cbd communityDecember 15, 2021
Download Lead the Change training module overview, 5 Actions to lead CBD in your program.
What major lesson have you learned? Don’t use the word “pilot” in the context of CBD implementation. As soon as you market something as a pilot project, your level of engagement goes down. People see pilots as not quite real – that you’re doing it for the sake of management instead of for the benefit of the participants. My advice would be to just do a project or don’t do it. But never sell CBD implementation as an experiment.
Final prototype testing almost complete.
The Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada and the Collège des médecins du Québec maintain national standards for the evaluation and accreditation of Canadian postgraduate medical training institutions and their residency programs across Canada’s 17 medical schools. Together they form the Canadian Residency Accreditation Consortium (CanRAC) and the collaborative relationship has resulted in CanERA.
The theme for the 2019 conference, “ Diversity in Residency Education: Training in a World of Differences ” will inspire forward-looking programming that explores issues, innovations and research related to diversity in residency education.
The aim of CanERA is to.
Built by CanRAC, proudly Canadian.
How are you tackling the big issue of engaging your faculty and managing their expectations? It’s going well, but we can always do better. One issue for internal medicine is that the program is so large. We have 100 residents and hundreds of staff at multiple locations, so it’s a real challenge getting everyone to buy in.
If you could pass on one piece of advice to another program director embarking on CBD implementation, what would that be? Communication is the big thing with all our stakeholders, be it residents, staff, the department leadership, everyone. And not just communication from us about what they should be doing or what to expect, but also hearing communication from them about their concerns and ideas, and making sure great ideas are brought forward. That’s how you encourage engagement and get results.
Following many years of collaboration, Canada’s new accreditation system will officially launch on July 1, 2019. Known as CanERA (Canadian Excellence in Residency Accreditation), this new system for residency education accreditation emphasizes outcomes focused on program quality, while embodying the values of efficiency, consistency and continuous quality improvement.
In talking to program leaders across the country about the challenges of implementing Competence by Design (CBD), the single most frequent issue that I hear about is the difficulty engaging faculty. As we know from neuroscience and psychology, we are wired to resist change as it requires us to replace our trusted standard operating procedures with new behaviours and habits. Our brains, which are ruled by two different systems — the rational and emotional —often have competing needs. As Chip and Dan Heath said in Switch: How to Change Things When Change is Hard , the rational mind wants a great beach body and the emotional mind wants an Oreo cookie.
To support the transition to CanERA, including familiarization with CanAMS and the new standards, a series of stakeholder-specific training, tools, and supports have been developed, and can be found on the CanERA website.
How are the faculty and residents of the Internal Medicine program reacting to the implementation of CBD? What’s the vibe right now? I’d say the attitude is one of cautious optimism. We definitely see the benefits of CBD. In particular, our PGY1 group that’s transitioning has engaged strongly and is doing well, which says to me that we’re on the right path. We just need to make sure we stay on it.
Dr. Steven Katz is director of the core internal medicine program, and associate chair, postgraduate medical education for the Department of Medicine at the University of Alberta. In this discussion, we check in with Dr. Katz about his program’s progress implementing CBD – in particular, the department’s success engaging faculty and residents.
These simple actions are about, in the wise words of organisation change guru Peter Block, building agency and true engagement of faculty by “confronting them with their freedom” versus overpowering with compliance (“have to”). This will enable faculty, who are vital to the work of CBD, to take responsibility for making it happen.
ICRE 2019 will be held in Ottawa, Canada, September 26-28, 2019.
What has been your biggest challenge in implementing CBD? This is a massive change-management exercise that requires people to establish new habits and a new culture of learning. We need to make sure we understand people’s concerns and the best ways to overcome them.
A big part of the challenge is in getting faculty to understand the importance of being open to providing residents with feedback. We want residents to try EPAs they don’t necessarily feel confident about so that they can learn by doing. And for that to happen, we need staff to give residents the impression that it’s okay to ask questions. It’s a concern because each staff member has to want to do it. We need to find the right carrot for everyone and that takes time.
Throughout the prototype testing, CanAMS has been accessed and tested by other key users including surveyors, specialty and accreditation committee members, and staff. Valuable feedback has been collected throughout this process and improvements to CanAMS (both planned and based on prototype feedback) are being incorporated, as appropriate.
So how can we apply these valuable insights to help you engage your faculty in CBD?
What are you particularly proud of? Our residents have been amazing through this transition. We have full CBD implementation already in Edmonton. It says a lot about the residents and their character that they’ve been successful in making this work, so I give them full credit.
Tools available at www.canera.ca.
CanERA introduces the following key features.
Currently, CanAMS access has been provided to the two P3 Universities, as well as to Western University and the University of British Columbia. The next group release of CanAMS, which is currently in progress, includes the University of Toronto, University of Montreal, Northern Ontario School of Medicine (NOSM), University of Manitoba, and University of Calgary. The final two group releases of CanAMS are anticipated for winter and spring 2019.
For more reading:
How do you see your program, faculty and residents benefitting from CBD? If done well, CBD creates an environment where faculty and residents are engaging in better feedback. It means residents can identify where they need to improve and, ideally, they’re doing that earlier under CBD. For faculty and administration, there’s a great benefit in identifying issues with residents earlier and giving them resources they need to get on track. The process of self-reflection and subsequent improvement makes for a better resident and a better physician down the road.
As part of CanERA, implementation of the new accreditation management system called CanAMS is also well underway. It is important to note that as we transition to this new system, the Royal College is allowing time to learn and adjust, and is supporting schools and their residency programs through this transition.
Although the prices per unit are near $60 to $70, Mills said she had no problem quickly selling out of CBD. She recommended placing the products near the register and within a locked case. If utilized with caution, CBD has the potential to substantially improve the revenue of a community pharmacy.
"It does mess with other drugs, there are studies that show this,” she added.
With the legalization of CBD products in 2018, many questions have emerged, not only on the laws governing these products, but on how to integrate CBD into community pharmacies. A presentation at the 2019 NCPA Annual Convention covered legal issues and strategies for how these products fit into a pharmacy.
“Be careful what you say about CBD. Be careful what you communicate about CBD. Pay attention to your state and the federal regulations of CBD as well,” said Karla L. Palmer, Esq, director, Hyman Phelps & McNamara, P.C, at the NCPA meeting. “Pay attention to the FDA’s website for warning letters. This is a very gray area, in terms of what is permitted, and what isn’t permitted. It’s legal, but we don’t know what you can and cannot do with it, but FDA is making headway about what you can and cannot say about CBD. Pharmacists need to be careful.”
Since its legalization, many formulations of CBD have emerged, some with low levels (<0.3%) of THC (labeled as full spectrum) or THC-free isolates. Additionally, differences exist between products, based on extraction method. CBD has been formulated into different methods, including oils, capsules, balms and salves, vape or flowers, and edibles. The edibles, since added to food, can present potential regulatory issues, Mills warned. The quickest acting method are the oils, she added, but the method with the highest bioavailability is through the lungs.
Some of the adverse effects of CBD could include drowsiness, GI upset, and drug interactions, as CBD uses CYP enzymes for metabolism. There have been signs of liver issues in some studies, Mills noted. If an individual is on a narrow therapeutic index drug, continue to monitor the patient once the begin taking CBD.
Despite not being illegal by federal law, the FDA still has the authority to regulate cannabis and cannabis-derived compounds. Moreover, the FDA has announced that it is unlawful to introduce food containing CBD or THC into interstate commerce or to market CBD or THC-containing materials as a dietary supplement. While it is not illegal, FDA can and will still take enforcement action.
Although the federal law allows for hemp, other laws still greatly vary from state to state, as does the definition of hemp. Staying up to date on the regulations is one of the more challenging issues, as the laws around cannabis, CBD, and hemp are evolving rapidly, Palmer noted.
"CBD interacts with our endocannabinoid system at CB1 and CB2 receptors. It interacts indirectly, unlike marijuana, and in 2019 we really aren't sure how it works," said Jesica Thomason Mills, PharmD, MBA, RPh, CNHP, Pharmacist, Naturopath, Hemp Expert, Owner, Owensboro Family Pharmacy and Wellness. "The endocannabinoid system uses neuromodulatory lipids to wake and strengthen the immune system, nervous system, and digestive system."
With the passage of the Hemp Farming Act of 2018, regulation of cannabis became based on THC content. Under the law, if the THC content is below 0.3%, it is considered hemp and no longer defined as marijuana. This allows hemp to no longer be defined as a controlled substance by the Drug Enforcement Agency. The passage of this law allowed for interstate commerce of hemp-derived products and established a framework for regulation of hemp production, although regulation is still in its infancy. For the most part, the law leaves it up to the states to regulate hemp production and marketing.
Unlike marijuana, CBD is nonpsychoactive and does not result in feelings of euphoria or intoxication, even if large quantities are taken. In addition to the endocannabinoid receptors CB1 and CB2, CBD also acts on the serotonin receptor, vanilloid receptors, orphan receptor, and nuclear receptor.
"The best thing to do is to lay low on what you're claiming for your CBD. Be careful of your website and social media claims," Palmer said. "Disease claims are not permitted for dietary supplements, food, or cosmetics. Since Epidiolex is approved, CBD cannot be a supplement. You can say you have it, but be very careful not to say it is for anything."
Although CBD is not meant to treat, mitigate, or prevent a disease, many patients believe in its effects. In most cases, they take oils for systemic issues, such as chronic inflammation, and balms for localized concerns, like joint pain. Moreover, the THC-free isolate version of the oil allows individuals to take CBD without failing a drug test, Mills noted. However, all full spectrum varieties of CBD will cause a positive drug test result.
For her patients and even local providers, Mills holds educational events on CBD in her pharmacy, with samples available. She has also used social media to promote the availability of CBD at her pharmacy, but noted that potential issues have occurred on Facebook and with credit card vendors to process payments.
Mills J, Palmer K. Hemp: Positioning Yourself as the Truth Expert. Presented at: NCPA 2019 Annual Convention & Expo; October 26, 2019; San Diego, CA.