m the co pyr ight ow ner , except for br ief quot at ion s emb od ied in crit ical a rt icles and reviews. M ateria ls appea ring in th is bo ok pr e- pa red by ind ividu als as pa rt of t heir off icia l du ties as U.S. govern ment em ployees a re n ot covered by t he a bo ve-ment ioned copyright. To r equ est per mission , plea se co nt act Wolt ers Kluw er at Two Co mm erce Squar e, 20 01 M ar ket Street , Philad elph ia, PA 19 103 , via ema il a t per mission [email protected], or via our website at lww.com (products and services).

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This work is no substitute for individual patient assessment based on healthcare professionals’ examination of each patient and consideration of,among oth er things, age, weight, gender, current or pr ior medical conditions, medication history, laborator y data, and o ther factors unique tothe patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals, and

not the publisher, are solely responsible for the use of this work, including all medical judgments, and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indica-tions, appropriate pha rmaceutical selections and dosages, and treatment options shou ld be made and healthcare professionals should consult avariety of sources. Wh en prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufactur -er’s package insert) accompanyin g each drug to verify, among ot her th ings, condition s of use, warn ings and side effects and identify any cha ngesin dosage schedule or contraind ications, pa rticularly if the medication to be admin istered is new, infrequently used, or ha s a na rrow therapeuticrange. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury or damage to personsor property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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editors, and publisher are not responsible for errors o r omissions or for any consequences from application of the information in this book andmake no warranty, express or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application ofthis information in a pa rticular situation remains the professional responsibility of th e practitioner; the clinical treatments described and recom-mended may not be considered ab solute and u niversal recommendations.The author s, editors, and pub lisher have exerted every effort to ensure that d rug selection and d osage set forth in this text are in accordance withthe current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations,and th e constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each dr ugfor any change in indications and do sage and for added warn ings and precautions. This is particularly importan t when the recommended agentis a new or infrequently employed drug.Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restrictedresearch settings. It is the responsibility of the healthcare provider to ascertain the FDA status of each drug or device planned for use in his orher clinical practice.To purchase additional copies of this book , call our customer service depart ment at (800)638 -3030 or fax orders to (301)223-2320. Internat ionalcustomers should call (301)223-230 0.Visit Lippincott Williams & Wilkins on the Internet at http://www.lww.com. Lippincott Williams & Wilkins customer service representatives

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Dedicated to our loving parents, Tofael and N adira Chowdhury, and

our brothers, Raiyan and R ezwan.

—Sheehan H. Chowdhury and Jeeshan H. Chow dhury

Dedicated to my parents, Ioan and N atalia Cozm a, Alexandra, and

my mentors

—Adrian I. Cozma


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CONTRIBUTORS

Assistant Editors

Omar Khan, BSc, BComm, MDResident PhysicianDepartment of MedicineUniversity of Ca lgaryCalgary, Alberta, Canada

Emmad Qazi, BScMedical StudentUniversity of Ca lgaryCalgary, Alberta, Canada

Zubair Bayat, BScMedical StudentUniversity of CalgaryCalgary, Alberta, Canada

Sally Engelhart, BAMedical StudentHarvard UniversityCambridge, Massachusetts, USA

Chapter 1: Introduction

Sheehan H. Chowdhury, BSc, MDResident PhysicianDepartment of PsychiatryUniversity of British ColumbiaVancouver, British Columbia

Adrian I. Cozma, MScMedical StudentUniversity of TorontoToronto, O ntario

Jeeshan H. Chowdhury, DPhil, MDCEO of ListRunner San Francisco, California

Chapter 2: CanMEDS

Gurdeep Parhar, MD, FRCPCExecutive Associate Dean, Clinical Par tnershipsand ProfessionalismFaculty of MedicineUniversity of British ColumbiaVancouver, British Columbia

David Leung, MDResident PhysicianDepartment of Family and Community MedicineUniversity of TorontoToronto, O ntario

Bez Toosi, MDResident PhysicianDepartment of Dermatology and Skin ScienceUniversity of British ColumbiaVancouver, British Columbia

Chapter 3: Cardiology

Mikael Hanninen, MD, FRCPC, CCDS, CEPSClinical Academic ColleagueDepartment of Cardiac SciencesUniversity of Alberta

Staff PhysicianDepartment of Cardiac SciencesEdmonton, Alberta

Chapter 4: Dermatology


Sonja Gill, MDResident PhysicianDepartment of RheumatologyUniversity of TorontoToronto, Ontario

Resident PhysicianDepartment o f Adult M edicineSUNY Upsta te M edical UniversitySyracuse, New York

Nisha Mistry, BSc, MD, FRCPCLecturer Department of DermatologyUniversity of TorontoToronto, Ontario

Contributors to 2nd Edition

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Chapter 5: Emergency Medicine

William Sevcik, MD, FRCPAssociate Professor, Site Chief Department of Emergency Medicine and Division ofPediatric MedicineUniversity of AlbertaEdmonton, Alberta

Katherine E. Smith, BSc, MDResident PhysicianDepartment of Emergency MedicineUniversity of AlbertaEdmonton, Alberta

Adam Thomas, BHSC, MDResident PhysicianDepartment of Emergency MedicineUniversity of British ColumbiaVictoria, British Columbia

Chapter 6: EndocrinologyJessica Mackenzie-Feder, MD, FRCPCClinical Assistant Professor Department of Medicine, Division of EndocrinologySt. Paul’s HospitalUniversity of British ColumbiaVancouver, British Columbia


Jonathan Cena, MD, PhDResident PhysicianDepartment o f Internal MedicineUniversity of ManitobaWinnipeg, Manitoba

Donald W. Morrish, MD, PhD, FRCPCProfessor Department of Medicine, Division of Gastroenterologyand M etabolismUniversity of AlbertaEdmonton, Alberta

Constance L. Chik, MD, PhD, FRCPCProfessor Department of Medicine, Division of Gastroenterologyand M etabolismUniversity of AlbertaEdmonton, Alberta

Chapter 7: Gastroenterology

Stephen E. Congly, MD, FRCPCClinical Assistant Professor Department of Medicine, Division of Gastroenterologyand HepatologyUniversity of CalgaryCalgary, Alberta

Tiffany Poon, BSc Pharm, MD, FRCPCGastroenterology FellowDepartment of Medicine, Division of Gastroenterologyand HepatologyUniversity of CalgaryCalgary, Alberta

Erin Ross, MD, FRCPCStaff PhysicianDepartment o f MedicineRegina Qu’Appelle Health RegionRegina, Saskatchewan

Matthew Sadler, MD, FRCPCHepato logy FellowInstitute of Liver StudiesKing’s College HospitalLondon, United Kingdom

Chapter 8: General Surgery

Ahmed Kayssi, MD, MSc, MPH, FRCSCResident PhysicianDepartment of Surgery, Division of Vascular SurgeryUniversity of TorontoToronto, Ontario

Najma A. Ahmed, MD, PhD, FRCSC, FACSAssociate Professor Department of SurgeryUniversity of TorontoToronto, Ontario

Assistant Trauma Director Trauma Surgery, General Surgery, and Critical CareSt. Michael’s HospitalToronto, Ontario

Ralph George, MD, FRCSCAssociate Professor

Department of SurgeryUniversity of TorontoToronto, Ontario

Medical Director CIBC Breast CentreSt. Michael’s HospitalToronto, Ontario

Contributors • v


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vi • Contributors

Girma (Gary) Gamme, MDResident PhysicianDepartment of SurgeryUniversity of AlbertaEdmonton, Alberta

Chapter 9: Geriatric Medicine

Dov Gandell, MDCM, FRCPCAssistant Professor Department of Medicine, Division of GeriatricsUniversity of TorontoToronto, O ntario

Geriatric Medicine ConsultantDepartment of Medicine, Division of GeriatricsSunnybrook H ealth Sciences Center Toronto, O ntario

Emily Kwan, MD, FRCPCClinical Lecturer Department of Medicine, Division of Geriatrics

University of Ca lgaryCalgary, Alberta

Staff PhysicianRockyview General HospitalCalgary, Alberta

Jarred Rosenberg, MDResident PhysicianDepartment of GeriatricsUniversity of TorontoToronto, O ntario

Sharon Straus, MD, MSc, FRCPCDirector

Department of Medicine, Division of GeriatricsUniversity of TorontoToronto, O ntario

Director Knowledge TranslationLi Ka Shing Knowledge InstituteSt. Michael’s HospitalToronto, O ntario

Chapter 10: Gynecology

Michael W. H. Suen, MDResident Physician

Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouver, British Columbia

Nicole Jensine Todd, MD, FRCSCClinical Assistant Professor Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouver, British Columbia

Staff PhysicianBritish Columbia’s Children’s H ospitalBritish Columbia Woman’s HospitalVancouver General Hospital

Vancouver, British Columbia

Chapter 11: Hematology

Mark Belletrutti, MSc, MD, FRCPCAssistant Professor Department of PediatricsUniversity of AlbertaEdmonton, Alberta

Staff PhysicianDivision of Pediatric H emato logy, Oncology andPalliative CareStollery Children’s H ospitalEdmonton, Alberta

Elena Liew, MD, FRCPCAssistant Clinical Professor Department of MedicineUniversity of AlbertaEdmonton, Alberta

Chapter 12: Nephrology

Valerie A. Luyckx, MBBCh, MScAssociate Professor Department of Medicine, Division of NephrologyUniversity of AlbertaEdmonton, Alberta

Alan W. McMahon, MD, FRCPCAssociate Professor Department of Medicine, Division of NephrologyUniversity of AlbertaEdmonton, Alberta

Magdalena Michalska, MD, FRCPCAssociate Clinical Professor

Department of Medicine, Division of NephrologyUniversity of AlbertaEdmonton, Alberta

Staff PhysicianDivision of NephrologyRoyal Alexandra HospitalEdmonton, Alberta

Chapter 13: Neurology/Neurosurgery

Julie A. Kromm, MD, FRCPCResident PhysicianDepartment of Medicine, Division of Neurology

University of AlbertaEdmonton, Alberta

Resident PhysicianDepartment of Critical Care MedicineUniversity of Ca lgaryCalgary, Alberta

Cameron A. Elliott, MDResident PhysicianDepar tment of Surgery, Division of N eurosurgeryUniversity of AlbertaEdmonton, Alberta


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Contributors • vi i

Michael Edward Knash, MD, FRCPCClinical Professor Department of Medicine, Division of NeurologyUniversity of AlbertaEdmonton, Alberta

Staff PhysicianRoyal Alexandria H ospital

Edmonton, Alberta

Chapter 14: Obstetrics

Sheila C. Caddy, MD, FRCPCClinical Assistant Professor Department of O bstetrics and GynecologyUniversity of CalgaryCalgary, Alberta

Staff PhysicianWomen’s Health ClinicSouth H ealth CampusCalgary, Alberta

Michael W. H. Suen, MDResident PhysicianDepartment of O bstetrics and GynecologyUniversity of British ColumbiaVancouver, British Columbia

Chapter 15: Ophthalmology

Imran Jivraj, BSc, MDChief Resident PhysicianDepartment of OphthalmologyUniversity of AlbertaEdmonton, Alberta

Matthew T. S. Tennant, BA, MD, FRCSC, ABOAssociate Clinical Professor Department of OphthalmologyUniversity of AlbertaEdmonton, Alberta

Chapter 16: Orthopedic Surgery

Jacqueline T. Ngai, MSc, PhD, MDResident PhysicianDepartment of OrthopaedicsUniversity of British ColumbiaVancouver, British Columbia

Robert J. Feibel, MD, FRCSCAssociate Professor Department of SurgeryDivision of O rthopedic SurgeryUniversity of OttawaOttawa, Ontario

Staff PhysicianDivision of O rthopedic SurgeryThe Ottawa H ospitalOttawa, Ontario

Chapter 17: Otolaryngology

André Isaac, BMSc, MDResident PhysicianDepar tment of Surgery, Division of O tolaryngology— Head and N eck SurgeryUniversity of AlbertaEdmonton, Alberta

Raiyan Chowdhury, MD, FRCSCClinical Lecturer Depar tment of Surgery, Division of O tolaryngology— Head and N eck SurgeryUniversity of AlbertaEdmonton, Alberta

Chapter 18: Pediatrics

Reena P. Pabari, MSc, MDResident PhysicianDepartment of PediatricsUniversity of Toronto

Toronto, Ontario

Leah Abitbol, MDResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, Ontario

Bradley De Souza, BMSc, MB BCh, BAOResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, Ontario

Gary Galante, BMSc, MD, FRCPCPediatrics Gastroenterology FellowDepartment of PediatricsUniversity of CalgaryCalgary, Alberta

Jessica Gantz, BSc, MDResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, Ontario

Lauren A. Kitney, BSc, MD

Resident PhysicianDepartment of PediatricsUniversity of TorontoToronto, Ontario

Melanie Lewis, MD, MMedEd, FRCPCAssociate DeanLearner Advocacy and WellnessUniversity of AlbertaEdmonton, Alberta

Associate Professor o f PediatricsStolley Children’s HospitalEdmonton, Alberta


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viii • Contributors

Lillian Lim, BSc, MDResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, O ntario

Fathima Razik, BSc, MBBSResident Physician

Department of PediatricsUniversity of TorontoToronto, O ntario

Devin S. Singh, MBBS, BMScResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, O ntario

Julia C. Sorbara, MDResident PhysicianDepartment of PediatricsUniversity of Toronto

Toronto, O ntario

Melanie Steele, MDResident PhysicianDepartment of PediatricsUniversity of TorontoToronto, O ntario

Chapter 19: Psychiatry

Jordan Cohen, MD, FRCPCPostgraduate Residency Training Director

Clinical Associate Professor

Department of PsychiatryUniversity of Ca lgaryCalgary, Alberta

Medical Director Foothills Medical Centre (Footh ills Hospital), Unit 26Young Adult Program & Child and Adolescent MentalHealth Urgent ServicesCalgary, Alberta

Medical Lead NW Family Adolescen t & Children Services ClinicCalgary, Alberta

Trisha Chakrabarty, MD

Resident PhysicianDepartment of PsychiatryUniversity of British ColumbiaVancouver, British Columbia

Julius O. Elefante, MDResident PhysicianDepartment of PsychiatryUniversity of British ColumbiaVancouver, British Columbia

Chief Resident PhysicianDepartment of PsychiatryRoyal Columbian H ospital

New Westminster, British Columbia

Ai Van Shelly Mark, BSc Pharm, MDResident PhysicianDepartment of PsychiatryVancouver Island Distributed SiteUniversity of British ColumbiaVictoria, British Columbia

Aleena Shariff, BSc

Medical StudentFaculty of MedicineUniversity of Ca lgaryCalgary, Alberta

Raheel Syed, BSc, MDResident PhysicianDepartment of PsychiatryUniversity of AlbertaEdmonton, Alberta

Anum Tabish, BSc, BEdMedical StudentFaculty of Medicine

University of Ca lgaryCalgary, Alberta

Chapter 20: Public Health

Amandeep Sheny Khera, MD, CCFP, MPHAssistant Professor Department of Family MedicineUniversity of AlbertaEdmonton, Alberta

Lisa J. Steblecki, MD, MPHAssociate Professor Department of Family Medicine

University of EdmontonEdmonton, Alberta

Staff PhysicianDepartment of Family MedicineMisericordia H ospitalEdmonton, Alberta

Fraser Brenneis, MD, CCFP, FCFPVice Dean o f EducationFaculty of Medicine and DentistryUniversity of Alberta

Associate Professor Department of Family MedicineUniversity of AlbertaEdmonton, Alberta

Chapter 21: Pulmonary Medicine

Mitesh V. Thakrar, MD, FRCPCClinical Assistant Professor Department of MedicineUniversity of Ca lgary

Staff PhysicianSouthern Alberta Pulmonary Hypertension & LungTransplant ProgramsPeter Lougheed Hospital

Calgary, Alberta


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Contributors • ix

Erika D. Penz, SM, MD, MSc, FRCPCAssistant Professor Department o f MedicineUniversity of Saskatchewan

Staff PhysicianRoyal University HospitalSaskatoon, Saskatchewan

Rhea Varughese, MD, FRCPCClinical Lecturer Department o f MedicineUniversity of CalgaryCalgary, Alberta

Brandie L. Walker, MD, PhD, FRCPCClinical Assistant Professor Department o f MedicineDivision o f RespirologyUniversity of Calgary

Medical Director

Calgary COPD and Asthma ProgramAlberta H ealth ServicesCalgary, Alberta

Chapter 22: Rheumatology

Daniel Ennis, MDResident PhysicianDepartment o f Internal MedicineUniversity of British ColumbiaVancouver, British Columbia

Jane Hsieh, MDResident Physician

Department o f Internal MedicineUniversity of British ColumbiaVancouver, British Columbia

Kun Huang, MD, PhDResident PhysicianDepartment o f Internal MedicineUniversity of British ColumbiaVancouver, British Columbia

Chapter 23: Urology

Premal Patel, BHSc, MDResident PhysicianSection of UrologyUniversity of ManitobaWinnipeg, Manitoba

Andre A. Matteliano, BHSc, MDResident PhysicianSection of UrologyUniversity of ManitobaWinnipeg, Manitoba

Julien Letendre, MD, FRCSCClinical FacultyDepartment of SurgeryUniversity of Montreal

Staff PhysicianDepartment of SurgeryMaisonneuve-Rosemont Hospital

Mon treal, Quebec

Tadeusz J. Kroczak, MDResident PhysicianSection of UrologyUniversity of ManitobaWinnipeg, Manitoba

Jasmir G. Nayak, MDResident PhysicianSection of UrologyUniversity of ManitobaWinnipeg, Manitoba

Kamaljot Singh Kaler, BA, BSc, MDResident PhysicianSection of UrologyUniversity of ManitobaWinnipeg, Manitoba

Al’a Abdo

Medical StudentUniversité de MontréalMontreal, Quebec

Hernish Jayant Acharya, MDResident PhysicianDepartment of Physical Medicine and RehabilitationGlenrose Rehabilitation H ospitalUniversity of AlbertaEdmonton, Alberta

Martha Ainslie, MD, FRCPC

Clinical Assistant Professor Department o f MedicineUniversity of CalgaryCalgary, Alberta

Staff PhysicianDivision of Respiratory M edicineDepartment o f MedicinePeter Lougheed HospitalCalgary, Alberta

Contributors to 1 st Edition


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x • Contributors

François Bénard, MD, FRCSCProgram Director Department of UrologyUniversité de MontréalMon treal, Quebec

Fraser R. Brenneis, MD, CCFC, FCFPSenior Associate Dean (Educat ion)

Faculty of Medicine & DentistryDepartment of Family MedicineUniversity of AlbertaEdmonton, Alberta

Meghan Brison, MDResident PhysicianDepartment of Emergency MedicineUniversity of British ColumbiaVancouver, British Columbia

Michael F. Byrne, MD (Cantab), BA, MA,MRCP (UK), FRCPCClinical Associate Professor

University of British ColumbiaVancouver, British Columbia

Michelle L. Catton, MDResident PhysicianDepartment of Internal M edicineUniversity of SaskatchewanSaskatoon, Saskatchewan

Andrea Cheung, MDResident PhysicianToronto East General HospitalUniversity of TorontoToronto, O ntario

Oliver Haw For Chin, MD, FRCPCAssistant Professor Division of General Internal M edicineDepartment of MedicineUniversity of Ca lgaryCalgary, Alberta

Jeeshan H. Chowdhury, BSc, MSc (Oxon)Medical StudentUniversity of AlbertaEdmonton, Alberta

Raiyan Chowdhury, BSc, MDStaff PhysicianDivision of OtolaryngologyHead and N eck SurgeryUniversity of AlbertaEdmonton, Alberta

John Crossley, MD, CCFP(EM), FRCPCPostgraduate Residency Training Director

Assistant Professor Division of Emergency MedicineDepartment of MedicineMcMaster UniversityHamilton, Ontario

Yen Dang, MDResident PhysicianDepartment of SurgeryDivision of General SurgeryQueen’s UniversityKingston, Ontario

Niloofar Dehghan

Medical StudentUniversity of OttawaOttawa, Ontario

Myriam Farah, MDChief Resident PhysicianDepartment of MedicineUniversity of British ColumbiaVancouver, British Columbia

Robert J. Feibel, MD, FRCSCAssociate Professor Department of Or thopaedic Surgery

The Ottawa HospitalOttawa, Ontario

W. L. Alan Fung, MD, MPhil, ScMResident PhysicianDepartment of PsychiatryUniversity of TorontoToronto, OntarioDepartment of EpidemiologyHarvard UniversityBoston, Massachusetts

Gerontology Research UnitMassachusetts General H ospital

Harvard M edical SchoolBoston, Massachusetts

Ahmed Galal, MD, FRCPDirector McGill Stem Cell Transplant ProgramAssociate Professor Faculty of MedicineMcGill University

Staff PhysicianDivision of Hematology, Department of MedicineRoyal Victoria HospitalMont real, Quebec

Stephane Michel Gauthier, MDResident PhysicianDepartment o f Internal M edicineUniversity of OttawaOttawa, Ontario

Ralph George, MD, FRCSMedical Director CIBC Breast Cent reSt. Michael’s HospitalToronto, Ontario


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Contributors • xi

Nicholas Giacomantonio, MD, FRCPCAssociate Professor of M edicineDepartment o f MedicineDalhousie UniversityHalifax, Nova Scotia

Staff PhysicianDepartment o f Medicine

QE II Health Sciences CentreHalifax, Nova Scotia

Jeremy Gilbert, MD, FRCPCStaff PhysicianDepartment o f MedicineDivision of EndocrinologyUniversity of TorontoToronto, On tario

Andrée Gruslin, MD, FRCSAssociate Professor Faculty of MedicineDepartment of O bstetrics and Gynecology

University of OttawaOttawa, Ontario

Staff PhysicianDepartment of O bstetrics and GynecologyThe Ottawa H ospitalOttawa, Ontario

Mohamed Shahul Hameed, MDStaff PhysicianEastern M aine Medical CentreBangor, Maine, USA

Christopher Hall, MD

Resident PhysicianDepartment of Emergency MedicineMcMaster UniversityHamilton, Ontario

Leora Horn, MD, MSCClinical Fellow in O ncologyDepartment o f MedicineUniversity of TorontoToronto, On tario

Scott Edward Jarvis, MD, PhDResident Physician

Department of N eurologyUniversity of CalgaryCalgary, Alberta

Michelle-Lee Jones, MDResident PhysicianDepartment of N eurologyMcGill UniversityMontreal, Quebec

Jaskaran KangMedical StudentQueen’s UniversityKingston, Ontario

Janna Kasumovic, MDResident PhysicianDepartment of Family MedicineUniversity of AlbertaEdmonton, Alberta

Ahmed Kayssi, MScMedical Student

Queen’s UniversityKingston, Ontario

James L. Kennedy, MD, FRCPCProfessor Department of Psychiatry and Institute of MedicalScienceUniversity of Toronto

Head of Neurogenetics SectionDirector, Department of NeuroscienceCentre for Addiction and M ental HealthToronto, Ontario

Hisham Khalil, MDResident PhysicianDepartment of O bstetrics and GynecologyUniversity of Ottawa and The Ot tawa H ospitalOttawa, Ontario

Stephen Kingwell, MDResident PhysicianDepartment o f Orthopaedic SurgeryUniversity of OttawaOttawa, Ontario

Valerie G. Kirk, MD, FRCPC

Associate Professor Department of PediatricsUniversity of CalgaryCalgary, Alberta

Staff PhysicianDepartment of PediatricsAlberta Children’s HospitalCalgary, Alberta

Radha P. Kohly, BSc, PhD, MDResident PhysicianDepartment of OphthalmologyUniversity of Toronto

Toronto, OntarioResident PhysicianDepartment of OphthalmologyToronto Western HospitalToronto, Ontario

Tehseen Ladha, MDResident PhysicianDepartment of PediatricsUniversity of CalgaryAlberta Children’s HospitalCalgary, Alberta


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xii • Contributors

Wai-Ching Lam, MD, FRCSCAssociate Professor Department of Ophthalmology and Vision SciencesUniversity of Toronto

Staff PhysicianDepartment of OphthalmologyToronto Western H ospital

Toronto, O ntarioDarren LauMedical StudentUniversity of AlbertaEdmonton, Alberta

Thierry Lebeau, MDResident PhysicianDepartment of UrologyUniversité de MontréalMon treal, Quebec

Brendan Leier, PhD

Assistant Professor John Dosseter Health Ethics CentreUniversity of Alberta

Clinical EthicistStollery Children’s H ospitalUniversity of AlbertaEdmonton, Alberta

Natasha B. Leighl, MD, MMSc, FRCPCAssistant Professor Department of MedicineUniversity of Toronto

Staff Physician

Department of O ncology and H ematologyPrincess Margaret Hospital—UHNToronto, O ntario

Julien Letendre, MDResident PhysicianDepartment of UrologyUniversité de MontréalMon treal, Quebec

Grace LiMedical StudentFaculty of MedicineUniversity of British Columbia

Vancouver, British Columbia

Jennifer Lipson, MDResident PhysicianDepartment of Obstetrics and GynecologyUniversity of Ottawa and The Ottawa H ospitalOttawa, Ontario

Richard Liu, MD, FRCPCPostgraduate Residency Training Director Division of OtolaryngologyHead and N eck SurgeryUniversity of AlbertaEdmonton, Alberta

Harvey Lui, MD, FRCPC

Professor and H eadDepartment of Dermatology and Skin ScienceVancouver General HospitalUniversity of British ColumbiaVancouver, British Columbia

Shaheed Merani, MD, PhDResident PhysicianUniversity of AlbertaEdmonton, Alberta, Canada

Nisha Mistry, MDResident PhysicianDepartment of Dermatology and Skin ScienceUniversity of British ColumbiaVancouver, British Columbia

Rajeev H. Muni, BSc, MDResident PhysicianDepartment of OphthalmologyUniversity of Toronto

Resident PhysicianDepartment of OphthalmologyToronto Western H ospitalToronto, Ontario

Mohamed Firdaus Bin Mohamed Mydeen, MD

Research AssociateDepartment o f PathologyDalhousie UniversityHalifax, Nova Scotia

Julian J. Owen, BHSc, MDResident PhysicianDepartment of Emergency MedicineMcMaster UniversityHamilton, Ontario

Lamide Oyewumi, MD, PhDResident PhysicianUniversity of Ottawa

Ottawa, Ontario

Erika Dianne Penz, SM, MDPulmonary Medicine FellowDivision of Respiratory MedicineDepartment of MedicineUniversity of Ca lgaryCalgary, Alberta


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Contributors • xiii

Farah Ramji, BSc, MHSc, MDResident PhysicianDivision of Respiratory M edicineDepartment o f MedicineUniversity of British ColumbiaVancouver, British Columbia

Sapna Rawal, MD

Resident PhysicianDepartment of Diagnostic RadiologyMcGill UniversityMontreal, Quebec

Surabhi Rawal, BScMedical StudentMcGill UniversityFaculty of Medicine

Theodore Elgin Roberts, MDAssistant Professor Director, Adult N eurology Residency

Department of Internal Medicine (Neurology)University of AlbertaEdmonton, Alberta

Staff PhysicianClinical Neurosciences ProgramCapital Health, University of Alberta HospitalsEdmonton, Alberta

Naminder K. Sandhu, MDResident PhysicianDepartment of PediatricsUniversity of CalgaryAlberta Children’s Hospital

Calgary, AlbertaC. Douglas Smith, MDAssociate Professor Department o f MedicineUniversity of OttawaOttawa, Ontario

Chief, Division o f RheumatologyDepartment o f MedicineThe O ttawa Hospital—Riverside CampusOttawa, Ontario

Ning Zi Sun, MD

Resident PhysicianDepartment o f MedicineMcGill UniversityMontreal, Quebec

Sharla Kae Sutherland, PhDDirector Alberta Academic Health Network O perationsEdmonton, Alberta

Tomoko Takano, MD, PhDAssociate Professor Department o f MedicineMcGill University

Staff PhysicianDepartment of Medicine (Neurology)McGill University Health Centre

Mon treal, Quebec

Lilly Teng, MDResident PhysicianDepartment of Diagnostic ImagingUniversity of TorontoToronto, Ontario

John Teshima, MD, FRCPC, MEdAssistant Professor Department of PsychiatryUniversity of Toronto

Staff Physician

Department of PsychiatrySunnybrook Health Sciences CentreToronto, Ontario

Yi Zhen TingMedical StudentDalhousie UniversityHalifax, Nova Scotia

Michael Tso, BScHMedical StudentFaculty of MedicineUniversity of British ColumbiaVancouver, British Columbia

Brandie Laurel Walker, PhD, MDPulmonary Medicine FellowDivision of Respiratory M edicineDepartment o f MedicineCalgary, Alberta

Kaylyn Kit Man Wong, HBScMedical StudentFaculty of MedicineUniversity of TorontoToronto, Ontario

René Wong, MD, MEd, FRCPCAssistant Professor, University of TorontoDepartment of Medicine, Division of EndocrinologyUniversity of TorontoToronto, Ontario

Evelyn Wu, MScMedical StudentFaculty of MedicineUniversity of British ColumbiaVancouver, British Columbia


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xiv • Contributors

Daphne Yau, MScMedical StudentQueen’s UniversityKingston, Ontario

Eric M. Yoshida, MD, MHSc, FRCP(C), FACP, FACGProfessor o f MedicineHead, Division of Gastroenterology

University of British ColumbiaVancouver, British Columbia

Clement Zai, PhDPost-Doctora l FellowInstitute of Medical ScienceUniversity of TorontoPsychiatric Neurogenetics SectionCentre for Addiction and M ental HealthToronto, O ntario

Gwyneth Zai, MD, MScResident PhysicianDepartment of PsychiatryUniversity of TorontoPsychiatric Neurogenetics SectionCentre for Addiction and M ental HealthToronto, Ontario

Jay Zhu, MDResident PhysicianDivision of OtolaryngologyHead and N eck SurgeryUniversity of AlbertaEdmonton, Alberta


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xv

The Medical Council of Canada Qualifying Examination (MCCQE) Part I is an

important milestone for medical student s, signifying a culmination of years of train-ing in basic science and clinical medicine. The Medical Council of Canada (MCC)recommends numerous separate texts as reference for this exam preparation. Such avast reading list is neither a pra ctical nor a feasible means of approa ching this criticalexam for most candidat es. The singular intent of this text is to provide a succinct yetcomplete review for t he MCCQ E Part I using the most efficient and effective means.

This book is based entirely on the MCC’s O bjectives for the Qualifying Exami-nation, 3rd edition, which “lay out exactly what you have to know for any of theMCC examinations.” This text contains only the specific and essential informationrequired to meet the O bjectives —all ext raneous informat ion has been deliberatelyomitted.

This text avoids time-wasting prose and effusive lists. Information is presentedonly in concise and easily assimilated visual formats. A focus on tables and flowcharts allows complex and detailed concepts to be swiftly and effectively reviewedfor comprehension and retention. Text within boxes signals the reader to key competencies highlighted by the O bjectives.

This text is a collaborative project that combines the perspective and insights ofstudents preparing for the examination with the experience of residents and acumenof faculty. The result is a novel and innovative resource to aid in the process of preparing for the MCCQE Part I. As medical school curricula are becoming more t ai-lored to the exam, we believe it will also prove useful in your general studies as well.

We would appreciate your feedback on how to improve this resource and wishyou the best success in the MCCQE Part I.

Sheehan H. Chowdhury Adrian I. Cozma

Jeeshan H. Chow dhury

PREFACE


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Please read the following carefully:

This publication is provided to assist you in preparing for the Medical Council ofCanada Licensing Examination Part I. Under no circumstances should the informa-tion contained in this publication be relied upon for any other purpose.

Although the authors have made reasonable efforts to ensure the accuracy of theinformation contained herein, the authors, editors, and publisher do not guaranteeor represent that this information is accurate, complete, current, or suitable for any part icular purpose or jurisdict ion.

The authors, editors, and publisher make no warranty whatsoever, whether express or implied, with respect to th is publication and its contents, and in no eventwill the authors, editors, or publisher be liable for any loss, damage, or injury arisingfrom or connected to use of this publication, including without limitation loss of profits and direct, indirect , specia l, incidental, consequent ial, o r punit ive damages.

This exclusion o f liability will apply whether such loss, dama ge, or injury is basedin contract, tor t, or negligence (including without limitation gross negligence).

NOTE TO READERS

THIS PUBLICATION HAS NOT BEEN AUTHO RIZ ED, REVIEWED, OROTH ERWISE SUPPO RTED BY THE MEDICAL CO UNCIL O F CANA DA

N O R DO ES IT RECEIVE EN DO RSEM EN T BY THE MED ICA L CO UN -CIL AS REVIEW M ATERIAL FOR THE MCCQE.


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We thank Amy Weintraub, Tari Broderick, Carla Vitale, and Matt Hauber of

Lippincott Williams & Wilkins for their editorial support a nd guidance in takingthis pro ject from a mere scheme to a reality. We also thank Jennifer Clements for theillustra tions and figures that a re such a key aspect to this project. Mar ian Bellus andChristine Fahey are to be thanked for guidance through the production and publica-tion process; and Michael McMahon for tha t with marketing.

We would like to extend our appr eciation to Shakeel Qazi, the dedicated contr ibu-tors to this book, the medical students who incorporated their own experiences in preparing fo r the exam, residents who were a ble to look back on their experiencesand shared advice and insights they only wished were available to them, and thefaculty who not only supervised and reviewed the chapters, but also shared theirknowledge and expertise.

ACKNOWLEDGMENTS


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xviii

Contributors iv

Preface xv Note to Readers xviAcknowledgments xvii

CONTENTS

Introduction 1

What is the MCCQE Part I? 1How to Use this Text? 2Clinical Presentation: Objectives Based 2

CanMEDS 4Health Advocate 4Collaborator 6Communicator 9Leader (formerly Manager) 11Professional 13Scholar 17Legal, Ethical and Organizationa l Aspects of Medicine 19CanMEDS Summary 27

Cardiology 31

Hypertension 31Hypertensive Cr ises: Emergencies and Urgencies 35Pregnancy-Associated Hypertension 37Heart Failure 39Hypotension 42Anaphylaxis 45Chest Pain 46Cardiac Arrest 52Syncope 55Abnormal Pulse 57Dyslipidemia 60Abnormal Heart Sounds 63

Systolic and Diastolic Murmurs 64Palpitations 68

Dermatology 75

Skin Rash, Macules 75Skin Rash, Papules 78Skin Tumors / Ulcers 83Skin Rash, Vesicles / Bullae 86Pruritus 87Ha ir Disorders 90 Nail Disorders 91

1C H A P T E R

2

C H A P T E R

3

C H A P T E R

4C H A P T E R


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Dermatologic Emergencies 93Skin Changes in Systemic Disease 93

Emergency Medicine 95

Allergies, Urticaria, and Anaphylaxis 95Bites: Human, Animal, and Insect 97Burns 100Facial Injuries 105Hyperthermia 107Hypothermia 110Poisoning 112Skin Wounds and Regional Anesthesia 116Submersion Injuries 118Trauma 120

Endocrinology 124

Weight Gain / Obesity 124Gynecomastia 127Hirsutism / Virilization 129Hyperglycemia: Diabetes Mellitus (DM) 132Hypoglycemia 137Adrenocor tical Insufficiency (AI) 140Thyroid Disease 142

Gastroenterology 147

Dysphagia 147Vomiting / Nausea 149Chronic Abdominal Pain 153Blood From GI Tract 155Hematemesis 156Hematochezia 160Acute Diarrhea 163Chronic Diarrhea 165Adult Constipation 169Fecal / Stool Incontinence 172Adult Hepatomegaly 174Abnormal Liver Function Tests 177Adult Jaundice 181Allergic Reactions / Food Allergies, Intolerance, Atopy 184

General Surgery 189

Abdominal Distension 189Abdominal Mass 194Abdominal and Groin Hernias 197Acute Abdominal Pain 199Anorectal Pain 204Breast Lump / Screening 207Chest Injuries 213Abdominal Injuries 194Vascular Injuries 218Preoperat ive Medical Evaluation 220

5C H A P T E R

6C H A P T E R

7C H A P T E R

8C H A P T E R

Contents • xix


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Geriatric Medicine 223

Hypertension in the Elderly 223Elder Abuse 226Falls 228Frailty in the Elderly 232

Gynecology 237

Amenorrhea and Oligomenorrhea 237Dysmenorrhea 239Abnormal Vaginal Bleeding 243Premenstrual Syndrome / Premenstrual Dysphoric Disorder 249Contraception 252Early Pregnancy Loss / Spontaneous Abortion 258Menopause 263Vulvar Itch, Vaginal Discharge, and Sexually TransmittedDisease 267Cervical Cancer Screening 274

Pelvic Masses 279Pelvic Pain 286Pelvic Prolapse 291Female Urinary Incontinence 293Female Infertility 295

Hematology 299

Fever of Unknown Origin 299Fever in the Immune Compromised Host / Recurrent Fever 301White Blood Cell Abnormalities 303Bleeding Tendency and Bruising 305

Venous Thrombosis, Hypercoagulable Stat e 308Splenomegaly 309Anemia 312Polycythemia / Elevated Hemoglobin 316Lymphadenopathy 317

Nephrology 321

Acid–Base Disturbances 321Hypomagnesemia 324Hyperkalemia 325Hypokalemia 329

Proteinuria 331Hypernatremia 335Hyponatremia 336Acute Renal Failure 340Chronic Renal Failure 345Hematuria 349Polyuria and Polydipsia 351Hypercalcemia 353Hypocalcemia 356Hyperphosphatemia 358Hypophosphatemia 359

9C H A P T E R

10C H A P T E R

11C H A P T E R

12C H A P T E R

xx • Contents


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Neurology / Neurosurgery 364

Overview 364 Neuroanatomy 365The Neurologic Approach 366Weakness 372Stroke 376

Sensory Complaints 379Speech and Language Abnormalities 382Movement Disorders 385Gait Disturbances 388Headache 390Episodic Transient Impairment / Loss of Consciousness 392Altered / Impaired Mental Status 396Coma 398Head Trauma 399End of Life in the Neurologic Patient 401

Obstetrics 404Pregnancy—Prenatal Care 404Preterm Labor 418Pregnancy—Intrapartum Care 423Pregnancy—Postpartum Care 432

Ophthalmology 434

Diplopia 434Red Eye 440Strabismus and/or Amblyopia 445Visual Disturbances / Loss 449

Pupil Abnormalities 453

Orthopaedic Surgery 458

Bone or Joint Injury 458 Neck and Back Pa in a nd Related Symptoms 460Fractures and Dislocations 464Ha nd and Wrist Injuries 468Spinal Trauma 471Limp in Children 474

Otolaryngology 477Ear Pain 477Dizziness / Vertigo 479Epistaxis 483Tinnitus 485Hearing Loss 488Sore Throat / Rhinorrhea 490Smell and Taste Dysfunction 492Mouth Problems 494 Neck Mass 495

13C H A P T E R

14

C H A P T E R

15C H A P T E R

16C H A P T E R

17C H A P T E R

Contents • xxi


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Contents • xxiii

Cyanosis / Hypoxemia / Hypoxia 636Cough 637Blood in Sputum 639Lower Respiratory Tract Disorders 642Asthma 643Pleura l Effusion / Pleural Abnormalities 646Pneumothorax 648

Unilateral / Local Edema 649Respiratory Allergy 652

Rheumatology 656

Inflammatory Arthr itis 656Mechanical Joint Pain 663 Nonar ticu lar Musculoskeletal Pain 665Generalized Pain Syndromes And Myopath ies 668

Urology 671

Dysuria, Urinary Frequency and Urgency, and/or Pyuria 671Erectile Dysfunction 676Hematuria 677Incontinence—Adult 679Incontinence—Child 682Infertility 684Scrota l Mass 687Scrota l Pain 689Urinary Tract Injury 690Urinary Tract Obstruction 692

22C H A P T E R

23

C H A P T E R

Table of Normal Lab Values 696A

A P P E N D I X

List of Abbreviations 699B

A P P E N D I X

Objectives for the Qualifying Examination Index 721C

A P P E N D I X

Index 733


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1

WHAT IS THE MCCQE PART I?

The MCC examines medical school gradua tes and grants licensure to legally practice

medicine in Canada. Licensure in Canada is formally obtained through the LMCC,which requires successful completion of the M CCQ E Parts I and II. In general, medi-cal students in Canada complete the MCCQE Part I at the end of their undergrad-uate medical education (just before graduation from medical school) and before beginning their postgraduate medical train ing (i.e., residency tr ain ing program).

The MCCQE Part I is a two-part computer-based test. The first section, lasting3.5 h, consists of 196 MCQs and is completed the morning of the examination day(Table 1.1). The afternoon component consists of the CDM section, a 4 h sectionof approximately 60 cases, each associated with one to four short-menu or short-written answer-style questions. For both portions of the examination, a table ofnormal values is provided.

The MCQ section of the examination is divided into 7 subsections (Medicine,Surgery, Pediatrics, Obstetrics & Gynecology, Psychiatry and Population Health,Legal, Ethical and Organizational Aspects of Medicine) of 28 questions each. Each

question is in the format of a question stem followed by a list of five answer choices.Only one answer choice is correct for each question. Each question may be accom- panied by an image or table.

The CDM section of the examination consists of approximately 80 questions, andfocuses on CDM and problem-solving skills. Questions in the realm of differentialdiagnosis, diagnostic test selection, clinical data collection, and pat ient managementshould be expected. In this section, there are short-menu questions, consisting of between 10 and 40 option choices; examinees are asked to either select one answer,a certain number of answer options, or as many answer options as are appropriate.Within the CDM section, short-written response (“write-in”) questions should beexpected. Responses should be specific, use generic drug names, and worded care-fully as directed by the question.

Both sections of the MCCQ E Part I are based on the O bjectives for the Qualify-ing Examination. The latest version of the O bjectives was established in 2009 by

1C H A P T E R

IntroductionSheehan H. Chowdhury • Adrian I. Cozma • Jeeshan H. Chowdhury

Table o f Contents

What is the MCCQE Part I?

How to Use This Text?

Clinical Presentation: ObjectivesBased

TABLE 1.1 • Summary o f MCCQE se ctions

MCQ CDM

When Morning Afternoon

Time allotted 3.5 h 4 h

Style Mu ltip le ch oice Cases wit h sh ort men u or w rit te n re spo nse

Questions 196 ~60 cases, 1–4 questions each

Weight 75% 25%

Computer adaptive Yes Yes


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2 • Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I

the MCC, and outlines the expectation of competent physicians, organized aroundCanMEDS roles.

The CanMEDS framework was created by the Royal College of Physicians andSurgeons of Canada and describes attributes and skills of a competent physician.The framework outlines seven roles: communicator, professional, scholar, health ad-vocate, leader (formerly manager), collaborator, and medical expert. The O bjectivesoutline these seven roles, and specifically expand on the medical expert role; theydo so by including clinical presentations to highlight the bu lk of clinical knowledge

expected of graduates.The Clinical Presentations of the MCCQE medical expert objective define the

clinical competencies of the medical graduate specific to select common presenta-tions. Within each clinical presentation, the MCC defines the pertinent data collec-tion, diagnostics, clinical problem solving, and management strategies required ofthe competent examinee.

HOW TO USE THIS TEXT?

Essentials fo r the Canadian Medical Licensing Exam: Review and Prep fo r MCCQ E Part I is written for medical students and international medical graduates who are preparing to write the M CCQ E Part I. As a summative review for the MCCQ E Part IO bjectives, this text will also be of value to medical students through their train-ing both in preclinical and clerkship years, and meet basic needs in postgraduateeducation.

All the content presented is based on the O bjectives which “lay[s] out exactly whatyou have to know for any of the MCC examinations,” and which “the MCC testcommittee use... when they are creat ing examination questions.”

Content is also organized based on the O bjectives. The text is divided into chap-ters, which add ress the main clinical specialties. Topics within each chapter a re orga-nized around the Clinical Presentations, to expand on the medical expert role of theMCCQ E Part I O bjectives. Many of the clinical presentations have a multispecialtyscope, but for ease of reference, we have avoided wherever possible to divide topicsinto separate chapters.

Chapter 2 is an overview of all the CanMEDS roles. Although distinct from the

format of the clinical chapters, this chapter forms a summative review of all theattributes expected of graduates. In the past, the MCC outlined specific objectivesfor the “cultural-communication, legal, ethical, and organizational aspects for the pract ice of medicine—C2LEO.” These objectives have been incorporated into theexisting objectives and clinical presentations. However, throughout the text of thistextbook, you will still see “C2LEO” boxes that highlight C2LEO concepts, whichare important to know. You will also come across Applied Scientific Concept “ASC”Boxes that emphasize basic scientific concepts of clinical impor tance.

It is expected that students reading this text will already have a basic conceptualunderstanding of the material. With this in mind, abbreviations have been used in thetext without introducing expansions at first occurrence. A complete list of abbrevia-tions is provided separately in Appendix C. This text organizes and presents mater ialin a highly effective format to allow for a reliable study plan, rapid comprehension,and durable recall that is useful both for examination and during clinical practice.

CLINICAL PRESENTATION: OBJECTIVES BASED

Each clinical chapter contains distinct topics based on the Clinical Presentations, ofwhich a list can be found in the Index. Taken directly from the list of MCCQ E Clini-cal Presentations, these topics form the framework of this text. Each topic is furtherdivided into the following subtopics:

DEf INITION/ RATIONALE

Outlines the fundamental definitions, scope, and epidemiologic facts of the clinical presentat ion.


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Chapter 1 / Introduction • 3

CAUSAL CONDITIONS

Present a systems-based approach for differential diagnosis.

APPROACH/MANAg EMENT

Provides an overview of physical exam, investigations, diagnosis, and managementof the clinical presentat ion.

APPLIED SCIENTIf IC CONCEPT

Reviews basic scientific concepts pert inent to the clinical management of the clinical presentat ion.

Ef f ECTIVE VISUAL LEARNINg TOOLS

In addition to the clinical presentation and objective-based design of the topics, anumber of highly effective visual learn ing tools are used. These tools succinctly dis- play complex and deta iled concepts for swift and h ighly effect ive review.

CLINICAL DECISION-MAk INg ALg ORITHMS

More complex clinical presentations will have diagrammatic CDM trees that focusstudent attention on clinical approach.

TABLES AND CHARTS

Details and lists are presented in system-based tables that organize information forimproved retention and recall.

CLINICAL BOXES

Highlight elements ranging from key concepts, high-yield points, mnemonics, andclinical pearls.

C2LEO BOXES

Specific applications of C2LEO aspects of medicine are identified.

ASC BOXES

Emphasize fundamental basic scientific concepts of clinical importance.

RED f LAg SUnderscore emergent matters or potential clues to serious medical conditions.

CanMED BOXES

Highlight oppor tunities in clinical practice to further develop the at tributes expectedof competent physicians.


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4

HEALTH ADVOCATE

MCC ObjECTiVE

Based on the Health Advocate role of O bjectives for the Qualifying Exam ination,3rd edition.

DETEr Min An Ts Of HEALTH

• Refer to Chapter 20: Public Health

ACCEs s TO HEALTH CAr E

Individuals are morally equal and equally worthy of respect. This is not to say thatequality of outcomes must follow: not all individuals who show up in hospital shouldreceive equal quantities of morphine, for example. In medical decision making, the

fundamental equality of individuals is observed when cases that are similar in mor-ally relevant ways are t reated similarly and d issimilar cases dissimilarly.The “morally relevant ways” usually boil down to need and potential benefit.

Differential treatment on the basis of such properties as age, sex, and religion istolerated only insofar as these properties can be demonstrably linked to need and potentia l benefit. Otherwise, these propert ies are irrelevant. All other things beingequal, granting a white female differential access to reproductive health over a fe-male of aboriginal descent—perhaps by providing better counseling or by providingaccess to services such as abortion more readily—represents a devaluation of theabor iginal female’s interests on the grounds of r ace. This sort of discrimination failsto recognize the pat ient as a morally significant being worthy of equal respect.

Legally, equality rights are recognized in Section 15 of the Canadian Charter of Rights and Freedoms. Constitutional case law has conceptualized equality obliga-tions into two sorts: Nondiscrimination requires that individuals be treated alike;

substantive equality requires that positive measures be undertaken to provide equalaccess for those whose special characteristics disadvantage them on the basis of race,religion, sex, disability, and so on.

The Charter of R ights and Freedom s may apply to hospitals operating under a public mandat e, or wit h public funds. Physicians ma y also be bound by profes-sional codes of ethics and by pr ovincial huma n rights statu tes that impose similarduties.

In clinical care, this means that discrimination is unacceptable. Resources should be allocated on the basis of morally relevant criteria , using fair and publicly defen-sible procedures. Positive measures (e.g., sign language or TTD services for the deaf,access to female physicians for female patients whose cultural beliefs prohibit carefrom a male physician, etc.) should be taken to ensure that the interests of all pa-tients are equally served.

Ta le o Co te t

Health Advocate

Collaborator

Communicator

Lead er (formerly Manager)

Professional

Scholar

Lega l, Ethical and OrganizationalAspects of Med icine

CanMEDS Summary

Gurde ep Parh ar • David Leu ng • Bez Too si

2CanMEDS

C H A P T E R


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Chapter 2 / CanMEDS • 5

THE CAn ADiAn HEALTH s y s TEM

In the Canadian constitutional framework (1867), the provinces have primary re-sponsibilities for health care, executed through a range of statutes that vary from province to province. The federal government nevertheless performs an importantand varied role in health care that goes beyond merely funding provincial efforts.Particularly important is the federal spending power. The national Canada HealthAct framework leverages the use of conditional federal-provincial transfer paymentsto achieve specific aims among and within the provinces.

THE CAn ADA HEALTH ACT

The CHA was passed in 1984. The CHA establishes criteria and conditions thatmust be met before provinces qualify for a full federal cash contribution for healthcare. Provinces must establish a publicly administered health care insurance programthat provides universal, comprehensive, porta ble, and a ccessible coverage.

Despite the lack of federal jurisdiction in health care, the CH A framework has fos-tered the estab lishment o f provincial health care plans along nationa l principles. The public health care system estab lished by the CHA has been charact erized as “nar row, but deep” : Within the narrow range of services that fall under the not ion of “ comprehensiveness” (i.e., medically necessary physician , hospital, and surgical-dentalservices), Canadians are very well provided for. The CHA framework representsan understanding that health care is a social good best provided for through public

support and that all citizens deserve adequate care regardless of their circumstances(Table 2.1).

TAbLE 2.1 • Conditions o f the CHA

Condition Each Provincial Health Care Insurance Plan Must

Accessibility Not impede or preclude reasonable access to insuredhea lth services a

Comprehensiveness Cover all med ically necessary hosp ital, physician, andsurgical-dental (i.e., those that require a hospital setting) services

Portability Cover new residents to the province within a waiting period ofnot more than 3 mo ; cover resident s leaving t he province during

a waiting period for new coverage; pay for insured services forresidents temporarily out of province or out of country b

Public administration Be operated on a nonprofit basis by a public aut horitydesignated by the province

Universality Insure all insurees at uniform terms and conditions

Quebec’s health insurance plan does not me et po rtability requirements. The federal government has no t pursued this breech .

a This condition is an addition to principles outlined in previous health care legislation. It targets such practices as usercharges, which impede access for th ose with lower incomes.

b The rates of pay for out-of-province services are defined according to rates for similar services in the province of deliv-ery. Those for out-of-country services are defined according to rates in the home province.

The CHA has been criticized for defining services that fall under its scope by provider and sett ing (i.e., physician and hospital services). Health care has changedmuch since the 1990s. Take-home d rugs, home care, long-term care, and the servicesof allied health professionals have become common and increasingly important to patien t-centeredness. For example, home care not only reduces the cost of unneces-sary hospitalization but also maintains patient autonomy by allowing the patient toremain independent in the setting of his or her choice for as long as possible. Andtake-home drugs impose a rapidly escalating cost on patients. Yet, the CHA confersno obligation that provincial insurance plans should provide for these services. Forthe most part, provinces have voluntarily taken it upon themselves to establish pub-lic financing for prescription drugs, long-term care, home care, and certain otherservices.


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Pr iVATE HEALTH CAr E

The CHA does not outlaw private funding for health care. However, six provinceshave statutes that outlaw private health insurance for medically necessary servicescovered by the public insurance scheme. The other provinces discourage privatehealth care insurance by preventing clinicians from operating in both private and public sectors.

Private sources of funding coexist with public funding for home care, long-termcare, and prescription drugs. Additionally, private sources provide most coverage fordental services, vision care, and complementary and alternative medicines. Publicinsurance funding for these services is minor.

COLLAb Or ATOr

MCC ObjECTiVE

Based on the Collaborator role of O bjectives for the Qualifying Examination, 3rd

edition.

COLLAbOr ATiOn WiTHin THE HEALTH s y s TEM

The provinces and territories regulate health professionals, hospitals, and other as-

pects of health ca re provision. Provinces and ter ritor ies administer hospita l and med-ical services through a universal single-payer system, remunerate physicians through billing schedules negotia ted with the provincial medical associat ion, and run spe-cialized public health services. Provinces, to varying degrees, also provide or funda variety of home care and long-term care services. All provinces also administer provincial drug p lans.

In the last two decades, health care reform efforts have led provinces to adopt geo-graphic health regions that bear responsibility for hospitals, long-term care, homecare, and public health. These regions receive global budgets and distribute healthresources in light of local circumstances.

• The federal department of health, Health Canada, is responsible for administeringthe CHA and for regulating drugs, medical devices, natural health products, and biologics.

• The FNIHB of Health Canada is responsible for the health needs of Canada’sabor iginal peoples.• The PMPRB is a quasi-judicial watchdog that reviews and regulates wholesale

drug prices for patented drugs.• The PHAC is a federal agency that performs a wide range of public health func-

tions, and has responsibility for national disease centers and laboratories.• Statistics Canada helps meet Canada’s health information needs.• The CIHR is Canada’s national health research funding agency.• At the intergovernmental level, the Conference of Federal/Provincial/Territorial

Ministers of Health is the premier policy-making instrument. A range of organiza-tions can be considered intergovernmental with various arrangements for fundingand governance. Examples include the Canadian Institute for Health Information,Canadian Blood Services, and the Health Council of Canada.

COn s u LTATiOn sThis can be made into a d iagram that outlines the process of the consultation andthe important steps:

• Recognize needed expertise and t riage based on u rgency• Identify correct consultant/service• Communicate (verbal/written)• Ensure appointment ma de• Receive verbal/written repor t• Carry out recommendations

Professional communication between physicians should:

1. Serve the best interests of the pat ients2. Be respectful, collegial, collaborative, and courteous


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Respo nsibilities of the Refe rring Physician and the Consultant (Table 2.2)

TAbLE 2.2 • Responsibilities of the referring physician and the consultant

Referring Physician The Consultant

• Provide a reason for consultation

• Provide contact/demograph ic information(patient and referring physician)

• When possible, state the expectation ofthe consult

• Provide a summary of history, physicalfindings, medications, allergies, and other physicians involved in ca re

• Provide copies/summaries of relevantinvestigations, imaging, other consultantreports, and pending tests

• Communicate whether other physicianshave been consulted for the same prob lem

To avoid delays

• Provide response acknowledging referraland anticipated wa it time

• Schedule the appo intment directly with pa tient

• Advise patient of requirements prior toappointment

• Advise patient to contact the consultantor referring physician if there is anychange in h is or her condition

After seeing the patient, the consultantshould provide a timely written reportincluding:

• Relevant history and findings

• Diagnosis/conclusions

• Diagnostic and therapeu tic interventionsimplemented and/or recommended

• Intended review or follow-up by theconsultant

Important t ips to keep in mind:

• The physician ordering any diagnostic or therapeutic intervention bears the re-sponsibility for pa tient follow-up.

• The referring physician should inform the consultant if the estimated wait timeis inappropriately long for the patient’s condition, or if the patient’s conditionhas changed during the wait period. Consideration should be given for referral

to another consultant if the original referred to consultant cannot accommodate.• Duty of care arises whenever a physician agrees to treat a patient. It is possible

that in courts, an interpretation may be made where this responsibility beginswhen the consultant accepts a referral. Consultants will want to have a system in place to t riage consultat ions ba sed on u rgency.

• Post consultation responsibilities should be agreed upon by the consultant andreferring physician and communicated to the patient within reason.

• All physicians have an obligation to be accessible (personally or through a del-egate). They should provide contact information for themselves or delegates.

• Medical office staff members are an extension of the medical practice of physi-cians, and the physicians are ultimately responsible for patient care.

Role Scope of Pract ice

Physician • The practice of medicine is the assessment of the physical or mentalcondition of an individual and the diagnosis, treatmen t, and preventionof any disease, disorder, or dysfunction (Medicine Act, 1991)

Nurse • The practice o f nu rsing is the promot ion o f health and t he assessmentof, the provision of care for, and th e treat ment of hea lth conditions bysupportive, preventive, therapeutic, palliative, and rehabilitative means inorder to attain or maintain optimal function (Nursing Act, 1991)

TAbLE 2.3 • Health care teams

(Continued)

HEALTH CAr E TEAMs (Table 2.3)


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Role Scope of Pract ice

• There are different scopes of practice for nurse pract itione rs, RN,registered practical nurses, etc. For example:

• Nurse p ractitioners—a RN with additional education to prep are foradvanced nursing practice in a specific area

• Registered nurses—able to auton omously meet the nursing careneeds of patients whose n eeds are no t we ll defined/established

• Registered practical nurses—can independently care for patientswhose care needs a re well defined and the health condition is wellcontrolled

Pharmacist • The practice of pharmacy is the custody, compounding and dispensingof drugs, the provision of nonprescription drugs, health care aidsand devices, and the provision o f information related to drug use(Pharmacy Act, 1991)

• Pharmacists are medication experts

Dietitian • The practice of dietetics is the assessment of nutrition and nutritionalconditions and the t reatmen t and prevention of nut rition-relateddisorders by nutritional means (Dietetics Act, 1991)

• Dietitians can contribute to health promotion and illness preventionstrategies, and develop specialized nutrition therapy and rehabilitation/support strategies to address specific nutrition-related illnesses (Dietitiansof Canada, 2001)

Midwife • Provide primary care to women with low-risk pregnancies—from thetime of conception until 6 wk postpartum

• Midwives are responsible for supervising the birth process bot h in homeand hospital settings and provide ongoing clinical care for womenthroughout p regnancy

Chiropodist/ podiatrist

• Provides care through the assessment of the foot and the treatmentand prevention of diseases, disorders, or dysfunctions of the foot bytherapeutic, orthotic, or palliative means (Chiropody Act, 1991)

• They are foot experts and treat patients in numerous ways, includingthrough the use of braces, casts, orthotic devices, physical therapy, orsurgery

Social work • The practice of social work is the assessment, diagnosis, treatment, andevaluation of individual, interpersonal, and societal problems throughthe use of social work knowledge, skills, interventions, and strategies toassist individuals, families, groups, communities, and organizations toachieve optimum psychosocial and social functioning (Ontario College ofSocial Workers and Social Service Workers, Code of Ethics and Standardsof Practice, 2000)

TAbLE 2.3 • Continued

COn f LiCT MAn Ag EMEn T

Difficult physician–patient encounters are often due to a combination of physician, patien t, and situat ional factors.

These encounters can be improved by the following strategies:

• Set prenegotiated time limits to meetings• Examine your own frame of reference• Use empathetic listening skills• Have a nonjudgmental, caring attitude• Evaluate the patient for medical and mental disorders• Identify previous abuse• Set boundaries• Use patient-centered communication


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Ch pt er 2 / CanMEDS • 9

COMMu n iCATOr

MCC ObjECTiVE

Based on the Communicator role of O bjectives for the Qualifying Examination, 3 rd edition.

COMMu n iCATin g WiTH PATiEn Ts An D f AMiLy

A Patient-Cente red Prot oco l for Breaking Bad New s

Patients should be provided with opportunities to know their health information.Admittedly, health information may be difficult to handle, and should be disclosedsensitively. Permission to disclose information should be sought first. The SPIKES protocol published by Baile et al. is usefu l.

Physician factors—whenever there is uncertainty surrounding the ability to improve a patient’s condition, the physician’s self-image as a competent health care professional may be undermined and he or she may actdefensively

• Attitudes—insecurity, burnout, time pressures, uncertainty

• Conditions—contextual stressors, health issues, lack of sleep, exhaustion, mental health concerns

• Knowledge—lack of medical knowledge, limited knowledge of patient’s medical condition

Skills—lack of communication skills, easily frustrated

Patient factors—the common characteristic trait in challenging patients is the ability to elicit a negative emo-tional response from the physician (e.g., frustration, anger)

• Behavioral issues

• Conditions—substance abuse, chronic pain syndromes, low literacy, multiple (more than four) medicalissues per visit, functional somatic disorders, previous abuse

• Psychiatric diagnosis—personality disorders, anxiety disorders, mood disorders

The Ca l MER a ppro ch

• Catalyst for change

• Evaluate stage of change

• Physicians should remind self of what they can and cannot control about the situation

• Physicians cannot control the patient’s behavior, but they can control their own responses• Alter thoughts to change feelings

• Physicians should identify which feelings they are experiencing in response to patients and then evalu-ate how those feelings are affecting the therapeutic physician–patient relationship

• Ask yourself—“what can I tell myself about this situation that will make me feel less upset?”• Listen and then make a diagnosis

• Try to truly listen/see what the patient is trying to communicate through verbal and nonverbal cues• Make an agreement

• Focus on making an agreement to continue the physician–patient relationship

• Confirm explicitly that the patient understands and agrees upon the proposal

• Education and follow-up

• Physicians should let go of their own agenda (even if they feel that it is more appropriate) and give a“doable” recommendation tailored to the “Stages of Change” model

• Reach out and discuss feelings

• Reflect upon the experience

• Identify ways of self-care to deal with next difficult encounter

• Discuss feelings and experiences with friends and colleagues

CLINICAL b o x

SPIKES Proto col forBreaking Bad New s

S—Setting up the interview

P—Assessing patient’s Perceptions

I—Obtaining the patient’s Invitation(i.e., to disclose information)

K—Giving Knowledge andinformation to the patient

E—Addressing the patient’sEmotions

S—Strategy and Summary


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The medical record is subject to physician control and responsibility. Medical staffmembers have professional duties to document clinical activities, observations, andinteractions on a medical record; to maintain the integrity of the record, and keepit up-to-date; to ensure for its secure storage; and to facilitate continuity of care by transmitting copies of the reco rd as appropriate. The physician-clinic maintainsownership over, control of, and responsibility for the medical record.

Patients should be allowed access and control over their health information. Forexample, a patient’s request that a copy of his or her medical record be transferred

to a new clinic must be respected. A patient should also be able to review his or hermedical record on request. It is reasonable to recover costs incurred by providingaccess to the medical record, perhaps with a small access fee.

Co m m u n iCa t io n w it h t h i r d Pa r t ie s

n l i c d

Infectious disease reporting to public health officials often constitutes mandatory dis-closures of health information. Practitioners should be familiar with local regulations.Additionally, it is usually desirable to notify the patient about the required disclosure.This practice may gain the support of the patient. At the least, it helps maintain the bond of t rust and t ransparency under lying the patient–physician relationship.

In the absence of legislation requiring otherwise, medical staff members need notrepor t gunshot wounds, stabbings, admitted u se of illegal drugs, or injur ies suffered

during the commission of a crime. Such information may be obtained by a policeofficer with a valid court order. Notifiab le diseases often include the following:

• Sexually transmitted infections such as H IV/AIDS, gonococcal infections, C. tra-chomatis infections, mucopurulent cervicitis, LGV, syphilis, and chancroid

• Hepatitis• Tuberculosis• Enteric pathogens• Foodbor ne illnesses• Smallpox• Anthrax• Viral hemorrhagic fevers, etc.

Le a d e r (f o r m e r Ly m a n a g e r )

mCC o bjeCt ive

Based on the Leader (formerly Manager) role of O bjectives for the Q ualifying Ex-amination, 3rd edition.

In 2015, it has been proposed to change the role of “Manager” to “Leader.” Thischange was proposed to better reflect physician’s scope of practice in this domain. Goingforward, the key competencies reflect renewed emphasis on patient safety and quality-improvement processes; broader inclusion of health informatics; and a greater emphasison the development of skills to achieve a balance between practice and personal life.

K C p c 2015

Physicians are able to:1. Contribute to the improvement of health care delivery in health care teams, or-

ganizations, and systems.2. Engage in the stewardship of health care resources.3. Demonstrate leadership in professional practice.4. Manage their practice and career.

e n g a g e i n t h e s t e w a r d s h iP o f h e a Lt h Ca r e r e s o u r Ce s

r c a ll c Cl c l d c m k

• The physician owes a primary duty to the patient.• Clinical care (i.e., microlevel decision making) must not be compromised by cost

constraints.


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• Resources should be allocated fairly on the basis of morally relevant criteria, thatis, need and po tential benefit, using fair and publicly defensible procedures.

• The impact of mesolevel and macrolevel rat ioning decisions should be discussedwith the patient in a supportive way.

• Resources should be deployed prudent ly.

Resource allocation decisions concern questions of justice: How are resources fairlydistributed among health needs? On what basis is it acceptable to make these de-cisions? The basis, whether intentional or unintentional, for differential access tohealth care goods and services among patients should meet ethical and legal stan-dards for fairness (Table 2.4).

Macrolevel Mesolevel Microlevel

Body Federal and provincial Health region/institution

Physician

Types ofdecisions made

Global budget Services and accessconditions

Clinical decisionmaking

Considerations Makes decisionsincorporating

considerations ofcosts and competinginterests

Makes decisionsincorporating

considerations ofcosts and competinginterests

Advocates for the pa tient—clinical

decisions should bedriven entirely by patient need and potent ial benefit

Resources Determines resourceframeworks andconstraints

Determines resourceframeworks andconstraints

Works within resourceframeworks andconstraints

Examples Health insurance policy, federal transfer payments

Decision to add ICU beds, ICU admissions policy

Prescriptiondecisions, aggressivevs. conservativeapproaches

TAbLE 2.4 • Levels o f he alth care reso urce allocation

Prudent Use of Clinical Resources and the Obligationto Seek th e Patient’s Best Inte rest s

In the late 1980s and 1990s, governments, perceiving budget deficits and risinghealth care costs, embarked on a series of health care reform initiatives. As a sideeffect, physicians have felt pressure to contain costs, for example, by minimizing theuse of expensive modalities. In the negligence case, Law Estate v. Simice et al., physi-cians accused of negligence in failing to provide a pat ient with a medically necessaryCT scan mentioned cost constraints. In response, British Columbia Supreme CourtJustice Spencer writes:

If it comes to a choice between a physician’s responsibility to his or her indi-vidual patient and his or her responsibility to the Medicare system overall, theformer must take precedence in a case such as this. The severity of the harm thatmay occur to the patient who is permitted to go undiagnosed is far greater than

the financial harm that will occur to the Medicare system if one more CT scan procedure only shows the patien t is not suffer ing from a serious medical condi-tion. ( Law Estate v. Simice)

Cost constraints should not interfere with clinical care. First, physicians, owing aduty of care to t heir pa tients, must meet the standard of care that can be expectedfrom a reasonable practitioner of similar training and experience. Cost constraintsare no defense against negligence. Second, physicians a re fiduciaries in a trust rela-tionship with their relatively vulnerable patients. They are duty-bound to look afterthe interests of their pat ients with the utmost loyalty. Because the cost of physicians’services in Canada is borne by the Medicare system, allowing cost considerationsinto clinical reasoning amounts to the entry of a third-party interest. Physicians areduty-bound to resist this intrusion and to maintain the independence of their clini-cal judgment. Where cost constr aints do affect clinical decisions, perhaps because of


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ACCOu n TAbiLiTy TO s OCiETy

The law recognizes the patient as a person with human and other legal rights,including the right to security of person and inviolability, and the right to free-dom from discrimination. These rights are formulated at a constitutional level, inthe Canada Charter of Rights and Freedoms. In addition, both common and civillaw recognize a fundamental right to self-determination. Rights are trumps thatcan normally be expected to take precedence over other considerations. However,rights may be legitimately limited for certain social interests. Specific instances un-der which individual rights must give way are recognized in various statutory andnonstatutory laws.

The law also recognizes the physician as a person to wh om duties apply. Indeed,the patient–physician relationship has been described as a fiduciary relationship,imposing on physicians one of the highest standards of conduct recognized a t law.In a fiduciary relationship, the physician is an a gent acting on behalf of a vulner-able par ty, and is obliged to act solely in that part y’s interests at a ll times. Current physicians, as the stewar ds of trust insp ired b y generat ions of previous pro fession-als, are obliged to honor and nurture this relationship for future generations of physicians.

Physicians must follow through on undertakings made to patients, must not ex- ploit the rela tionship for personal advantage, and must maintain and respect pro-fessional boundaries at all times. Physicians are obliged to provide for continuous

and accessible care, and never to abandon their patients. These basic duties arisefrom ethical and legal understandings of the patient–physician relationship, and areterminated only when care has been transferred, or after adequate notice has beengiven to allow the patient to make alternative arrangements. The patient–physicianrelationship, as the central fixture of medical practice, permeates medicine’s legal,ethical, and organizational aspects.

Duty to Warn

There are occasions when a physician’s duty to society may outweigh the obliga-tion of physician–patient confidentiality, thereby justifying the voluntary disclo-sure of information about a patient to the appropriate authority. The SupremeCourt of Canada has acknowledged a pub lic safety exception to physician–patientconfidentiality.

The following three factors should be considered (the importance of each will vary

depending on the specifics of each individual case):• There is a clear risk to an identifiable person or group of persons• The risk is one of serious bodily harm or death• The danger is imminent

Key issues to keep in mind:

• Would a reasonable person consider the potential danger to be clear, serious, andimminent?

• The information disclosed should be limited to only what is necessary• Ask for advice and counsel

ACCOu n TAbiLiTy TO THE Pr Of Es s iOn

Professionalism refers to the practice of medicine according to a common set ofnorms and standards, characterized by ethical conduct, clinical independence,and self-regulation. Physicians are charged by statute, and obliged by socialcontract, to set and uphold these common standards of conduct. Additionally,standards of professional conduct translate principles of patient autonomy, be-neficence, nonmaleficence, justice, and patient-centered care into clinical prac-tice. Adhering to professional norms ensures sound care, helps guarantee fidelityto the core principles of medicine, and maintains the public’s trust in the profes-sion (Figure 2.1).


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Certification and Licensing

The two barriers to entry into the health care market are certification and licensure.In a certification regime, certain agencies are granted exclusive powers to certify

individuals as having met particular performance or educational standards. The na-tional character of these organizations means that the medical degree and certifica-tion are portable from province to province.

Cana da’s physician certification bodies include the following:

• CFPC—Family Practice• RCPSC—Specialty Practice• MCC—Independent Medical Practice

Under a licensing regime, unlicensed individuals are legally prohibited from provid-ing certain services. Provincial physician-run colleges or boards govern licensing.Licensure is nontransferable from province to province, and must be sought andawarded by the college or board responsible for medical licensing in each provinceof practice. Additionally, provincial colleges typically require certification from theMCC, as well as certification from one of the CFPC or RCPSC. In practice, then,

uncertified physicians are excluded from medical practice, although certifying bodies bear no responsibility for licensing.

Self-regulation

Physician certification and licensing bodies are self-regulating. However, the interestsof the profession may occasionally clash with the interests of the public. To pre-vent conflicts of interest, distinct medical associations—the CMA and its provincialchapters—carry out professional

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