topics

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TORONTO NOTES

Common Acronyms and Abbreviations Used in Medicine

Common Unit Conversions

Commonly Measured Laboratory Values

Ethical, Legal, and Organizational Medicine

Anesthesia

ELOM

Cardiology and Cardiac Surgery.

Clinical Pharmacology

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General and Thoracic Surgery . .

Geriatric Medicine

Gynaecology

Hematology

Infectious Diseases

Medical Genetics MG

Medical Imaging

Nephrology

Neurology

Neurosurgery...

Obstetrics

Ophthalmology OP

Orthopaedic Surgery OR

Otolaryngology OT

Paediatrics P

Palliative Medicine PM

Plastic Surgery

Psychiatry

Public Health and Preventive Medicine

Respirology

Rheumatology ..

Urology

Vascular Surgery

TORONTO NOTES

IJ \.1

-_Qna

COMPREHENSIVE MEDICAL REFERENCE

AND A REVIEW FOR MCCQE +

Editors-in-Chief •Anders Erickson & Jennifer Parker

Associate Editors, Primary •Dorrin Zarrin Khat & Ming Li

Associate Editors, Medicine •Karolina Gaebe & Alyssa Li

Associate Editors, Surgery •Vrati Mehra & Chunyi Christie Tan

TORONTO NOTES

2023

Comprehensive Medical Reference

and a Review for the Medical Council of Canada Qualifying Exam

(MCCQE)

39th Edition

Editors-in-Chief:

Anders W. Erickson & Jennifer Parker

Toronto Notes for Medical Students, Inc.

Toronto, Ontario, Canada +

AL GRAWANY

2 Editorial Toronto Xotcs 2023

Thirty-ninth Edition

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AL GRAWANY

4 Editorial Toronto Notes 2023

Preface - From the Editors

and the Climate Crisis are also fully addressed. In addition to

content updates, theToronto Notes 2023Clinical Handbook has

been restructured to prioritize high-yield content to guide your

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Dear reader.

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The 2023 edition features substantial content revisions to

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Sincerely,

L J

Anders W. Erickson, MD/PhD student

Jennifer Parker, MD/PhD student

Editors-in-Chief, Toronto Sotes 2023

5 Editorial Toronto Notes 2023

Acknowledgements

We would like to acknowledge the exceptional work of all previous Toronto Notes (formerly MCCQE Notes)

Editors-in-Chief and their editorial teams, lhe 39th edition of this text was made possible with their contributions.

2022 (38th ed.): Yuliya Lytvyn and Maleeha A. Qazi

2021 (37th ed.): Megan Urupals and Matthacus Ware

2020 (36th ed.):Sara Mirali and Ayesh Seneviratne

2019 (35th ed.):Taraneh (Tara) Tofighi and Mark Shafarenko

2018 (34th ed.): Tina Binesh Marvasti and Sydney McQueen

2017 (33rd ed.):Jieun Kim and Ilya Mukovozov

2016 (32nd ed.):Zamir Merali and Justin D. Woodfine

2015 (31th ed.):Justin Hall and Azra Premji

2014 (30th ed.):Miliana Vojvodic and Ann Young

2013 (29th ed.):Curtis Woodford and Christopher Yao

2012 (28th ed.):Jesse M. Klostranec and David L. Kolin

2011 (27th ed.):Yingming Amy Chen and Christopher Tran

2010 (26th ed.):Simon Baxter and Gordon McSheffrey

2009 (25th ed.):Sagar Dugani and Danica Lam

2008 (24th ed.):Rebecca Colrnan and Ron Somogyi

2007 (23rd ed.):Marilyn Heng and Joseph Ari Greenwald

2006 (22nd ed.):Carolyn Jane Shiau and Andrew Jonathan Ibren

2005 (21st ed.):Blair John Normand Leonard and Jonathan Chi-Wai Yeung

2004 (20th ed.): Andrea Molckovsky and KashifS. Pirzada

2003 (19th ed.): Prateek Lala and Andrea Waddell

2002 (18th ed.): Neety Paint and Sunny Wong

2001 (17th ed.):Jason Yue and Gagan Ahuja

2000 (16th ed.):Marcus Law and Brian Kotcnberg

1999 (15th ed.):Sofia Ahmed and Matthew Cheung

1998 (14th ed.):Marilyn Abraham and M Appleby

1997 (13th ed.):William Harris and Paul Kurdyak

1996 (12th ed.):Michael B.Chang and Laura J. Macnow

1995 (11th ed.):Ann L. Mai and Brian J. Murray

1994 (10th ed.):Kenneth Pace and Peter Ferguson

1993 (9th ed.):Joan Cheng and Russell Goldman

L J

1992 (8th ed.):Gideon Cohen-Nehemia and Shanthi Vasudevan

All former Chief Editors from 1991 (7th ed.) to 1985 (1st ed.)

AL GRAWANY

6 Editorial Toronto Notes 2023

Student Contributors

Editors-in-Chief

Anders Erickson

Jennifer Parker

Clinical Handbook Editors

Justin Lu

Rayoun Ramendra

Mercy Danquah

Marta Karpinski

BMC Production Editors

Jennifer Xin Ran Shao

Aimy Meng Yu Wang

Online Content Managers

Jeffrey Lam Shin Cheung

Sandra Lee

Amanda Mac

Muhammad Shahid

BMC ILLUSTRATORS

Viktoriva Khymych Viola Yu Amy Ke Er Zhang

PRIMARY

EBM Editor

Yijithan Sugumar

Associate Editors

Ming Li

Dorrin Zarrin Khat

CHAPTER EDITORS

Ethical, Legal, and

Organizational Medicine

Kenya Costa-Dookhan

Zuhal Mohmand

Dermatology

Natalie Kozlowski

Yuliya Lytvyn

Sara Mirali

Family Medicine

Neda Pirouzmand

Bree Sharma

Maryam Thrava

Paediatrics

Onyinyechukwu Esenwa

Anna Jiang

Raima Rasouli

Mary Xie

Tinting Yang

Psychiatry

Tania Da Silva

Rawaan Elsawi

Rachel Goud

Anestlicsia

Evan Tang

Kathak Vachhani

Emergency Medicine

V'inyas1Iarish

Danny Ma

Kwasi Nkansah

Tsz Ying So

Medical Genetics

Andrew Mazzanti

Public Health and

Preventive Medicine

Jenny Cho

Muhammad Maaz

Palliative Medicine

Manu Sharma

Christine Wu

Medical Imaging

Grace Grafham

Jeffrey Lam Shin Cheung

Clinical Pharmacology

Max Solish

COPY EDITORS

Ethical, Legal, and

Organizational Medicine

Noroh Dakim

Alex German

Dermatology'

Chidalu Edechi

Jaycie Dalson

Family Medicine

Jaskaran Gill

Shiyu Sunny Zheng

Psychiatry'

David Kim

Paediatrics

Tania Da Silva

Priscilla Kim

Ajantha Xadarajah

Yasmeen Razvi

Public Health and

Preventive Medicine

Caitlin Monaghan

HunsterYang

Emergency Medicine

Graham Colby

Sanch Gupta

Lara Murphy

Daniel Shane

Medical Genetics

Anesthesia Ryan Karimi

Max Solish

Janet Tang

Palliative Medicine

Medical Imaging Samuel Wier

Victoria Anthes

Hayley McKee

r T

c. J

Clinical Pharmacology

Fatimah Roble

7 Editorial Toronto Notes 2023

Student Contributors

MEDICINE

Associate Editors

Karolina Gaebe

Alyssa Li

EBM Editors

Wei Fang Dai

Camilla Giovino

CHAPTER EDITORS

Cardiology and Cardiac

Surgery

I lardil Bhatt

Akachukwu Nwakoby

Jeremy Roslt

Emily Tam

Gastroenterology

Sahibjot Grewal

Anna Lee

Andrew Rogalsky

Hematology

Reid Gallant

Syed Sluhan I laider

Nathan Kuelmc

Nephrology

David Buchan

IJuaqi Li

Respirology

Brian Bursic

Emma Price

Rajiv Tanwani

Neurology

Thomas Milazzo

Maleeha Qazi

Geriatric Medicine

Imnan Khcrani

Saba Manzoor

Infectious Diseases

Christopher Knox

Erika Nakajima

Rachel Tran

Rheumatology

Rachel Goldlarh

Endocrinology Eden Meisels

Maria Samy

Claire Sethuram

COPY EDITORS

Cardiology and Cardiac

Surgery

Shamara Nadarajah

Julianah Oguntala

Calurn Slapnicar

Vivian Tam

Endocrinology

Winston Li

Kathryn Wiens

Hematology

Pedro Boasquevisque

Daniel Lindsay

Brandon Tse

Nephrology

Anders Erickson

Jennifer Parker

Respirology

Andrew Rogalsky

Raza Syed

Gastroenterology

Oliver Chow

Parker McNabb

Neurology

Lauren Kanee

Kristiana Xhima

Rheumatology

Serena Dienes

Tsz Ying So

Infectious Diseases

NicholasChiang

TediIloxha

Geriatric Medicine

Pooja Sankar

SURGERY

Associate Editors

Vrati Mehra

Chunyi Christie Tan

EBM Editor

Arjan Dhoot

CHAPTER EDITORS

General and Thoracic

Surgery

Ryan Daniel

Jacqueline Lim

Smruthi Ramesh

Neurosurgery

Dan Budiansky

Jack Su

Raza Syed

Ophthalmology

Michael Balas

Josh I Ierman

Michelle Lim

Otolaryngology

Alyssa Li

Jessica Trac

Sheila Yu

Urology

Adree Khondker

Shamir Malik

Vascular Surgery

George Elzawy

Raumil Patel

Obstetrics

I Iarsukh Benipal

Emma Sparks

Jane Zhu

Orthopaedic Surgery

John-Petcr Bonello

Kalter 1 Iali

Robert Koucheki

Marc Manzo

Plastic Surgery

Shaishav Datta

Tiffany Ni

Gynaecology

Eliot Winkler

Sarah Zachariah

Rehona Zamani

COPY EDITORS

General and Hioracic

Surgery

Tasnim Abdalla

Audrey Jong

Lisa Vi

Neurosurgery

Bhadra Pandya

Jacob Peller

Ophthalmology

Kevin Chen

Matthew Veitch

Otolaryngology

Ryan Daniel

Siddhartha Sood

Urology

Kellie Kim

Gabriela Leon

r T

L J

Obstetrics

Julia Avolio

I layley Good

Erin Pucrsten

Orthopaedic Surgery

1lannah Drkulec

Anders Erickson

Plastic Surgery

Thomas Milazzo

Jenn Parker

Vascular Surgery

Serena I lope

Gynaecology +

Laura Diamond

Katherine Kim

I Iolsa Zia

AL GRAWANY

S Editorial Toronto Notes 2023

Faculty Contributors, University of Toronto

All of the following contributors have been appointed at the University of Toronto.

PRIMARY

ETHICAL, LEGAL. AND

ORGANIZATIONAL MEDICINE

Andria Bianchi, PhD

Bioethicist, University Health Network

Assistant Professor, Delia Lana School of Public

Health, University of Toronto

Affiliate Scientist, KITE Research Institute,

Toronto Rehab

Education Investigator 2,TIER (The Institute for

Education Research)

Nadia Incardona,MD,MHSc.BSc,CCFP (EM)

Assistant Professor

Department of Family and Community Medicine

Michael Garron Hospital

Chase Everett McMurren, BA, BEd, MD,CCFP

Department of Family and Community Medicine

University of Toronto

ANESTHESIA

Ahtsham Niazi, MBBS,FCARCSI, FRCPC

Department of Anesthesia and

Pain Management,University Health Network

CLINICAL PHARMACOLOGY

Dasid Juurlink, BPhm, MD, PhD, FRCPC

Division of Clinical Pharmacology and

Toxicology, Departments of Medicine and

Paediatrics,Sunnybrook Health SciencesCentre

Cindy Woodland, PhD

Associate Professor,Teaching Stream

Director,Collaborative Speci.tli7.uion in

Biomedical Toxicology

Director, Applied Clinical Pharmacology Program

DERMATOLOGY

Patrick Fleming, Sc ( Nutrition!.MSc (Community

Health),MD, FRCPC,FCDA

Assistant Professor of Medicine,

Department of Medicine,University of Toronto

Dermatologist, York Dermatology & Research Centre

Consultant Dermatologist,

University Health Network

Marissa Joseph, MD,MScCH. FRCPC, FRCPC

Division of Dermatology, Department of Medicine

Women'

s College Hospital and The Hospital for Sick

Children

Kaif Pardhan, BSc MD MMEd FRCPC

Emergency Physician

Sunnybrook Health SciencesCentre & McMaster

Children’

s Hospital

FAMILY MEDICINE

Ruby Alvi, MD,CCFP,MHSc FCFP

Department of Family and Community Medicine

University of Toronto

Chung Kit (Jacks) Lai. MD,CCFP

Department of Family and Community Medicine

Royal Victoria Regional Health Centre

University'of Toronto

Chase Everett McMurren, BA, BEd,MD, CCFP

Department of Family and Community Medicine

University of Toronto

Rachel Walsh, MD, MSc,CCFP

Department of Family and Community Medicine

Sunnybrook Health SciencesCentre

University'of Toronto

MEDICAL GENETICS

Vanda McNiven,MD,MSc,FRCPC

Division of Clinical Genetics and Metabolics &

Division of Hematology and Oncology

Departments of Paediatrics and Medicine

The Hospital for Sick Children,The University Health

Network, and Mount Sinai Hospital

Graeme AM Nimmo,MBBS,MSc, FRCPC,FCCMG

The Fred A Litwin Family Centre in Genetic

Medicine,Department of Medicine

Mount Sinai Hospital and University Health Network

MEDICAL IMAGING

Andrew Brown, MD, MBA,FRCPC

Assistant Professor

Vascular and Interventional Radiology

Department of Medical Imaging

Unity Health Toronto - SL Michaels Hospital

Beniamin Fine, SM.MD, FRCPC

Clinician Scientist, Medical Imaging

Trillium Health Partners, University of Toronto

Kieran Murphy, MB,FRCPC,FSIR

Interventional Neuroradiology,

Professor of Medical Imaging

Ciara O’Brien, MB BCh BAO (MD), FFR RCSI

Staff Radiologist, Abdominal Division

Joint Department of Medical Imaging

University I Iealth Network,Ml Sinai 1 Iospital,

WomensCollege Hospital

Assistant Professor, Department of Medical Imaging, liana Shawn, MD FRCPC

University'of Toronto ‘ ' "

Department of Psychiatry,Sc Michael'

s1Iospital

Assistant Professor Department of Psychiatry

Anastasia Oikonomou,MD,PhD, FRCPC

Associate Professor, University of Toronto PUBLIC HEALTH AND

Division of Cardiothoradc Imaging, PREVENTIVE MEDICINE

Department of Medical Imaging,

Jason J Pennington. MD,MSc, FRCSC

Sunnybrook Health SciencesCentre Division of General Surgery, Department of Surgery,

Scarborough Health Network

PAEDIATRICS Assistant Professor,Department of Surgery'

Tanvi Agarwal,MD,FRCPC MScCH (c) University'of Toronto

Division of Paediatric Medicine

Department of Paediatrics Andrew Pinto, BSc,MD,CCFP,FRCPC,MSc

The Hospital for SickChildren Department of Family and Community Medicine,

SL Michaels Hospital

Jillian Baker,MD, MSc,FRCPC Department of Family and Community Medicine

Assistant Professor of Pediatrics, University of Toronto University of Toronto

Divisions of Pediatrics and Hematology/Oncologv Dalla Lana School of Public 1Iealth,

Department of Pediatrics,Unity Health Toronto (St University'of Toronto

Michaels Hospital) & TheHospital for Sick Children

Tyler Groves,MSc.MBBS, FRCPC

Department of Paediatrics, Michael Garron Hospital

Giuseppe (Joey) Latino.MD, FRCPC

Department ot Paediatrics

Division of Genetics,Department of Medicine

North York General Hospital

Laila Premji, MD. FRCPC

Division ol Paediatric Medicine,

Department of Paediatrics

The Hospital for SickChildren

Shazeen Suleman MSc,MD, MPH ( FRCPC!

Women and Childrens Health

SL Michaels HospitaL Unity Health Toronto

Janaki Vallipuram,MD. FRCPC

Division of Paediatric Medicine,

Department of Paediatrics

The Hospital for SickChildren,

Markham Stouffville Hospital

PALLIATIVE MEDICINE

Risa Bordman,MD,CCFP(PC),FCFP

Associate Professor

Faculty Development Program Lead,

Office of Education Scholarship

Department of Family & Community Medicine

Adam Rapoport, MD, FRCPC, MHSc

Departments of Paediatrics and Family &

Community Medicine,University of Toronto

Paediatric Advanced Care Team, SickKids

Emily’s House Childrens Hospice

Donna Spaner,MD,CCFP( PC), FCFP, MScCH

Division of PalliativeCare, Department of Family and

Community Medicine

Toronto Grace Health Centre

PSYCHIATRY

Saulo Castel, MD, PhD, FRCPC

Director,Inpatient Services

Sunnybrook Health SciencesCentre

Assisiant Professor Department of Psychiatry

Tamara Milovic,MD, MBA, FRCPC

Psychiatrist,Centre for Addiction and Mental Health

Lecturer, Department ot'

Psychiatry,

University ot Toronto

Jerome Perera,MD, FRCPC

Psychiatrist, North York General IIospital

Clinician Teacher. Department of Psychiatry,

University of Toronto

Jensen Yeung, MD, FRCPC

Division of Dermaiology, Department of Medicine

Women'

sCollege Hospital

EMERGENCY MEDICINE

Mark Freedman, BSc,MD,FRCPC

Department of EmergencyMedicine

Sunnybrook Health SciencesCentre

Laura Hans, MD,CCFP (EM)

Department of Emergency Medicine

SL Michael'

s Hospital

Adam Kaufman,MD CCFPiEM)

Emergency Physician, Michael Garron Hospital,

Toronto East Health Network

.Assistant Professor, Department of Family and

Community Medicine,University of Toronto

Jo Jo Leung, MD,CCFPIEM),MScCH(HPTE)

Emergence Physician, University Health Network and

Trillium Health Partners

Assistant Professor, Department of Family and

Community Medicine, University of Toronto

r T

L J

9 Editorial Toronto Notes 2023

Faculty Contributors, University of Toronto

MEDICINE

CARDIOLOGY AND CARDIAC SURGERY

Paul Dorian, MD, MSc, FRCPC

Division of Cardiology

St. Michael'

s Hospital

Thiru Yogaparan, MD, FRCP

Division of Geriatric Medicine, Department of

Medicine, Baycrest Ilealth Sciences

Alireza Zahirieh, MD, FRCPC

Division of Nephrology, Department of Medicine

Sunnybrook Ilealth Sciences Centre

HEMATOLOGY

MatthewCheung,MD. FRCPC

Division of Medical Oncology and 1lematology.

Department of Medicine

Sunnybrook Health SciencesCentre

NEUROLOGY

Charles D. Kassardjian,MD, MSc, FRCPC

Division of Neurology, Department of Medicine

St.Michael'

s Hospital

Douglas 1. Ing, MD, FRCPC, FACC

Division of Cardiology

Toronto General Hospital

Alexandra MucciUi,MD, MEd, FRCPC

Division of Neurology, Department of Medicine

SL Michaels Hospital

Bobby Yanagawa, MD, PhD, FRCSC

Division of Cardiac Surgery

St Michael'

s Hospital

Lisa Chodirker, MD, FRCPC

Division of Medical Oncology and Hematology,

Department of Medicine

Sunnybrook Health SciencesCentre Liza Pulcine,MD,MSc, FRCPC

Assistant Prolessor, Fellowship Director

Children'

s Stroke Program

Division of Neurology, Department of Paediatrics,

The Hospital for Sick Children

ENDOCRINOLOGY

Angela Assal, MD, MHSc, FRCPC

Division of Endocrinology and Metabolism,Depart- Helena Dhamko.MD,FRCPC MScCH

Division of Hematology.E>epartment of Medicine

University Health Network

ment of Medicine

Sunnybrook Health SciencesCentre

University of Toronto

RESPIROLOGY

Samir Gupta,MD, FRCPC

Division ofRespirology Department of Medicine

Unity Health Toronto

Zachary Liederman, MD, FRCPC MScCH

Division of Hematology,Department of Medicine

Universitv Health Network

Jeremy Gilbert, MD, FRCPC

Division of Endocrinology and Metabolism

Sunnybrook Health Sciences Centre

Michael Scott,MD,FRCPC

Clinical Hematologist;Adjunct Lecturer,

Division of Medical Oncology and HematologyDepartment of Medicine,Unity Health Toronto,

SL Michael'

s Hospital

Ambrose Lau,MD, MEd, FRCPC

Division ofRespirology,Department of Medicine

University Health Network and

Unity HealthToronto

Assistant Professor, University of Toronto

Adrian Lau,MD, MScCH, FRCPC

Division of Endocrinology and Metabolism

Department of Medicine

Women’s College Hospital

Universityof Toronto

Martina Trinkaus,MD,FRCPC

Division of Hematology,E>epartment of Medicine

SL Michael'

sHospital

Christopher Li,MD, FRCPC, DABSM

Division ofRespirology;Department of Medicine

Unity Health Toronto - SL Michael’s

Maria Wolfs, MD MHSc FRCPC

Division of Endocrinology and Metabolism

St. Michael's Hospital

INFECTIOUS DISEASES

Andrea K.Boggild,BSc,MSc,MD,DTMH,

FRCPC

Tropical Disease Unit,Toronto General Hospital

Division of Infectious Diseases,

University- Health Network

Department of Medicine, University of Toronto

Institute of Medical Science, University of Toronto

RHEUMATOLOGY

Ahmed Omar, MBBCh, MRCP, MSc

Assistant Professor, University of Toronto

Division of Rheumatology, Department of Medicine

Mount Sinai Hospital, University Health Network

GASTROENTEROLOGY

Maria Cino, BSc(Hon), Hon BSc, MSc,MD,

FRCPC CAGF

Division of Gastroenterology,

Department of Medicine

University Health Network - Toronto Western Site

Associate Professor, University of Toronto Arthur Bookman, MD, FRCPC

Division of Rheumatology, Department of Medicine

Paul L Bunce, BSc.MA.MD. FRCPC University 1lealth Network

Division of Infectious Diseases

Department of Medicine

University Health Network

Flavio Habal,MD,PhD,FRCP,FAGA

Division of Gastroenterology

University Health Network,

Toronto Western Division

Associate Professor, University of Toronto

SahilKoppikar. MD FRCPC

Assistant Professor, Division of Rheumatology

Department of Medicine,

Women'

Susan M. Poutancn, MD.MPH, FRCPC sCollege I lospital

Department of Microbiology,

University Health Network & Sinai Health

Division of Infectious Diseases,

Department of Medicine

University Health Network & Mount Sinai Hospital

Piero Tartaro, MD, MScCl I, FRCPC

Division of Gastroenterology,

Department of Medicine

Sunnybrook Health SciencesCentre

Dharini Mahendira, MD, FRCPC, MScCH

Assistant Professor, Division of RheumatologyDepartment of Medicine, St. Michael'

s Hospital

Medha L.Soowamber, MD, MSc, FRCPC

Division of Rheumatology, Department of Medicine

Mount Sinai Hospital

GERIATRIC MEDICINE

Jillian .Alston, MD, FRCPC, MScCH

Division of Geriatrics

Department of Medicine

St. Michael'

s Hospital

NEPHROLOGY

Damien Noone.MB BCh BAO,MSc

Division of Paediatric Nephrology,

Department of Paediatrics

The Hospital tor Sick Children

r i

L J

Vicky Chau,MD, MScCH, FRCPC

Division of Geriatric Medicine,

Department of Medicine

Sinai Health System & University Health Network

Gemini Tanna,MD,FRCPC

Division of Nephrology,Department of Medicine

Sunnybrook Health SciencesCentre

AL GRAWANY

10 Editorial Toronto Notes 2023

Faculty Contributors,University of Toronto

SURGERY

Melissa Walker, MD,MSc,ERCSC

Abdollah Behzadi,MD,MBA, ERCSC FACS Staff Obstetrician Gynecologist, Department of

Division of Thoracic Surgery, Department of Surgery Obstetrics & Gynecology,Mount Sinai Hospital

Trillium Health Partners, University of Toronto

Sayf Gazala, MD.MSc,FRCSC

Assistant Professor,Thoracic Surgery Department of

Surgery;Michael Garron Hospital

GENERAL AND THORACIC SURGERY PLASTIC SURGERY

Joel Fish, MD, MSC, FRCS

Professor, Plastic and Reconstructive Surgery

Department of Surgery

The Hospital for Sick Children

Assistant Professor,Department of Obstetrics &

Gynecology;University of Toronto

OPHTHALMOLOGY

Asiin Ali, MD, FRCSC

Professor of Ophthalmology,University of Toronto

Ophthalmologist-in-Chief,The Hospital for Sick

Children

Siba Haykal,MD, PhD, FRCSC, FACS

Division of Plastic and Reconstructive Surgery,

Department of Surgery

Jesse Pasternak,MD,MPH,FRCSC University'Health Network

Section of EndocrineSurgeryDivision of General Surgery, Department of Surgery

University Health Network

UROLOGY

Monica Farcas,BEng, MEng, MD, FRCSC

Assistant Professor, Division of Urology

Department of Surgery, Unity I Iealth Toronto

Yonah Krakowsky, MD, FRCSC

Division of Urology

Womens College & Mount Sinai Hospital

Wai-Ching Lam, MD, FRCSC

Department of Ophthalmology and Vision Science

University Health Network,

Toronto Western Hospital

The Hospital for Sick Children

Fayez Quereshy,MD, MBA, FRCSC

Department of General Surgery

University Health Network.

Toronto Western

Hospital Jonathan Micicli, MD, FRCSC

Department of Ophthalmology and Vision Sciences;

Division of Neurology;Department of Medicine;

Kensington Vision and Research Centre,

St. Michaels Hospital, University of Toronto

GYNAECOLOGY

Michael Chaikof.MD,FRCSC,MS-HPEd

Division of Urogynecology

Department of OBGYN

Sunnybrook Health SciencesCentre

Jason Lee, MD.MHPE, FRCSC

Division of Urology;Department of Surgery

University Health Network. Toronto General

Hospital

ORTHOPAEDIC SURGERY

Jeremy Hall,MD, FRCSC

Division of Orthopaedic Surgery,Department of

Surgery;St. Michaels Hospital

Michael Ordon, MD,MSc,FRCSC

Division of Urology;Department of Surgery

SL Michael’s Hospital

Sari Kives,MD,FRCSC

Associate Professor

Division of Obstetrics and GynecologyDepartment of Obstetrics and Gynecology

St Michaels hospital

Paul Kuzyk, MD, MASc,FRCSC

Assistant Professor

Lower Extremity'Reconstruction SurgeryDivision of Orthopaedic Surgery

VASCULAR SURGERY

Elisa Greco,BSc, MEd, MD, RPYI, FRCSC

Vascular Surgeon, St Michaels Hospital

NEUROSURGERY

Sunit Das,MD, PhD

Division of Neurosurgery

St.Michaels Hospital

George Oreopoulos, MD, MSc, FRCSC

Division of Vascular Surgery,

Department of Surgery

University Health Network

Jesse Wolfstadt, MD, MSc, FRCSC

Granovsky Gluskin Division of Orthopaedic Surgery,

Department of Surgery,Sinai 1Iealth Sy stem

Michael G.Fehlings, MD. PhD, FRCSC, FACS

Professor of Neurosurgery;Department of Surgery;

University ofToronto

Vice Chair Research,Department of Surgery;

University of Toronto

Senior Scientist, Krembil Brain Institute,

University Health Network

Staff Neurosurgeon,University- Health Network

Co-Director,University of Toronto Spine Program

OTOLARYNGOLOGY

Yvonne Chan, MD, MSc, FRCSC

Otolaryngologist-in-chief,

St. Michael’

s Hospital, Unity Health

Associate Professor and Continuing Professional

Development Director

Department of Otolaryngology -

Head & Neck Surgery

Antoine Eskandcr,MD,ScM, FRCSC

Assistant Professor

Department of Otolaryngology -

Ilead & Neck Surgery

Sunnybrook Health SciencesCentre,

Odette Cancer Centre

Michael Garron Hospital

Eric M.Massicotte MIX MSc,MBA, FRCSC

Associate Professor University of Toronto

Staff Neurosurgeon,University Health Network

Medical Director,Back & Neck Program Altum

Health

OBSTETRICS

Richard Pittini, MD, MEd. FRCSC, FAC.OG

Department of Obstetrics and Gynecology;

University of Toronto

Sunnybrook I Iealth SciencesCentre

Jonathan Irish, MD, MSc, FRCSC

Department of Otolaryngology,

l lead and Neck Surgery,

University Health Network

Mara Sobel, MD, MSc.FRCSC

Department of Obstetrics and Gynecology;

University- of Toronto

Mount Sinai Hospital University Health Network,

Toronto General Hospital,Womens College Hospital

11 Editorial Toronto Notes 2023

Table of Contents

Index Abbreviations

Common Acronyms and Abbreviations Used in Medicine

Common Unit Conversions

Commonly Measured Laboratory Values

Ethical, Legal, and Organizational Medicine

Anesthesia

ELOM

Cardiology and Cardiac Surgery.

Clinical Pharmacology

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General and Thoracic Surgery . .

Geriatric Medicine

Gynaecology

Hematology

Infectious Diseases

Medical Genetics MG

Medical Imaging

Nephrology

Neurology

Neurosurgery...

Obstetrics

Ophthalmology OP

Orthopaedic Surgery OR

Otolaryngology OT

Paediatrics P

Palliative Medicine PM

Plastic Surgery

Psychiatry

Public Health and Preventive Medicine

Respirology

Rheumatology ..

Urology

Vascular Surgery

R ri

L J

VS +

AL GRAWANY

12 Editorial Toronto Notes 2023

How To Use This Book

This book has been designed to remain as one book or to be taken apart into smaller booklets.Identify the beginning and end

of a particular section, then carefully bend the pages along the perforated line next to the spine of the book.Then tear the pages

out along the perforation.

The layout of Toronto Notes allows easy identification of important information.

These items are indicated by icons interspersed throughout the text:

Icon Icon Name Significance

This icon is found next to headings in the text.It identities key objectives and conditions as

determined by the Medical Council of Canada or the National Board of Medical Examiners

in the USA.If it appears beside a dark title bar, allsubsequentsubheadingsshould be S considered key topics.

Key Objectives

This icon isfound in sidebars of the text.It identifies concise,important information which

will aid in the diagnosis or management of conditions discussed in the accompanying text.

Clinical Pearl

This icon isfound in sidebars of the text.It identifies helpful mnemonic devices and other

memory aids.

Memory Aid

(§)

This icon isfound in sidebars of the text.It indicatesinformation or findings that require

urgent management orspecialist referral.

Clinical Flag

This icon isfound in sidebars ofthe text.It identifies key research studiesfor evidencebased clinical decision making related to topics discussed in the accompanying text.

Evidence Based Medicine

This icon isfound next to headingsin the text.It indicatestopics that correspond with Wi imagesfound in theColour Photo Atlas available online (www.torontonotes.ca).

Colour Photo Atlas

This icon isfound next to headings in the text.It indicates topics that correspond to images EH found in the Radiology Atlas available online (www.torontonotes.ca).

Radiology Atlas

This icon isfound next to headingsin the text.It indicates topics that correspond with

electronic resourcessuch as Functional Neuroanatomy or ECGs Made Simple, available S online (www.torontonotes.ca).

Online Resources

Chapter Divisions

To aid in studying and finding relevant material quickly, many chapters incorporate the following general framework:

Basic Anatomy/Physiology Review

• features the high-yield,salient background information students are often assumed to have remembered from their early medical school

education

Common Differential Diagnoses

• aims to outline a clinically useful framework to tackle the common presentations and problemsfaced in the area of expertise

Diagnoses

• the bulk of the book

• etiology, epidemiology, pathophysiology, clinical features,

investigations, management, complications, and prognosis r “i

L J

Common Medications

• a quick reference section for review of medications commonly prescribed +

13 Editorial Toronto Notes 2023

Common Acronyms and Abbreviations Used in

Medicine

The following are common medical acronyms/abbreviations that may be used without definition throughout the Toronto

Notes text. These are typically not included in the acronym list at the beginning of each chapter. Please refer back to this

list for definitions.

U electrocardiogram

emergency department

electroencephalography

electromyography

cars, nose, and throat

erythrocyte sedimentation rate

cthanol/alcohol

concentration ECC,

p-hCG beta human chorionic gonadotropin ED

EEC

ABx antibiotics

angiotensin-converting enzyme

Adrenocorticotropic hormone

acquired immune deficiency syndrome

alkaline phosphatase

alanine aminotransferase

absolute risk

acetylsalicylic acid

aspartate transaminase

asymptomatic

abdominal x-ray

EMC.

ACE ENT

ACTH

AIDS

ESR

EtOH

ALP

family medical history

follicle stimulating hormone

ALT FMHx

AR FSH

ASA

glucosc-6-phosphate dehydrogenase

gamma-glutamyl transferase

growth hormone

gamma hydroxybutyrate

gastrointestinal

genitourinary

AST G6PD

aSx GG.T

AXR GH

GHB

twice a day (bis in die)

body mass index

blood pressure

BPM/bpm beats per minute

BID GI

BMI GU

hemoglobin

human immunodeficiency disease

heart rate

hypertension

history

HIV

C/I contraindication

culture and sensitivity

coronary artery disease

complete blood count

chief complaint

congestive heart failure

chronic obstructive pulmonary disease

cardiopulmonary resuscitation

creatinine

corticotropin-releasing hormone

cerebrospinal fluid

computed tomography

chest x-ray

C&S HTN

CAD Hx

CBC

CC I&D incision and drainage

intracranial pressure

intensive care unit

intramuscular

intravenous

CHF ICP

COPD ICU

CPR IM

Cr IV

CRH

CSF JVP jugular venous pressure

lactate dehydrogenase

liver function test

luteinizing hormone

likelihood ratio

CXR LDH

LFT

D&C dilatation and curettage

diastolic blood pressure

differential diagnosis

diabetes mcllitus

do not resuscitate

diagnosis

LH r

dBP LR

DDx

DM +

DNR

AL GRAWANY

H Editorial Toronto Notes 2023

Common Acronyms and Abbreviations Used in

Medicine

monoamine oxidase

monoamine oxidase inhibitor

metered-dose inhaler

myocardial infarction

magnetic resonance imaging

musculoskeletal

systolic blood pressure

subcutaneous

sublingual

systemic lupus erythematosus

shortness of breath

urgent or immediately (statum)

sexually transmitted infection

symptom(s)

MAO

MAOI

sBP

MDI SL

MI SLE

MRI SOB

MSK STAT

STI

N/V nausea/vomiting

nasogastric

N-Mcthyl-D-aspartate

nothing by mouth (nil per os)

non-steroidal anti-inflammatory drug

TlDM

T2DM

type 1 diabetes mellitus

type 2 diabetes mellitus

tuberculosis

three times a day (ter in die)

tumour, nodes, and metastases

thyroid releasing hormone

thyroid stimulating hormone

treatment

NMDA

NPO

NSAID TB

TID

OR operating room TNM

OTC over-die-counter TRH

TSH

PCR polymerase chain reaction

pulmonary embolism

past medical history

oral administration (per os)

point-of-care ultrasound

proton pump inhibitor

as needed ( pro re nata)

PMHx U/A urinalysis

ultrasound

urinary tract infection

urine toxicology screen

PO U/S

POCUS UTI

PPI UTox

PRN

VDRL Venereal Disease Research Laboratory test

QID four times a day (quatcr in die)

WBC white blood cell

red blood cell weight

randomized controlled trial

review of symptoms

medical prescription

RBC wt

RCT

ROS

15 Editorial Toronto Notes 2023

Common Unit Conversions

To convert from the conventional unit to the SI unit,multiply by conversion factor

To convert from the SI unit to the conventional unit,divide by conversion factor

Conventional Unit Conversion Factor SI Unit

ACTH pg/mL 0.22 pmol/L

Albumin g/dL 10 g/L

Bilirubin mg/dL 17.1 pmol/L

Calcium mg/dL 0.25 mmol/L

Cholesterol mg/dL 0.0259 mmol/L

Cortisol pg/dL 27.59 nmol/L

Creatinine mg/dL 88.4 pmol/L

Creatinine clearance mL/min 0.0167 mL/s

Ethanol mg/dL 0.217 mmol/L

Ferritin ng/mL 2.247 pmol/L

Glucose mg/dL 0.0555 mmol/L

HbA1c % 0.01 proportion of 1.0

Hemaglobin g/dL 10 g/L

HDL cholesterol mg/dL 0.0259 mmol/L

Iron,total pg/dL 0.179 pmol/L

Lactate (lactic acid) mg/dL 0.111 mmol/L

LDL cholesterol mg/dL 0.0259 mmol/L

x lO^

ells/mm 3 Leukocytes 1 x 109cells/L

Magnesium mg/dL 0.411 mmol/L

MCV pm3 1 fL

x lO^

Platelets ells/mm 3 1 x 109cells/L

Reticulocytes % of RBCs 0.01 proportion of 1.0

Salicylate mg/L 0.00724 mmol/L

Testosterone ng/dL 0.0347 nmol/L

Thyroxine (T4) ng/dL 12.87 pmol/L

Total Iron Binding Capacity pg/dL 0.179 pmol/L

Triiodothyronine (T3) pg/dL 0.0154 pmol/L

Triglycerides mg/dL 0.0113 mmol/L

Urea nitrogen mg/dL 0.357 mmol/L

Uric acid mg/dL 59.48 pmol/L

Celsius •

Fahrenheit F = (C x 1.8) + 32 r

L J

Fahrenheit Celsius C = (F - 32) x 0.5555

Kilograms •

Pounds 1 kg = 2.2 lbs

Pounds Ounces 1 lb = 16 oz +

Ounces •

Grams 1 oz = 28.3 g

Inches •

Centimetres 1 in = 2.54 cm

AL GRAWANY

16 Editorial Toronto Notes 2023

Commonly Measured Laboratory Values

Test Conventional Units SI Units

Arterial Blood Gases

7.35-7.45

35-45 mmHg

80-105 mmHg

7.35-7.45

4.7-6.0 kPa

10.6-14 kPa

PC02

PO2

Serum Electrolytes

Bicarbonate

Calcium

Chloride

Magnesium

Phosphate

Potassium

Sodium

22-28 mEq/L

8.4-10.2 mg/dL

95-106 mEq/L

1.3-2.1 mEq/L

27-4.5 mg/dL

3.5-5.0 mEq/L

136-145 mEq/L

22-28 mmol/L

2.1-2.5 mmol/L

95-106 mmol/L

0.65-1.05 mmol/L

0.87-1.45 mmol/L

3.5-5.0 mmol/L

136-145 mmol/L

Serum Nonelectrolytes

Albumin

ALP

ALT

Amylase

AST

Bilirubin (direct)

Bilirubin (total)

BUN

Cholesterol

Creatinine (female)

Creatinine (male)

Creatine Kinase - MB fraction

Ferritin (female)

Ferritin (male)

Glucose (fasting)

HbA1c

LDH

Osmolality

3.5-5.0 g/dL

35-100 U/L

8-20 U/L

25-125 U/L

8-20 U/L

0-0.3 mg/dL

0.1-1.0 mg/dL

7-18 mg/dL

<200 mg/dL

10-70 U/L

25-90 U/L

0-12 U/L

35-50 g/L

35-100 U/L

8-20 U/L

25-125 U/L

8-20 U/L

0-5 pmol/L

2-17 pmol/L

2.5-7.1 mmol/L

<5.2 mmol/L

10-70 U/L

25-90 U/L

0-12 U/L

12-150 pg/L

15-200 pg/L

3.8-6.1 mmol/L

<0.06

100-250 U/L

275-300 mOsm/kg

12-150 ng/mL

15-200 ng/mL

70-110 mg/dL

<6%

100-250 U/L

275-300 mOsm/kg

Serum Hormones

ACTH (0800h)

Cortisol (0800h)

Prolactin

Testosterone (male,free)

Thyroxine (T4)

Triiodothyronine (T3)

TSH

<13.2 pmol/L

138-635 nmol/L

<20 ng/mL

0.31-1 pmol/L

64-155 nmol/L

1.8-2.9 nmol/L

0.5-5 pU/mL

<60 pg/mL

5-23 pg/dL

<20 ng/mL

9-30 ng/dL

5-12 ng/dL

115-190 ng/dL

0.5-5 pU/mL

Hematologic Values

ESR (female)

ESR (male)

Hemoglobin (female)

Hemoglobin (male)

Hematocrit (female)

Hematocrit (male)

0-20 mm/h

0-15 mm/h

12.3-15.7 g/dL

13.5-17.5 g/dL

36-46%

41-53%

1.0-1.1

4.5-11 x 103cells/mm 3

88-100 pm 3

150-400 x 103/mm3

25-35 s

0.5-15% of RBC

0-20 mm/h

0-15 mm/h

123-157 g/L

140-174 g/L

36-46%

41-53%

10-1.1

4.5-11 x 109cells/L

88-100 fL

150-400 X 109/L

25-35 s

20-84 x 109/L

r "> \

1 <-

J J

INR

Leukocytes

MCV

Platelets

PTT

Reticulocytes

ELOM Ethical,Legal, and Organizational Medicine

Konya Costa-Dookhan and Zuhal Mohmand, chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, EBM editor

Dr.Andria Bianchi, Dr. Nadia Incardona, and Dr.Chase McMurren,staff editors

Acronyms EL0M2

The Canadian Healthcare System.

Overview of the Canadian Healthcare System

Legal Foundation

History of the Canadian Healthcare System and CrownIndigenous Relations Pursuant to Healthcare

Healthcare Expenditure and Delivery in Canada

Physician Licensure and Certification

Role of Professional Associations

Ethical and Legal Issues in Canadian Medicine

Introduction to the Principles of Ethics

Confidentiality

Consent and Capacity

Negligence

Truth-Telling

Ethical Issues in Health Care

Reproductive Technologies

End-of-Life Care

Physician Competence and Professional Conduct

Research Ethics

Physician-Industry Relations

Resource Allocation

Conscientious Objection

Clinical Informatics and Ethical Considerations

Key Terms

Overview of Digital Health Technologies

Indigenous Health

Overview of the History and Impact of Colonialism

Movement Towards Reconciliation

Indigenous Disproportionate Over-Representation of Biological,

Psychological, and Social Co-Morbidities

Indigenous Health Coverage and Jurisdictions

Resources in Indigenous Health

References.

EL0M2

ELOM8

ELOM23

ELOM24

ELOM31

further information on these topics can be found in the Objectives of the Considerations of the Legal, Ethical, and

Organizational Aspects of the Practice of Medicine (CLEO) - which can be downloaded free of charge from the Medical

Council of Canada website at http://mcc.ca/wp-content/uploads/CLEO.pdf.

There are three main types of law in Canada: criminal, civil, and administrative. The penalties for violating each are,

in general, as follows: criminal-fine or incarceration;civil- monetary damages paid to the wronged party; and

administrative - sanctions by the regulator (such as a suspension by the College of Physicians and Surgeons). All three

types of law can be engaged by a single act. l or example, a physician that inappropriately touches a patient can be liable

for criminal (sexual assault), civil (monetary'damages paid to the patient for the civil wrong of sexual assault), and

administrative (fines and sanctions up to and including loss of ability to practice medicine for sexual abuse) penalties.

Canadian law applicable to medical practice varies between jurisdictions and changes over time.

r n

L J

+ Criminal law is nationwide, but civil and administrative law varies between provinces and territories. This section is meant

to serve only as a guide.Students and physiciansshould ensure that their practices conform to local and current laws.

EL0M1 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

AL GRAWANY

EL0M2 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Acronyms

CPSO College of Physicians and

Surgeons of Ontario

electronic medicalrecord

IMCC Licentiate of the Medical Council PTMA

of Canada

MAID Medical Assistance in Dying

MCC Medical Council of Canada

OECD Organization for Economic Co- RDoC

operation and Development

OMA Ontario Medical Association

OTC over the counter

PHO Provincial House staff

Organization

PIPEDA Personal Information Protection

and Electronic Documents Act

POA Power of Attorney

Provincial/Territorial Medical

Association

RCPSC Royal College of Physicians and

Surgeons of Canada

Resident Doctors of Canada

SOM substitute decision-maker

IRC Truth and Reconciliation

Commission

AE adverse event

assisted reproductive

technologies

Canadian Federation of Medical FMEO

Students

ART

EMR

Federation medicale etudiante

du Quebec

CFPC College of Family Physicians of FRCPC Fellow of the Royal College of

Canada

CIHR Canadian Institutes of Health

CFMS

Physicians of Canada

FRCSC Fellow of the Royal College of

Surgeons of Canada

GA gestational age

GDP gross domestic product

HCCA Health Care Consent Act

IVF in vitro fertilization

Research

CMA Canadian Medical Association

CME continuing medical education

CMPA Canadian Medical Protective

Association

The Canadian Healthcare System

Overview of the Canadian Healthcare System

• one federal, three territorial, and ten provincial systems

• major complexities in establishment of Canadian health policy include geographical diversity,

socioeconomic divisions, and international pressures

• financed by both the public (70%) and private (30%) sectors

• each provincial/territorial plan must cover all medically necessary health services and remain in

compliance with the Canada Health Act in order to receive federal transfers

• provincial/territorial governments may choose to offer and fund supplementary services not covered

under the Canada Health Act,such as prescription drugs and vision care

• non-insured health services and fees are either covered by private insurance or by the individual

• workers’ compensation funds cover treatment for work-related injuries and diseases

Table 1. Division of Government Responsibilities in Healthcare

Principles of the Canada Health Act

1. Public Administration:provincial/

territorial health insurance programs

must be administered on a not-forprofit basis by public authorities

2. Comprehensiveness: provincial/

territorial health insurance programs

must cover all medically necessary

diagnostic,physician,and hospital

services

3. Universality:all eligible residents

must be entitled to healthcare

services (including status First

Nations peoples and Inuit:note

that non-status First Nations and

Metis are included under all eligible

residents)

4. Portability:emergency health

services must be available to

Canadians who are outside their

home province, paid for by the home

province

5. Accessibility: provincial/territorial

plans must ensure reasonable access

to medically necessary hospital and

physician services without financial

or other barriers

Federal Government Provincial Government

Healthcare services for Indigenous peoples (Status First Nations

peoples and Inuit only,Non-Insured Health Benefits (NIHB)),federal

government employees (RCMP and armed tones),immigrants,and civil

aviation personnel

Marine hospitals and quarantine (Constitution Ad, 186?)

Investigations into public health

Regulation ol food and drugs

Inspection of medicaldevices

Administration of healthcare insurance

General information services related to healthconditions and practices

Role inhealth derives from constitutional responsibility over criminal

law.spending powers,and legislation for 'peace,order, and good

government.’Examples include CanadaHealthAct,Food and DrugsAct.

ControlledSubstancesAct, and Canada Health IransferAct)

Establishment,maintenance,and management of hospitals,asylums,

charities,and charitable institutions {ConstitutionAct,1867)

licensing of physicians,nurses,and other hcallli professionals

Determining the standards for licensing all hospitals

Administering provincial medical insurance plans

Financing healthcare facilities

Delivery of certain public health services

Legal Foundation

• the legal foundation of the Canadian health system is based on:

• five constitutional documents:

1. Royal Proclamation (1763): the foundation for the rights of Indigenous peoples in Canada;

sets out the sovereignty of Indigenous peoples in Canada

2. Constitution Act (1867): deals primarily with the jurisdictional power between federal and

provincial governments

3. Treaty 6 (1876):included the Medicine Chest Clause,svhich addresses Indigenoussovereignty

in healthcare delivery and equitable access to all forms of medicine

4. Dreavervs. King court ruling (1935): provided the legal precedence for Non-Insured Health

Benefits

5. The Canadian Charter of Rights and f reedoms (1982): does not guarantee a right to

healthcare; but, if the government decides to finance healthcare, they are constitutionally

obliged to do so consistently with the rights and freedoms outlined in the Charter (including

the right to equality, physicians’ mobility rights, etc.)

two statutes:

I. Canada Health Act (1984): outlines the national terms and conditions that provincial health

systems must meet in order to receive federal transfer payments

The federal government can reduce its

contributions to provinces that violate

the key principles of the Canada Health

Act

L J

EL0M3 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

2. Canada Health and Social Transfer Act (1996):federal government gives provinces a single

grant for healthcare,social programs, and post-secondary education; division of resources at

provinces’ discretion

History of the Canadian Healthcare System and CrownIndigenous Relations Pursuant to Healthcare

Europeansfirst arrive in Canada

• settlersfind healthy inhabitants with complex societies, cultures, and beliefsystems

• Indigenous peoples’ have specific knowledge of local environment and medicines

• early instance of medical practice occurs when local Indigenous nation

(Haudenosaunee) used cedar as a source of vitamin C to treat scurvy experienced by

European settlers

1534

Royal Proclamation

• identifiesIndian Country that was under British sovereignty but Indigenous possession

• sets out guidelinesfor European settlement of Indigenous territories in what is now

North America;statements include:Aboriginal title (a legal term for ancestral land

rights) has existed and continuesto exist, and that all land would be considered

Aboriginal land unless ceded by treaty

• forbids settlers from claiming land from the Indigenous occupants, unlessit wasfirst

bought by the Crown and then sold to the settlers

• only the Crown can buy land from first Nations

1763

1764 Treaty of Niagara

• the treaty is signed with 24 Indigenous Nations represented

• Indigenous peoples and the Crown agree to co-exist and build their relationship on

Turtle Island

British North America Act (now Constitution Act 1867)

• establishes Canada as a confederacy

• “establishment,maintenance, and management of hospitals” under provincial

jurisdiction

• gives the federal government control overlands reserved for “Indians”

Manitoba Act

• Metis land is protected and they are given an additional 1.4 million acres for their

descendants

• this act wassubsequently ignored and infringed upon as this land was given freely to

incoming settlers

1871-1921 Numbered Treaties

•transfer large tracts of Indigenous land to theCrown with various promises made to

Indigenous Peoples

• Treaty 6 explicitly includes medicine, while others contain agreements related to

social factors affecting health

1867

1870

Indian Act

•reinforces the federal government’s exclusive jurisdiction over Indians and lands

reserved for Indians

•gives complete control of “ Indian bands,"

status, and reserves to the Canadian

government

•enfranchisement (the process of terminating one'

s legal Indian Status, identity, and

ancestral rights in order to gain full Canadian citizenship) becomes legally compulsory

in many situations (such as becoming a physician)

•outlaws the practice of Indigenous culture and spirituality

•imposes band councils and “Indian agents"

1884-1996 Residential Schools and Indian Hospitals

•legislated genocide (see Public Health and Preventive Medicine. PH7)

Execution of Metisleader Louis Riel

•leader of the North-West Rebellion against the federal government due to infringement

on Metis ancestral lands, rights, and way of life

1876

1885 r1

L J

Court Decision Reference Re Eskimo rules that the federal government is hassimilar

responsibility for Inuit people as Indigenous Peoples

• following tnis decision the government developed policies that enforced assimilation

and benefited governmental goals, with disregard for Inuit wellbeing.Thisleadto

extensive harms,some of which are noted below:

1939

AL GRAWANY

EL0M4 Ethical,Legal, and Organizational Medicine Toronto Notes 2023

• coercive relocation to isolated and sedentary communities away from ancestral lands,

ending seasonally dynamic way of life

• sled dogs were killed, which discontinued the Inuit traditional way of life and forced

them to rely on government supplies

• discs, to be worn around the neck, were issued with numbers in lieu of Inuit

surnames and to ease bureaucratic workload

Royal Commission on Health Services(Hall Commission) recommendsfederal leadership

and financialsupport with provincial government operation

National Medical Care Insurance Act

•federal government'

sfirst legislation with the goal of free access to healthcare

•federal government to pay half of medicare costs in any province with insurance

plans that meet criteria of being universal, publicly administered, portable, and

comprehensive

•Indian Health Services budget is reduced under the guise of equality and social and

legal integration. Individuals can only receive support for healthcare servicesif they

prove they are Indigenous, have been refused fundsfrom their band, and can not obtain

provincial health services, financial limits are set to prevent “overuse” of services.

This createsfurther barriersto accessing healthcare, while reducing barriersfor nonIndigenous peoples

Canada Health Act is passed by federal government

• replaces Medical Care Act (1966) and Hospital Insurance and Diagnostic Services Act

(1957)

•provides federal funds to provinces with universal hospital insurance

•maintains federal government contribution at 50% on average, with poorer provinces

receiving more funds

•medical insurance must be “comprehensive, portable, universal, and publicly

administered”

•bans extra-billing by new fifth criterion:accessibility

Bill C-31

• the Indian Act forced Indigenous women who married non-lndigenous men to lose their

Indian status

•Bill C-31 attempted to stop the involuntary enfranchisement of Indigenous women (and

their children) who married non-lndigenous men

•Bill C-3 in 2011 and later cases ensured that eligible grandchildren of women who lost

status could regain it

1965

1966

1984

1985

Oka Crisis

•land dispute over ancestral Kanienkehaka (Mohawk) territory

•brought about the Royal Commission on Aboriginal Peoples (1996)

Canada Health and Social Transfer Act passed by federal government

•federal government gives provinces a single grant for healthcare,social programs, and

post-secondary education; division of resources at provinces’discretion

1990

1996

Royal Commission on Aboriginal Peoples

•established in the wake of the Oka Crisis.The Commission’s Report, the product of

extensive research and community consultation, was a broad survey of historical and

contemporary relations between Aboriginal and non-Aboriginal peoples in Canada

• recommendations made on how to repair the relationship between Indigenous peoples

and Canada

1996

Kirby and Romanow Commissions appointed

•Kirby Commission (final report,October 2002)

•examines history of the healthcare system in Canada, pressures and constraints of

current healthcare system, role of federal government, and healthcare systems in foreign

jurisdictions

2001

Romanow Commission (final report, November 2002)

•dialogue with Canadians on the future of Canada'

s public healthcare system

first Ministers' Meeting on the future of Health Care produces a lOyearplan

•priorities include reductions in waiting times, development of a national pharmacare

plan, and primary care reform

2004

Chaoulli v.Quebec,Supreme Court of Canada decision

• rules that Quebec’s banning of private insurance is unconstitutional under the Quebec

Charter of Rightssince patients cannot access the relevant services under the public

system in a timely manner

2005

EL0.M5 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Jordan'

s Principle

•Iordan Anderson was a First Nations child from Norway House Cree Nation born with

complex medical needs

•he spent two unnecessary years in hospital because provincial and federal governments

could not decide who was responsible for paying for the home-based care that Jordan

needed to be discharged.Consequently, he died in hospital at age 5 without ever going

home

2007

•Iordan'

s Principle is a legal obligation that promisesthat First Nations children will get

prompt and equitable access to healthcare and that payments (federal/provincial/local)

will be determined later

•in 2016, the Canadian Human Rights Tribunal found that the Canadian government was

racially discriminating against First Nations children and their families for its failure to

properly implement Jordan’s Principle,

lhe Tribunal issued legally binding orders that

Canada has an obligation to fulfill

First progress report by the Health Council reviews progress toward 2004 First Ministers’

10 year plan

•significant reductions in wait times for specific healthcare areas (such as cancer care,

joint replacements, and sight restoration), but may have inadvertently caused increased

wait timesfor other services

•despite large investments into EMRs,Canada continues to have low uptake, ranking

last in the Commonwealth Fund International Health Policy survey, with only 37% use

among primary care physicians

•minimal progress in creating a national strategy for equitable access to pharmaceuticals;

however,there has been some success in increasing pharmacists’

scope of practice,

reducing generic drug costs,and implementing drug information systems

•increase Funding to provinces at 6% per annum until the 2016-2017 nscal year; from

then onwards, increases tied to nominal GDP at a minimum of 3% per annum

2011

Second progress report by the Health Council reviews progress towards 2004 First

Ministers’ 10 year plan

•funding issufficient; however, more innovation is needed including incentivizing

through models of remuneration

•46 recommendations are made to address the lack of progress

Expiry of 10 Year Health Care Funding Agreement between federal and provincial

governments

•Canadian Doctors for Refugee Care v.Canada,the Federal Court of Canada rules that

the federal government could notsignificantly reduce/eliminate healthcare servicesfor

refugee claimants, as to do so would constitute “cruel and unusual treatment" contrary

to theCharter of Rights and Freedoms

Negotiations underway for a new Health Accord with a S3billion investment over four

years to homecare and mental health services by the elected Liberal government

lheTruth and Reconciliation Commission releases 94 “calls to action" (or

recommendations) to further reconciliation between Canada and Indigenous peoples

•the full list of calls to action can be found here:http://trc.ca/assets/pdf/Calls_to_

Action_English2.pdf, while health-specific calls and subsequent government actions

can be found here: https://www.rcaanc-cirnac.gc.ca/eng/15244990246l4/15575l 2659251

•the seven calls to action included under health are the following:

18. we call upon the federal, provincial, territorial, and Aboriginal governments to

acknowledge that the currentstate of Aboriginal health in Canada is a direct

result of previousCanadian government policies, including residential schools,

and to recognize and implement the health-care rights of Aboriginal people as

identified in international law, constitutional law, and under the Treaties

19. we call upon the federal government, in consultation with Aboriginal peoples,

to establish measurable goals to identify and close the gaps in health outcomes

between Aboriginal and non-Aboriginal communities, and to publish annual

progress reports and assesslongterm trends.Such efforts would focus on

indicatorssuch as:infant mortality, maternal health,suicide, mental health,

addictions, life expectancy, birth rates, infant and child health issues, chronic

diseases,illness and injury incidence, and the availability of appropriate health

services

20. in order to addressthe jurisdictional disputes concerning Aboriginal people

who do not reside on reserves, we call upon the federal government to recognize,

respect, and address the distinct health needs of the Metis, lnuit, and off-reserve

Aboriginal peoples

21. we call upon the federal government to provide sustainable funding for existing

and new Aboriginal healing centres to address the physical,mental, emotional,

and spiritual harms caused by residential schools, and to ensure that the funding

of healing centres in Nunavut and the Northwest Territories is a priority

2012

2014

2015

EL0M6 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

22. we call upon those who can effect change within the Canadian health-care

system to recognize the value of Aboriginal healing practices and use them in the

treatment of Aboriginal patients in collaboration with Aboriginal healers and

Elders where requested by Aboriginal patients

23. we call upon all levels of government to: i. Increase the number of Aboriginal

professionals working in the health-care field, ii. Ensure the retention of

Aboriginal health-care providers in Aboriginal communities,iii. Provide cultural

competency training for all healthcare professionals

24. we call upon medical and nursing schools in Canada to require allstudentsto

take a course dealing with Aboriginal health issues, including the history and

legacy of residential schools, the United Nations Declaration on the Rights of

Indigenous Peoples,Treaties and Aboriginal rights, and Indigenous teachings

and practices. This will require skills-based training in intercultural competency,

conflict resolution, human rights, and anti-racism

Canada’s Minister of Indigenous Affairs announces their fullsupport for the United

Nations Declaration on the Rights of Indigenous Peoples

•document describes individual and collective rights of Indigenous peoples and provides

guidance about how to maintain a relationship with Indigenous peoples based on

equality, partnership, good faith, and mutual respect

New 10 year Canada Health Accord is reached with a $11.5 billion federal investment

over 10 years to homecare and mental health services and a 3% annual rise in the Canada

Health Transfer (from 6% in the previous agreement)

Missing and Murdered Indigenous Women and Girls Inquiry Pinal Report and Calls for

justice

• reveals that persistent and deliberate human and Indigenous rights violations and

abuses amount to genocide and are the root cause behind Canada’sstaggering rates of

violence against Indigenous women,girls, and 2SLGBTQQ1A people

•the report calls for transformative legal and social changes to resolve the crisis that has

devastated Indigenous communities acrossthe country

2016

2017

2019

The federal government announces the creation of a national drug agency,

it will negotiate

prices on benalfof Canada’s drug plans, assess the efficacy of prescription drugs, and

2019

develop a national formulary

Healthcare Expenditure and Delivery in Canada

• the projected total healthcare expenditure in 2019 was expected to reach $265.5 billion, or $7064 per

person. Health spending was expected to comprise 11.5% of Canada’s GDP that year

Sources of Healthcare Funding

•69% of total health expenditure in 2018 came from public-sector funding with 65% coming from the

provincial and territorial governments, and another 5% from other parts of the public sector:federal

direct government, municipal, and social security funds. 31% is from private sources including out of

pocket (16%), private insurance (12%), and other (3%)

• public sector coversservices offered on either a fee for service, capitation, or alternate payment plan in

physicians'

offices and in hospitals

• fee-for-service is a payment model where services are unbundled and paid forseparately.This can

serve as an incentive for physicians to provide more services because payment is dependent on

the quantity of services provided

in Ontario, each service has a corresponding billing code defined by the Ministry of Health and

Long-term Care in the Physician Services under the Health Insurance Act

• capitation is a physician remuneration payment model determined by the number of patients

rostered

APP is a mutual agreement between a physician (or group of physicians) and their provincial

health authority.The agreement outlinesthe physician’

ssalary, incentives,and various after-hour

bonuses

• public sector does not cover services provided by privately practicing health professionals (e.g.

dentists, chiropractors, optometrists, massage therapists, osteopaths, physiotherapists, podiatrists,

psychologists, private duty nurses, and naturopaths), prescription drugs, OTC drugs, personal health

supplies, and use of residential care facilities

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