By: Jill Davies, Director, Medcan Genetics

It was splashed across the Globe and Mail’s front page—a report detailing the deaths of three children after they’d taken the common painkiller codeine. Our livers metabolize codeine into morphine, which gets distributed through the bloodstream. The problem? High doses of morphine can be lethal, and the three children were among the approximately 5% who possess a rare genetic mutation that means they metabolize codeine more rapidly than most. (Adults also can be affected, although we tend to get sick, rather than die.)

The incidents were tragic, and avoidable. Codeine sensitivity affects those with multiple copies of a DNA component called CYP2D6. And because it’s a genetic trait, it can be screened through the sort of testing offered by Medcan’s pharmacogenomics program. (In addition to codeine sensitivity, Medcan also analyzes the body’s response to many different types of drugs, including the blood thinner warfarin and statins, used to treat high cholesterol.)

As part of our ongoing drive to provide its clients with cutting-edge personalized medicine, Medcan has for the last three years partnered with San Francisco’s Navigenics, which uses a simple saliva sample to look for patterns in one’s genetic code—the DNA that guides every aspect of our genetic identity.

At Medcan our genetic screening capabilities allow us to explore risk factors for a large number of diseases and medications. For example, for the past three years we’ve been able to identify whether clients have an increased susceptibility for such maladies as Alzheimer’s or cardiovascular disease. Then our genetic counsellors sit down with our clients to go over the ways one can mitigate those risks.

Because genomic screening is one of the fastest-developing areas of medical science, we’re constantly coming up with new and exciting ways to utilize the technology to improve Medcan’s preventive health arsenal. Some of the most exciting developments:

Improved Screening Protocols: Medcan’s partner, Navigenics, improves its screening protocols as new scientific discoveries identify new genetic markers tied to certain conditions. Earlier this year, these improvements allowed us to more accurately identify risk for heart attack and diabetes, and also to add a new condition, ischemic stroke, to the panel.  For example, we’re now able to screen for a gene on chromosome 12 known as NINJ2, which was found to increase an individual’s risk for stroke by 40%. And Medcan will work with those who do have the NINJ2 marker to identify lifestyle practices that will mitigate the risk.

Pre-Pregnancy Genetic Testing: One in 280 children is affected by a rare hereditary disorder. Medcan is the first private clinic in Ontario to offer couples pre-pregnancy testing for more than 100 rare diseases. This non-invasive saliva test determines whether the parent is a carrier for hereditary conditions, such as cystic fibrosis, spinal muscular atrophy, sickle cell disease and Tay-Sachs disease. And if the parents’ combined results create an elevated risk of hereditary disease in the child, Medcan can suggest options, such as amniocentesis for testing during a pregnancy or even pre-implantation genetic diagnosis, which uses in-vitro fertilization to select only embryos free of specific genetic mutations.

Next generation sequencing is already being developed and is used in many research settings, allowing the analysis of all three billion base pairs of a person’s genome. (Current techniques provide access to only a few hundred variations in a person’s genome.) Full sequencing is available now, but is cost limiting, and takes months to get the results. However, technology is being developed that provides full sequencing within 24 hours at a cost of $1,000. And with better sequencing, we’ll gain a nuanced portrait of the subtle variations and possible mutations that can occur—providing us with a much fuller picture of medication responses and disease risk.  

A decade ago, learning whether a child has a codeine sensitivity from a saliva test would have been the stuff of science fiction. Today it’s available to anyone who places a strong value on preventive medicine. Who can say where genomics is headed? One thing’s for certain: Whatever it is, it’ll be exciting—and Medcan’s genetic counsellors will educate our clients on what it means for them.

To learn more about Medcan Genetics, contact a Genetic Counsellor at (416) 350-5908, genetics@medcan.com or visit medcan.com/services/genetics.

”Larry” is one of the healthiest guys I know. He’s in his late middle ages, and he reads a lot of medical and fitness magazines to try to gain an edge. He watches what he eats. He exercises regularly, he makes a point of getting plenty of sleep and he’s proactive about his medical strategy. Last week, he came in for an appointment and asked me to test his testosterone levels, because he’d heard about something called male hormone replacement.

The same week, I noticed a large feature in Esquire magazine that revolved around an outfit in Burlington, Ont., known as the Masters Men’s Clinic, which, according to the article, is run by a gynecologist who bills himself as an expert on male hormone replacement. (Normally, male hormones would be the domain of an endocrinologist. A gynecologist typically specializes in women’s health.) But the really strange thing about the article was its cheerleading tone. “What do these doctors think the various compounds can accomplish?” posed Craig Davidson, the Canadian writer of the Esquire piece. “Very simply, a life that is good to the end.”

It’s not difficult to discern why male hormone replacement is becoming a hot topic. Male baby boomers are getting older, and as they age, they’re looking for ways to stave off Father Time. Men tend to experience testosterone levels that fall over time. That decrease has in the last several years received a name:andropause. The medically significant term, which refers to abnormally low levels of testosterone in men with clinical symptoms, is male hypogonadism. The medical professionals who hope to make money treating “testosterone deficiency” are billing the phenomenon as the male counterpart to menopause, the transition that happens in a woman’s life some time after the age of 45, when the female body stops making estrogen and progesterone. (In women, hormone levels drop quickly, whereas in men, it is more of a gradual decline.)

The problem? As a 2010 New England Journal of Medicine editorial concluded, the symptoms of hypogonadism — decreases in sexual function, muscle mass and strength, increased fatigue and depressed mood — are remarkably similar to the normal effects of aging. “Therefore, it is frequently unclear in caring for individual older patients whether the diagnosis of hypogonadism is appropriate and whether testosterone administration might be helpful or might instead cause adverse effects,” noted William Bremner, the writer of the editorial. In plainer language? Who is to say whether the patient is suffering from the malady of testosterone deficiency — or just plain old age?

Doctors such as myself are now seeing early adopters with normal hormone levels who seek testosterone-replacement therapy as a way to stave off the effects of aging. In all likelihood, Masters Men’s Clinic is benefitting from interest from a similar demographic — as is Cenegenics, the anti-aging system marketed with photos of septuagenarian strongman Dr. Jeffry Life of Las Vegas.

If you’re a doctor speaking with a patient, male hormone therapy represents a bit of a dilemma. Academics have shown that it does have short-term effects that will be alluring for many middle-aged guys. “Many studies involving limited numbers of men have shown that the administration of testosterone results in improved muscle mass and strength, increased bone mass, and other positive effects,” Bremner noted in the New England Journal of Medicine.

But if you’re asking my opinion, it’s a short-term fix. And it’s controversial, too. In 2010, the Endocrine Society recommended limiting a diagnosis of testosterone deficiency only to “men with consistent symptoms and signs and unequivocally low serum testosterone levels” — in other words, healthy older men with normal, age-related declines in testosterone levels should not receive the therapy.

Worse, some of these advertised “therapies” espouse the advantages of bio-identical hormones — chemically derived synthetic molecules, some of which haven’t yet been adequately studied. The New England Journal editorial references a testosterone study conducted on 209 men aged 65 or older. Bremner notes: “The testosterone group showed greater leg and arm strength … but also had higher rates of cardiovascular adverse effects” — so much higher that an ethics committee prematurely halted the study. Other doctors wonder if hormone therapy increases the patient’s likelihood of developing subclinical prostate cancer. Why treat someone who is “normal” and asymptomatic?

There’s a whole movement out there tapping into our society’s psyche of aging, catering to men who want to stay young by manipulating hormones. Do these men live longer? I haven’t seen any evidence that they do. Do they feel stronger, more active and happier? Perhaps for a short period of time. But they also place themselves at the risk of a whole host of side effects that amount to the body’s premature burnout. And who knows at this point about long-term effects?

Until I see hard scientific evidence that the therapy is safe for healthy men over the long-term, I would advise consuming the rhetoric about testosterone-replacement therapy with a healthy dose of skepticism. And as for my ultra-healthy patient, Larry, I told him I could test his testosterone.

“But it’s going to be normal,” I said. “And if you want someone to prescribe you with testosterone, you’re going to have to find another doctor.” If Larry lives longer, it’s going to be because of good genes and a healthy lifestyle. There is no shortcut to the fountain of youth.

Originally published in the National Post, April 17, 2012.

It is a dilemma unlike anything I’ve faced in my career.

Jeff is a middle-aged family man who has been a client of my clinic since 2004. During that time, he’s appeared in our offices exhibiting a series of conditions. Red spots appeared on his skin. His kidneys weren’t working properly. His heart’s left ventricle was dilated and weakened. He’d lost the ability to sweat, and back in 2001, he’d had something that may or may not have been a stroke. Besides that, he suffered from an irregular heartbeat, swollen lymph nodes and intense limb pains.

Over the years, we’d treated each event as a separate symptom. But after extensive testing, we struck on the idea that the symptoms matched those of a peculiar and rare genetic condition called Fabry disease. In Fabry disease, a genetic mutation prevents the body from manufacturing enough of an enzyme called alpha-galactosidase. That means the body can’t metabolize, or break down, a kind of energy-containing molecule called a glycolipid. In turn, too many glycolipids leads to proteins accumulating in various organs leading to extreme, and often fatal, symptoms.

Fabry’s is a progressive disease affecting the heart, neurological and kidney systems. There’s gastrointestinal pain, as well as pain in extremities such as the hands or feet. Over time, the glycolipids can cause the kidneys to shut down, requiring the patient to go on dialysis. People with Fabry disease tend to die prematurely from kidney failure, strokes or heart disease. Very few patients live past the age of 60.

To confirm the diagnosis, we administered a gene test, which tested positive for a genetic mutation associated with mild Fabry disease. Now we faced a dilemma: Fabry’s doesn’t have a cure. The best treatment involves infusing the body every two weeks with doses of the deficient enzyme. That improves the patient’s quality of life, and delays symptom onset. The problem is the cost: As it stands today, the enzyme replacement therapy costs upwards of $250,000 a year.

With the therapy, Jeff could live for decades. There is a Canadian Fabry Disease Initiative, a partnership between governments and pharmaceutical companies, which provides patients with the therapy as part of an ongoing academic study. But because Jeff tested positive for only a mild variant of the disease, he wasn’t certain to qualify.

Jeff’s dilemma brings to mind the way shrinking per-capita budgets are forcing physicians to become increasingly cognizant of the cost of treatments they prescribe. Medical science has evolved to a point where extraordinary measures can extend or improve human life, whatever the malady. The problem is many of these measures are expensive. How much should we spend to improve a life? And do we want our doctors to become de facto accountants, considering dollar signs as they decide on courses of treatment?

In the United States, for example, a Boston obstetrician resident, Neel Shah, has created something called the Teaching Value Project with Harvard Medical School and the University of Chicago’s Pritzker School of Medicine. That’s a series of educational modules that will help medical students optimize both the cost and the quality of care. The goal, says one doctor associated with the project, is to get doctors “thinking about how to integrate cost consciousness into practice.”

In Canada, cost is perpetually on the minds of physicians, particularly when governments are striking from the list of medical treatments they will fund such things as blood tests (Vitamin D, PSA), some vaccines, counselling services and eye examinations, among other things. And more de-listing lies ahead — at least in Ontario. Meanwhile, doctors are encouraged by medical schools and their own professional guidelines to consider cost when deciding on care.

My thinking on the cost of care has evolved throughout my career. Today, I don’t have any hard and fast guidelines. My strategy is to empower the patient with knowledge so that we can collaborate and decide together on the best treatment. Interestingly, a study published in the March issue of Health Affairs found that health-care consumers are remarkably savvy when they collaborate with physicians on a course of treatment. The patients didn’t simply choose the most expensive treatment; in fact, when given a list of options that provided equal quality health care, the patients tended to opt for the better value, instead of the higher cost option.

From the consumer’s point of view, you always want to make sure your doctor has your best interests in mind. And if it can’t be provided within your system, then the doctor and patient should work together to determine a creative solution. That’s what Jeff and I and the rest of the medical team are doing now. We’re investigating whether we can solicit opinions on the case from internationally regarded specialists, in an effort to discover whether another, less expensive option might help. Meanwhile, we’re also doing more tests, such as a kidney tissue biopsy, to make the case that he would benefit from the enzyme-replacement treatment. If the $250,000 therapy is the best option, we’ll work together to figure out a way to get it. Because in this case, we’ve decided that Jeff’s health is worth the cost.

Originally published in the National Post, April 3, 2012.

Medical science is constantly striving for advancements to provide better and pioneering care.  In the past three years we have seen the first in utero heart surgery, full facial transplant, and removal of a cancerous tumor in the prostate by a robot.  It is certainly worth applauding these advancements in medicine.  Another innovative and growing trend in medicine has worked to rediscover the foundations of medicine.  This trend is Integrative Medicine, the blending of conventional, natural and traditional medicines.  It seeks to extend the effectiveness of medical care by using ancient therapies in a new way, some that have been in use for over 5,000 years.  This branch of medicine is now available at Medcan.

The Integrative Medicine program at Medcan will feature Naturopathic Doctors (ND), who are experts in the natural medicine field.  Their training is founded in conventional medical science and further includes natural and traditional medicines.  Naturopathic Doctors are perfectly positioned to consider both the conventional and natural, along with the modern and the ancient when it comes to providing the patient with a holistic perspective that works towards their best care. 

Two areas of Integrative Medicine that have ancient roots but are expanding the effectiveness of medical care are herbal medicine and acupuncture.  Naturopathic Doctors are trained in the use of herbal medicines – many of which were the forerunners to modern pharmaceuticals.  Before there was Aspirin^TM many traditionally used white willow bark to provide pain relief, as far back as 400 BC to the days of Hippocrates.  Modern science discovered the active ingredient in the bark was salicin, which is now chemically derived in Aspirin^TM today.  Not every herb has a pharmaceutical counterpart and herbal medicine provides a myriad of treatment options in modern medicine.   Herbs can also be blended into personalized formulas to provide specific and targeted treatments, which may be preferred over standardized pharmaceuticals. 

Acupuncture is another example of a traditional treatment that is now a well-researched and effective tool used by NDs.  Its roots stem back over 5,000 years and it is a mainstay in Chinese culture and healthcare today.  Primitive sharp stones and bamboo were used initially and these helped map out the modern acupuncture points that we currently use.  Now, each sterile, surgical grade, single-use needle is about the diameter of single strand of hair.  These modern precise needles along with practitioner skill allow this ancient craft to be useful in modern medicine.  According to the National Institutes of Health, a global leader in scientific research in Washington DC, acupuncture is being used on the cutting edge of medicine as a tool in pain management, immune function, osteoarthritis, asthma, and adjunctive cancer care to name a few.  This research is just one example where acupuncture is at the forefront of medical care.  It is diverse in its effectiveness and is now highly sought-after in North America.

Medcan Integrative Medicine is proud to offer herbal medicine and acupuncture among its natural health offerings.  We invite you to explore more of what the Integrative Medicine program at Medcan has to offer.  We think you’ll appreciate how a natural medical perspective can help you achieve your health goals. At Medcan Integrative Medicine, what’s old is new again and this old adage gives a unique twist when applied to modern medicine. 

For questions about Medcan's Integrative Medicine Program visit our frequently asked questions page or contact Biljana Krstanovic at 416-350-5900 x.5416 or biljanakrstanovic@medcan.com.

Early in my career, I was a junior doctor at a clinic where one of the senior doctors would go on smoke breaks with his patients. He had the look of a lifelong smoker - lots of wrinkles, hoarse voice and yellowed fingers. I would leave the building where we both worked and there he'd be, a little distance from the door, mid-smoke. At the time, I was still working out my own take on the responsibilities doctors have to act like role models for their patients. The sight of a senior physician engaging in health-harmful behaviour, and with a patient, no less, provoked all sorts of questions for me.

Should doctors smoke with their patients? More to the point, what responsibilities does a doctor have to act as a role model? To what extent does a physician's personal behaviour affect the care that physician provides? Such questions sprang to mind again when I saw the study published earlier this year in Obesity by researchers at the Johns Hopkins Bloomberg School of Public Health. The study authors claimed it was the first to examine whether a physician's weight affected the doc's care of obese patients.

As the study noted, remarkable parallels exist between academic studies conducted years ago on smoking physicians, and more contemporary work on obese physicians. Older studies on smoking physicians suggest that a doctor's personal behaviour does affect the medical care that doctor provides. For example, studies suggest that MDs who smoked were less likely to raise smoking as a health issue with their patients. They were also less likely to encourage patients to quit smoking, and less likely to make stopping smoking a high priority for patients.

Such findings bring to mind a British Medical Journal editorial from 1995, which wondered whether medical students who smoked should be channelled away from working as general practitioners. "An apocryphal tale in public health, said to have originated from a candid tobacco industry executive, is that each doctor who smokes is worth hundreds of thousands of dollars to the [tobacco] industry," went an opening line in the editorial by Simon Chapman, then an associate professor at the University of Sydney.

If overeating is today's equivalent to smoking as an epidemic behaviour that poses severe and underacknowledged health risks, then should we be asking whether overweight medical students should also be channelled away from primary care?

A physician's weight is an attribute that is both a part of an MD's appearance, and a suggestion of his or her behaviour. The issue of doctor appearance is something that's been studied a lot by academia. For example, numerous studies suggest that a work uniform of a white lab coat and formal attire "may favourably influence trust and confidence-building in the medical encounter." At the clinic where I manage the medical team, we encourage our doctors to dress professionally with lab coats - and I tend to wear a tie and white lab coat when meeting with patients.

However, we don't have any guidelines concerning the weight of our physicians. Which brings us back to that study from the Johns Hopkins Bloomberg School of Public Health. A U.S.-wide survey of the behaviour of 500 primarycare physicians revealed tendencies that were similar to the older smoking studies. Obese doctors were less likely to diagnose for obesity, for example, and heavier doctors also were less likely to bring up obesity as a health issue for their patients. Meanwhile, normal-weighted physicians were a lot more likely to believe that MDs had a responsibility to act as role models for patients by maintaining a healthy weight and exercising regularly.

Nevertheless, I agree with the study authors when they counsel against "isolating heavier physicians for intervention" because it "may increase obesity stigma." As a profession we all have a duty to combat obesity - regardless of our weight, or any other attributes. To really combat the growing health problem of obesity, we should train all doctors on the risks, regardless of their own weights, and encourage doctors to engage in regular exercise and healthy eating habits. At my own clinic, employees are offered fitness boot camps and discounts for personal training appointments. They also receive newsletters on healthy nutrition. Among our physicians are serious runners and cyclists, and many recreational athletes who work out regularly at the gym.

So, should a patient avoid overweight doctors, doctors who smoke, or any medical professionals who engage in health-harmful behaviour? Not necessarily. People seeking a primary care practitioner who is a perfect role model for healthy behaviour would find themselves selecting from a very short list. Medical professionals are as flawed as anyone else. The doctor-patient relationship must include rapport and trust. While many of us may prefer our physicians to be trim and professionally dressed, others may prefer a doctor who is as flawed and as human as they are. The bottom line? The MD should always encourage healthy behaviour regardless of personal biases - but action speaks louder than words.

Originally published in the National Post, March 20, 2012.

Frank is a successful 45-year-old executive on medication for high blood pressure and depression. He called to book a same-day appointment with me, but refused to tell the receptionist what the problem was. It was one of those days where my itinerary was full of pre-scheduled appointments. But I agreed to squeeze him in, and some time later, Frank arrived with his girlfriend. He was severely depressed, he said, and had thoughts of suicide. A reformed alcoholic with more than 20 years of sobriety, he'd recently started drinking again because of a relationship breakdown and stress at work.

I ended up spending an hour with Frank to assess his condition. I found a psychiatrist colleague at a local hospital who agreed to see Frank in an emergency psychiatric department. We also co-ordinated an urgent assessment at an in-patient alcohol treatment centre. Next, I wrote a note summarizing Frank's medical history for the specialists. Only then did I return to my usual schedule - now with a full waiting room of patients looking at their watches and thinking, "Why can't docs ever stay on schedule?"

The problem? On this day, I'd faced an unexpectedly complex patient. The term "complex patient" refers to people who consume a lot of resources, and it's had a lot of currency lately. Last month's Drummond report, which outlined potential improvements to Ontario's budget, included a section on complex patients. Drummond used a statistic: About 1% of Ontario's population accounts for 49% of home and hospital care costs. The challenge? If we can manage caring for those 1% more effectively, perhaps we can realize significant savings.

So who is this other 1%? According to Drummond: "They are people who are frequently in and out of our health care system, constantly being admitted to, discharged from, and then readmitted to hospitals." That makes it sound as though most complex patients are older and nearing the end of their lives. But that's not always the case. Those deemed complex as a result of heavy use of emergency rooms tend to be young - more than half under 45, according to the Drummond report. They also tend not to have what we might consider as conventionally serious health issues: addiction or mental health problems.

Is there a way to predict who is going to be a complex patient? The issue is pertinent to general practitioners. A busy doctor's office may book six to eight patients an hour. That allows less than 10 minutes per patient, without much wiggle room. Anyone requiring longer snarls the schedule.

What's more, Canadian doctors are seeing a greater proportion of complex patients, according to a 2010 survey of 18,000 Canadian doctors. The survey showed that only 61% of Canadian doctors were able to see an urgent case with a single day's notice - a figure that was down from 65% in 2007. Asked what was eating up their time, 72% identified increasingly complex patient caseloads.

If we're able to predict in advance which of our patients will be complex cases, we could allow those cases more time. That would mean we could manage schedules more efficiently - and our patients would spend less time in waiting rooms.

But a new study, which appeared in December in Annals of Internal Medicine, reflects how difficult it can be to arrive at a definition of complexity. A team affiliated with Massachusetts General Hospital and Harvard Medical School decided to ask doctors to select what they consider to be complex patients. The 40 participating doctors were shown 120 patients at random, then asked to select which ones they considered complex.

The results are fascinating. Independent predictors of complexity included factors such as age, poorly controlled diabetes, prescription of antipsychotics, alcohol-related problems and inadequate insurance. For older people, complex patients tended to exhibit a greater need for psychotherapy and care coordination. Patients who were non-compliant with appointments or medical advice were also deemed complex.

The results suggest that nonmedical issues count just as much as maladies when a doctor decides to spend more time with someone. "Our results demonstrate that in the primary care setting," researchers wrote, "physician-defined patient complexity reflects a wide range of medical, social and behavioural factors that seem distinct from other measures -"

Someone like Frank would never have been treated appropriately in a 10-minute appointment. Complex patients are best served if the doctor can spend enough quality time to assess the patient. The doctor also requires enough resources to co-ordinate after-care.

The challenge is getting everyone's agendas aligned to provide an affordable system that can support adequate time between clinician and patient. The system needs proactive solutions, not symptom-based "reactive" treatment. Band-aids can't stop the bleeding.

Originally published in the National Post, March 6, 2012.

At Medcan, we so believe in our Comprehensive Health Assessment (CHA) that we provide our employees with a complimentary one every year. Dr. David Macklin is a rising star among Canadian physicians who work in the weight-loss field. He joined Medcan last spring, and shortly after, he made an appointment to get his CHA.

What happened next attests to the potentially life-saving benefits of Medcan’s individual-based approach to preventative medicine. A moderate exerciser who pays attention to his diet, Dr. Macklin was the sort of person everyone expected to pass his physical. But something came up as he was going through his blood work with his supervising physician, Dr. David Wortzman. “He’s thinking I’m going to go through as the healthiest guy in the world,” recalls Dr. Macklin. “Cholesterol’s great, sugar’s great, and then we get to the very last thing: the result for the prostate-specific antigen test. It was 6. And we both knew what that means: 50-50. There’s a 50% chance it’s just an infection. And the other 50% is the C-word: cancer.”

“It was totally out of the blue,” adds Dr. Macklin. “I didn’t have any family history. Nothing on the physical exam. And I didn’t have any symptoms.”

A few days later, Dr. Macklin was talking with a good friend of his, who also happened to be a radiation oncologist. Dr. Macklin told his friend the results of the PSA test. “So what do you think?” Dr. Macklin said.

“I’ll get you in to see Tony Finelli,” said the radiation oncologist, naming a Toronto surgeon renowned as one of the rock stars of the prostate cancer field. “He’ll do your surgery.”

“Wait a second,” Dr. Macklin said. “Couldn’t it be benign prostatic hypertrophy?”

“Sure, it could be,” shrugged the radiation oncologist, whose gut instinct clearly told him otherwise. “But listen, I’ll get you in to see Finelli.”

Over the course of the summer, Dr. Macklin underwent a course of antibiotics that should have decreased his PSA score if the cause was infection. But his PSA score stayed the same. Next came a prostate biopsy. Dr. Finelli gave him the results. With the bluntness characteristic of a surgeon, he said, “Sorry Macklin, it’s cancer. Not only that, but it’s at a level where you need the surgery right away.”

Dr. Finelli didn’t stop there. “You’re lucky you got screened early,” the surgeon added. “Usually they don’t screen until 48 or 50. And I don’t think anyone would have ever been able to screen you.”

Dr. Macklin didn’t understand at first. “What do you mean? Of course they could have screened me.”

“No,” said Dr. Finelli. “You wouldn’t have been around.”

In other words, Dr. Finelli believed Dr. Macklin’s cancer would have killed him long before he was old enough to be screened under the government recommendations.

Dr. Macklin scheduled his surgery for early December. He spent the weeks leading up to the date trying not to think about anything related to prostate cancer. That was pretty near impossible, considering that November was Movember, the time of year that many men grow mustaches to promote prostate-cancer awareness. “Bank tellers, restaurant waiters—someone’s back would be to me, they’d turn around and there’d be the mustache,” the doctor recalls. “I would groan every time it happened.”

Finally, the day came. The procedure Dr. Macklin received was the same minimally-invasive high-tech treatment used by the Medcan urology team. The technique uses something called a Da Vinci machine, a precision robotic device that provides a surgeon greater control of the procedure, leading to decreased recovery times. Thankfully, the surgery went well and Dr. Macklin didn’t experience any lasting side effects. “We took a couple lymph nodes, too, just to be safe,” Dr. Finelli told him. “But we didn’t see any signs of spreading.”

Analysis of the excised prostate and lymph nodes revealed no cancer near the tissue’s edges—once again, suggesting it hadn’t spread. Another waypoint happened six weeks after the surgery, when Dr. Macklin’s PSA levels came back “undetectable.” He’ll undergo regular PSA tests for some time, and still faces a slightly elevated risk of another round of prostate cancer. But his prognosis is as good as it’s possible to get.

“Population-based guidelines suggest not to get the PSA until the age of 50,” Dr. Macklin acknowledges. “Medcan’s approach is individual- rather than population-based—that’s why we include the PSA test in the Comprehensive Health Assessment. I’m lucky I started at Medcan when I did. Getting this new job saved my life.”

Schedule a Medcan Comprehensive Health Assessment by calling (416) 350-5900 or emailing bookings@medcan.com.

By: John Mozas, President and Chief Operating Officer

Occasionally I’ll get some feedback, usually from our one of our longtime corporate clients—a commodities trader, say, who is on his eighth or ninth annual visit, and who doesn’t have any major health issues: “Why does the Comprehensive Health Assessment take four hours?” the e-mail says. “That’s too long for me to be away from my business.” It’s a sentiment that I understand, as does the rest of the Medcan executive team.

The challenge with the Comprehensive Health Assessment (CHA) is to provide an all-over examination of every aspect of health—while being considerate of our clients’ time. We try to get our CHA patients in and out of our clinic in about four hours, and we try to optimize the visit so that 80% of the process is spent in tests, while accompanied by a Medcan employee. The rest may be spent in transit from station to station, in the lounge eating or (most unfortunately) waiting for the next station. For some this wait time is a breather between stations, an opportunity to get ready for the next test. For others it’s plain and simple waiting, and they don’t enjoy it.

Achieving a four-hour medical on average takes a tremendous amount of behind-the-scenes logistics planning. When I started here in 2003 we only had two physicians handling 12 physicals a day. Today we have 10 physicians (from a total team of 55) working concurrently to handle up to 70 CHAs a day. Multiply those 70 CHAs by 15 different stations per client and that’s 1,050 appointments per day we’re coordinating for our CHA clients alone. The real complexity is that every station has a different duration and every client has different needs. Some may take 15 minutes for a stress electrocardiogram and some may take 30. Some have no issues to discuss with the physician and others may take more than 90 minutes. All this creates tremendous complexity.

Before I joined Medcan I was the GM of Grocery Gateway, the online retailer, where staff we called “pickers” filled grocery orders our customers submitted through the Web. At Grocery Gateway, one of many logistical challenges involved coordinating a picker’s movements to fill the average 40-item order as efficiently as possible. Our software development team created an algorithm that organized the list in such a way that the picker’s route minimized both distance and time.

Navigating Medcan’s fifteen unpredictable stations is a more complex version of the picker’s dilemma—and perhaps a software program could help us solve things, too. With a team of developers, we created an app called Patient Manager that debuted in 2004. The program is operated by a member of the Medcan team called a “flow coordinator”—the clinic’s version of an air traffic controller.

It works like this: The program begins tracking visit duration the second a client checks in on the 15^th floor. Patient Manager knows where the client has been, where the client is, how long the client’s been there and which stations the client still must complete. Crucially, Patient Manager (with the discretion of the flow coordinator) identifies the optimal station for the client to proceed to next. The software has helped us optimize each client’s visit: minimize the total duration of the medical, and create appropriate times between stations so the visit feels neither rushed nor slow. Most days, the flow of patients from station to station seems effortless because we are in a rhythm.

We’ve learned a lot about client preferences and logistics during the eight years we’ve been using Patient Manager, and along the way we’ve made a lot of tweaks to the program. Some of our stations, such as ultrasound and blood tests, require fasting, so they need to go early in the CHA to allow the client to get a breakfast bite and a coffee (this makes everyone happier). As the number of clients increased, the process became more complex, so we hired professors from the University of Toronto’s operations and statistics group to analyze the efficiency implications of grouping certain stations together—allowing us to break up the main clinic into three mini clinics to minimize the distance our clients walk.

We’ve also worked hard to optimize the amount of time a client waits between stations. When the client’s been waiting anywhere for ten minutes, a yellow frown comes up next to the client’s Patient Manager icon. At 15 minutes, the frown turns red. We track the number of reds we get each day at the clinic. Our ultimate goal? Zero reds through the course of a day.

The next major tweak we plan will see our clients able to specify a personal preference for how long the CHA should take. Is the client a repeat customer with few health concerns, who just wants to get in and out as soon as possible? Or would the client prefer lots of time between stations, to relax and allow the information they’ve received to penetrate? Perhaps we could create a sliding scale for time preference, which allows each of our clients to specify how long they’d prefer the CHA to take. And we’re also looking into creating an express CHA for people like the commodities trader I mentioned above, whose job responsibilities make it necessary to speed through all 15 stations as quickly as possible.

Our system isn’t yet perfect. When you’re dealing with nearly 1,400 appointments a day, 1,050 of them through the CHA, occasional backlogs happen. But we’re improving with each month that passes—and one of these days, we’ll eliminate the backlogs completely.

Leslie has graciously accepted to continue to be a Senior Advisor for Medcan on Nutrition and continuing medical and client education, as well as working with our Director of Genetics, Jill Davies, on launching our Nutrigenomics program.

Our clients’ nutrition and weight loss needs will continue to be served by Dr. David Macklin who specializes in weight loss through behaviour management, our team of registered dieticians and our weight loss coach. 

I tell everyone I know who is over the age of 45 or who has a loved one over the age of 45 (so yeah – I tell EVERYONE) that they should have a screening colonoscopy.

We have a lot of clients come to Medcan that meet the criteria to have a screening colonoscopy.

You meet the criteria to have a screening colonoscopy if you are over the age of 45 and you have never had one before. You also meet the criteria if it has been 5 years since your last colonoscopy or if you have a family history of colon cancer.

Unfortunately, we are seeing a trend of clients cancelling appointments or repeatedly rescheduling these appointments to the point they never come to have this important test. Here’s the thing: A screening colonoscopy really could save your life.

I’m training for the Around the Bay race (30km running race at the end of March). There are plenty of times when I don’t feel like going for a run, particularly when it’s cold out. Or icy. Or rainy. Or dark. Or early morning. In the words of my friend Jim….”Suck it up Buttercup”. That’s how I feel about people who want to put off their colonoscopy – suck it up, Buttercup and get it over with already!!!

March is Colon Cancer Awareness Month. This information is for everyone…because we all know someone over the age of 45.

By: John Mozas, President and Chief Operating Officer

Samantha* is a marketing executive who injured her leg in an automobile accident. She saw a doctor, who diagnosed her with a possible torn ACL and damaged meniscus, and referred her for an MRI. The problem? The MRI wasn’t for two months—and meanwhile, Samantha was hobbling around on crutches, unable to work properly, exercise or carry her kids. Now she faced two months of anxiety. Did she need surgery? Was the injury, in fact, a torn ACL? Or something more serious?

Luckily, Samantha was a member of our executive health program. The marketing executive called her Medcan Nurse Consultant, who engaged our specialist referral team. At that point, team leader Angela Hamilton began working the phones. According to Ontario’s own wait-time statistics, people in the province can wait for an MRI for anywhere between one to three months, depending on the hospital. But a short time later, Angela called back Samantha with great news: The Medcan team leader had found her an appointment just four days away.

Thanks to such remarkable results, I hear a lot of questions about our referral system. We regularly provide our clients appointments with specialists or imaging clinics within half the wait time posted on provincial tracking sites.

Many wonder how we achieve the results we do. Some believe we traffic in ‘favours.’ Plenty of regular people do that. Occasionally you’ll hear from a friend who obtained a next-week referral appointment through an acquaintance—a cousin or a neighbour, say, who happens to be a gastroenterologist. Sure that happens. But we take a different approach. It’s impossible to run a business as big as ours on favours (which, strictly speaking, are also off-side legislatively). In fact, we firmly adhere to the regulations specified in the province’s 2004 Commitment to the Future of Medicare Act. What we do is absolutely legal.

So how do we do it? Well, place yourself after work on a Friday afternoon. You’re at the supermarket to pick up a few things for the weekend, and the checkout queues are mayhem. How do you decide which checkout to select? Experience helps tremendously in a situation like this. If you’re a frequent shopper at this grocery store, then you know certain facts that will help you make a strategic choice. For example, you know that a new face behind the till is a warning sign—potentially a trainee, and a lot slower. But where’s that familiar, cheerful red-haired cashier? She’s lightning quick.

At Medcan, we’re in a situation that’s similar to the experienced Friday supermarket line selector. Angela Hamilton leads a team of nine that makes 40,000 referrals a year. (In comparison, the average physician’s office may make 500 referrals a year.) Over the years the Medcan team has acquired a tremendous amount of knowledge about the province’s queue geography. Backlogs can last for months—but those backlogs are not evenly distributed. Certain imaging clinics tend to have shorter lines; others, longer. Medcan makes it our business to discover which facilities tend to have the shortest queues.

The clinics themselves help with this. For example, one Toronto-area MRI facility recently realized that it faced a backlog of only 15 days. It sent out a notice to major sources of referrals—and we started sending our clients there. Then there’s our preferred provider network, which is a list of high-quality specialists who have been recommended by our on-staff physicians. These are specialists who are renowned in their fields, yet still have a good bedside manner. We’re ensuring our preferred provider network includes only Canada’s best specialists with the upcoming launch of a post-referral survey that asks our clients to provide feedback on the specialist appointment (this sounds basic, but no one does it!). We’ll use that information combined with clinical feedback provided by our on-staff physicians to continually refresh the network.

So choosing from the best-managed queues, among specialists with the best customer-service instincts—that’s important. But that’s only part of why we’re able to get our clients in to their referrals so quickly. Unlike in a supermarket, in our situation it’s also useful to know how to wait in the queues. The Canadian system is so overburdened that any specialist has a voice mailbox or fax tray filled to capacity. The trick, then, is to work out a way to get the receptionist on the phone. “We know it’s a waste of time to call during lunch hour,” Angela says. “We know not to call at the end of the day.” Some clinics answer the phones only on Tuesdays and Thursdays. Others, only on Wednesday afternoons, or exclusively in a 15-minute slot between 8:45 and 9:00 a.m. We keep track of this information, and distribute it among our team, because that’s our business. And we’re persistent in a way that many people just don’t have time to be.

Finally, experience helps when we get the receptionist on the phone. These receptionists have a tremendous amount of discretionary power. Recount the client’s situation in the right clinical manner, and some of them are able to slot in a particularly urgent case in under-utilized parts of the day—such as five minutes before the clinic’s official opening hour. Lots of specialists and imaging clinics maintain last-minute cancellation lists. We make judicious use of those as well.

So a faxed requisition from a physician’s office might garner a wait time of six months. But if you know which clinic to approach, know how and when to get the scheduling attendant on the phone, and know what to ask for when you do, then you can beat the system-wide average for wait times.  At Medcan, that’s our business.

John Mozas is Medcan’s President and Chief Operating Officer. To learn more about enlisting the services of our referral team, contact 416-350-5900 or email bookings@medcan.com.

*Name and identifying details have been changed.

Originally published in the National Post, February 21, 2012.

One of my good friends has gone through two rounds of company restructuring in five years. He’s a producer in the media industry, and the first happened when his freewheeling, anarchic company was swallowed by a comparatively more corporate broadcaster. A culture clash ensued, and a big round of layoffs. My friend worried he’d lose his job. He’d recount stories about the social withdrawal and depression he saw, and the people around him who took days off for “stress leave.” Meanwhile, he kept his head down and postponed any time off — he figured, the harder he worked, the harder he would be to fire.

Then, there’s a patient I saw recently. He’s a financial industry executive whose company merged with an investment firm. The investment firm featured executives who were high-octane. Porsche equivalents. They were Type-A guys who really hustled. His company moved a little more slowly, and amid the stress of the restructuring that followed, my patient responded to the stress by spending more late nights at work. He drank more, stopped exercising and slept less — classic symptoms of being stressed out.

I thought about these men recently as I read over two new articles about the health effects of mergers and acquisitions — a relevant topic amid our current period of economic uncertainty. The first study is a Canadian one led by researchers from the University of Calgary and published in January in Occupational and Environmental Medicine.

To conduct it, researchers followed 3,280 randomly selected employees for one year, assessing them along the way for job exposure to mergers and acquisitions as well as mental health disorders. Surprise, surprise: The employees who endured mergers or acquisitions had a much higher incidence of generalized anxiety disorder compared to those who did not — 6.7% of the M&A group had anxiety, compared to only 2.4% of the group that did not experience a merger or acquisition.

The second study, conducted by Dutch researchers and published in the January issue of the Journal of Occupational and Environmental Medicine, aimed to analyze exactly how the process of restructuring harmed the health of the people who survived it. If researchers discovered the mechanics of the process, they figured, then perhaps they could change the process, to improve things.

The Dutch researchers used an enormous survey called the Netherlands Working Conditions Cohort Study, about 9,076 of which satisfied the in-depth survey requirements. Conducted beginning November 2007, the survey focused on employees who had experienced a corporate takeover, or significant downsizing. The survey also asked employees to rate their own health on a five-point scale from excellent to poor. Respondents also were assessed with a tool called the Utrecht Burnout Scale, which analyzes employee response to statements such as, “I feel tired when I wake up in the morning and I am confronted with my job.”

Once again, it will be no surprise to anyone who has survived a restructuring that the study concluded: “Prolonged exposure to enterprise restructuring increased the likelihood of poor general health …” Also: “Emotional exhaustion was more likely in employees with prolonged exposure to enterprise restructuring …”

One interesting thing? The effects were temporary; employee health stopped deteriorating once restructuring stopped. But perhaps the survey’s most valuable finding was the extent that restructuring was less damaging than restructuring’s symptom: job insecurity. In other words, it’s not the restructuring itself, but the job insecurity that’s so harmful. The researchers speculated that the cause was multifactorial. When facing job insecurity, people experienced anxiety and elevated heart rates. They smoked more, and they ate less healthily.

Both the Canadian and the Dutch researchers provided some advice to corporate titans who wish to keep their employees in the best health possible. The Canadians suggested employers begin programs that promote mental health among employees after a merger announcement.

The Dutch researchers were more specific: They believed employers should do as much as possible to minimize the duration of a restructuring. Employers should “limit the time they expose employees to job insecurity during restructuring processes,” they said, adding that employee health would benefit from “open and clear communication,” with more involvement and consultation from rank-and-file employees.

All of that sounds good to me. Occupational health professionals have long known that employee health varies proportionally to the amount of control the employee feels at work. (The stress levers are demand vs. control and effort vs. reward.) The perception during a merger or acquisition? The employee has no control. There’s a feeling of potential doom — or at least, the ongoing possibility of layoffs. Employers should attempt to limit the instability. And as I told my friend working as a media producer, it would benefit the rank-and-file employees to engage in healthy, stress-busting pursuits, such as regular exercise, hobbies and spending time with loved ones.

In a world of perpetual change, invest time and effort within your sphere of influence. Improve your health, resiliency and happiness. The long-term personal “return on investment” will outlast the economic turbulent times.

“Companies that successfully re-qualify for the prestigious Canada’s 50 Best Managed Program are making a positive impact in the Canadian marketplace by pursuing innovation and investing in meeting the needs of their clients,” said Jon Hountalas, Executive Vice-President, Business Banking, CIBC.

Established in 1993, the Canada’s 50 Best Managed Companies is a national awards program, recognizing Canadian companies that have implemented world-class business practices and created value in innovative ways. Applications are reviewed by an independent judging panel that evaluates how companies address various business challenges, including new technologies, globalization, brand management, leadership, leveraging and developing core competencies, designing information systems, and hiring the right talent to facilitate growth.

About Canada’s 50 Best Managed program
Canada's 50 Best Managed Companies continues to be the mark of excellence for Canadian-owned and managed companies with revenues over $10 million. Every year since the launch of the program in 1993, hundreds of entrepreneurial companies have competed for this designation in a rigorous and independent process that evaluates their management skills and practices. The awards are granted on three levels:

1) Best Managed winner: one of the 50 new winners selected each year;
2) Requalified member: repeat winners retain the Best Managed designation for two additional years, subject to annual operational and financial review;
3) Gold Standard winner: after three consecutive years of maintaining their Best Managed status, these winners have demonstrated their commitment to the program and successfully reapplied for the designation. Companies may requalify for two additional years, subject to annual operational and financial review;
4) Platinum Club member: winners that maintain Best Managed status for a minimum of six consecutive years.

Program sponsors are Deloitte, CIBC, National Post, and Queen's School of Business. For further information, visit www.canadas50best.com. Visit the online community for private companies the Best Managed channel on the Financial Post Executive site: http://www.financialpost.com/executive/best-managed/index.html.

Medcan’s weight-loss team uses psychology, science and common sense to help you shed the pounds—and keep them off.

Sometimes the news that one is about to become a parent can prompt an evaluation of the way one lives. That’s what happened in insurance executive Greg Smith’s case. His wife became pregnant with the couple’s first child in the spring of 2011, and soon after that Greg found himself heading into Medcan for his annual Comprehensive Health Assessment. Aged 35, and standing six-feet tall, Greg Smith discovered during the Assessment that he weighed 335 pounds.

So when Mr. Smith’s doctor asked whether he was interested in learning more about Medcan’s new weight-loss program, the answer was yes. Medcan’s personalized and holistic 12-week program realizes that everyone is different when it comes to weight loss. Clients meet weekly with program coordinator Adele Tevlin, a nutritionist, and physician Dr. David Macklin, a weight-loss specialist, allowing the pair to create a custom lifestyle strategy that aims for a steady and sustainable path to health.

By combining the science of reward circuitry with behavioral psychology, we can help an individual understand what underlies their overeating patterns.

Mr. Smith’s initial appointment happened May 30, 2011. The first task was to determine Mr. Smith’s resting energy expenditure—the amount of calories his body burned simply to run itself at rest. That information, in turn, helps to determine the daily caloric intake that optimizes the body for sustainable weight loss. Eat too much, and the body gains weight. That’s common sense. But eating too little can be almost as bad. If you eat too few calories, you will feel hungry. Hunger works against sustainable weight. The body goes into starvation mode, a state humans have evolved over millennia to conserve energy during famine or drought. Starvation mode also makes weight loss extremely difficult.

The Bod Pod gives the most accurate view of an individual's body composition.

To determine the optimal number of calories Mr. Smith should consume each day, Dr. Macklin and Ms. Tevlin asked Mr. Smith to sit inside the Bod Pod, a computerized, egg-shaped chamber that uses a technique called Air Displacement Plethysmography to determine body-fat composition. By analyzing the volume of air a body displaces, the Bod Pod is able to determine an individual’s resting energy expenditure. With all this information, Dr. Macklin determined that Mr. Smith’s personalized calorie prescription was 1,800 calories per day.

Next, Ms. Tevlin and Dr. Macklin set about determining how to help Mr. Smith hit that target. “It became clear that Greg wasn’t over-eating 24-7,” says Dr. Macklin. “His problem calories were in pockets throughout the day.” One “trigger spot” was restaurant lunches, for example.

Ms. Tevlin found that Mr. Smith was setting himself to overeat at lunch thanks to the food he consumed every morning. Breakfast tended to be cereals, and then in his car, between appointments, he tended to stop at coffee shops for high-carbohydrate snacks like pastries or muffins. The problem? Digesting a pastry can cause insulin spikes, which causes blood sugar to crash only a short time later. “So Greg would be just ravenous heading into lunch,” Ms. Tevlin says. “And no one makes good choices about food when they’re ravenous.”

To beat the cycle, Ms. Tevlin “front-loaded” Mr. Smith’s eating by making sure he ate a protein-rich breakfast, such as eggs, Greek yoghurt or cottage cheese. Then, two or three hours later, she encouraged him to have a mid-morning snack—but rather than the coffee-shop pastries he once consumed, Mr. Smith should have protein-rich nuts, and some fruit. Lunch didn’t entail huge changes. Ms. Tevlin encouraged Mr. Smith to eat sandwich-and-salad combos, with the sandwiches made with whole-wheat bread around a protein, such as chicken, turkey or tuna. Or perhaps lunch was a protein-rich salad, with the dressing on the side.

Mr. Smith could still go out for restaurant lunches—but before he left the office, he should plan in advance what he was going to order.

Meanwhile, Dr. Macklin worked a lot on the behavioral science behind Mr. Smith’s eating. Lunch at a restaurant or a pub could prime Mr. Smith for an atmosphere of indulgence, Dr. Macklin discovered—an attitude of “just this once” that could lead Mr. Smith to order high-calorie ice-cream desserts, or burger-and-fry entrées. So Dr. Macklin engaged in some behavioral psychology. “For years, Greg’s brain has associated this lunchtime-restaurant setting with sugar and fat, which in turn creates a powerful dopamine response in the ancient reward brain,” Dr. Macklin says. “It’s addictive. But by combining the science of reward circuitry with some behavioral psychology, we can help an individual understand what underlies their overeating patterns—and then counteract them.”

According to Dr. Macklin, Mr. Smith could still go out for those stress-relieving restaurant lunches—but before he left the office, he should plan in advance what he was going to order. And he should do that by calling up the restaurant’s menu, online, and writing down his order before he ever left the office. “The idea is to create a plan without any options,” Dr. Macklin says. “All that is left is to execute the plan.”

“So I know walking in the door I’ll have a steak salad with dressing on the side,” Mr. Smith says. “That was a big breakthrough for me. Planning in advance was a tool that empowered me more than I knew I could be empowered. I found that incredibly fascinating—each time I saw Dr. Macklin it was like a miniature course in the science of human behavior.”

Eating high-carb snacks can sabotage your plan at meal times.

Mr. Smith also could use similar planning techniques during his other trigger times, such as dinners out with his family. To counteract night-eating, Ms. Tevlin and Dr. Macklin encouraged Mr. Smith to snack several times in the afternoon, so that he’d already consumed three-quarters of his daily calories before he started dinner. The strategy, once again, was designed to ensure that Mr. Smith wasn’t ravenous when he sat down for one of the day’s major meals.

Dr. Macklin assessed Mr. Smith with the Bod Pod for the second time in November. At that point he’d lost 70 pounds—and with the help of the Bod Pod, Dr. Macklin was able to determine that most of that weight was fat, rather than muscle.

Since then, Mr. Smith has lost another 15 pounds, bringing his total weight lost to 85. From a start weight of 335, he now weighs 250 pounds, and he’d like to get down to 235 or 220. Mr. Smith and his wife celebrated the arrival of their first child, a baby girl, on December 1. Now he’s certain he’ll be able to keep up with her.

“It’s amazing,” Mr. Smith marvels. “This January was the first in years that I didn’t resolve to lose some drastic amount of weight. There’s nothing crazy or unnatural about what I’m eating. I’m not hungry. Yet I feel a hundred per cent better. I sleep more soundly. I have way more energy. You don’t realize how good you can feel until you lose the weight.”

Interested in crafting a personalized weight-loss strategy with Dr. David Macklin, weight-loss coordinator Adele Tevlin and the rest of the Medcan team? Contact bookings@medcan.com or 416-350-3621 today.

Originally published in the National Post, January 17, 2012.

Over the holidays I took my children to get their flu shots at our pediatrician’s office. Only one parent was allowed to go into the office with them. My wife and I left it up to the kids to choose who they wanted. And they chose their mother. I’m the doctor, and yet they chose their mother!

In any event, the experience allowed me to spend some time in an area of the medical profession I see only rarely: the waiting room. Many of the children around me exhibited the red nose and frequent sneezing of those suffering from the common cold. And I noticed something: All of the small children were coughing into their sleeves.

Years ago, parents would tell kids to use their hands to cover their mouths when they coughed. Then those children would use the same hand to touch subway poles, escalator railings or door handles, transmitting the germs they just coughed out. Then came “sleeve sneeze” public health campaigns. So far as I can tell through media database searches, Toronto’s began in 2006, amid increasing concerns about the pandemic flu. Whenever it started, the “sleeve sneeze” campaign must be one of the great public health victories of the early 21st century: Everyone seems to use it.

I do wonder, however, whether we’re all becoming a bit too paranoid about germs. I include my own family in this group. Once we left the doctors’ office, for example, my wife and I encouraged our children to use a hand sanitizer. When our kids were toddlers our house had alcohol wipes and Purell vials all over the place. But is all this washing and disinfecting really necessary? Is it proactive prevention? Or overly paranoid fear?

That, at least, is the thinking behind the “hygiene hypothesis,” a school of thought first proposed by David P. Strachan in 1989, and now experiencing a resurgence that’s probably a response to society’s mania for cleanliness. Strachan’s original study sought to explain why British kids with greater numbers of older siblings had fewer incidences of hay fever, speculating that perhaps it could be the fact kids with lots of older siblings tend to be exposed to greater numbers of germs. While it was greeted with skepticism early on, Strachan’s theory has since been confirmed. In fact, in the decades since, greater exposure to germs early in life has also been associated in epidemiological studies with lower levels of asthma, some allergies and even such autoimmune diseases as type-1 diabetes and multiple sclerosis.

For example, a study published in the New England Journal of Medicine in February 2011 found that kids who grew up on the comparatively microbe-rich environment of rural farms “had lower prevalence’s of asthma.”

The paper analyzed two large, longitudinal studies based on more than 16,000 elementary school children located in south Germany, Switzerland and Austria. The researchers collected and analyzed dust from the children’s homes. They found that dust from farming homes contained more microbes than suburban homes, which stands to reason. What’s more, researchers believe this explains the farm kids’ significantly lower incidence of asthma. The remarkable thing? How big the difference was; in one of the studies, farm kids had half the asthma rates of the greater population.

“These data support the idea that the greater diversity of microbial exposure among children who live on farms is associated with the protection from the development of asthma,” study researchers reported, speculating that microbial exposure may encourage development of immune system cells that in turn suppress the production of the sort of immune-system cells that trigger asthmatic reactions. Researchers’ next hope to determine which microbes are most responsible for preventing asthma — and that, perhaps, may lead to new therapies, such as targeted microbe exposures, for the dreaded respiratory malady.

More broadly, the study is a reminder that humans have been living and fighting off germs for tens of thousands of years. Particularly when we’re young, germs serve an important purpose for the development of the immune system. By depriving our children of exposure to germs, we may be depriving them the benefits of a process the human body has evolved over aeons, a process that helps to create healthy and allergy-free adults.

I’m not suggesting we give up the sleeve sneeze. Nor am I suggesting that parents encourage their kids to go out and intentionally expose themselves to germs, by licking the surfaces in subway cars or attending chicken-pox parties. As in most things, it’s balance that’s important. Maybe we recognize we’re becoming a bit paranoid about germ exposure. Maybe we pare back a little bit on the Purell and the hand-washing (unless the risk of significant infection is high). After all, germs are one of those things that complies with the old adage: What doesn’t kill us often makes us stronger.