This Bulletin is forwarded to every medical practitioner in the province. Decisions of the College on matters of standards, amendments to Regulations, guidelines, etc., are published in Bulletins. The College therefore assumes that a practitioner should be aware of these matters.
President - Dr. Marc Panneton, Campbellton
Registrar - Dr. Ed Schollenberg
At its meeting on 11 April, 2003, Council considered the following matters:
There was a complaint that a physician had written a prescription for a patient not seen. The prescription was then filled by a third party and sent to another country where the medication was not easily available. The physician involved plead guilty to a charge of professional misconduct for misuse of the authority to prescribe and received a penalty of an unpublished reprimand.
An elderly patient had been admitted for persistent somnolence. The underlying diagnosis was illusive, despite the involvement of several consultants. The complaint suggested that more aggressive investigation and treatment should have been instituted. In reviewing the matter, and noting developments which occurred when the patient was transferred to another centre, the Committee could find no fault with the care provided. The eventual diagnosis proved to be extremely rare, there was no evidence that any treatment would have altered the course, and there was no rationale for treating such a condition before its diagnosis.
There was a complaint regarding the management of a patient with chest pain in an Emergency Room. The patient had attended twice and was sent home both times. Symptoms were non-specific, but the patient was hypertensive, with a family history of heart disease. Investigations were equivocal. The patient eventually succumbed to a heart attack. There was an allegation that the patient was not adequately assessed on the earlier visits. The Committee felt that these matters can be extremely difficult to judge after the fact. The facts of this case did suggest some factors which would have had this patient admitted in many circumstances. Nevertheless, considering the entire picture, no specific fault could be found with the care provided.
There was a complaint that a physician had missed the diagnosis of a fracture and dislocation of the shoulder. For several reasons, the patient was very difficult to examine. Furthermore, there were limited radiology services available at the hospital. In reviewing the matter, the Committee noted that, under these circumstances, this was the kind of diagnosis which could be missed. There was no evidence of significant harm to the patient. The Committee felt that no action need be taken on the matter.
A patient was seen by a series of three surgical consultants. After almost a year, a specific diagnosis was reached. The patient complained that the initial assessment by the first specialist was insufficient. The Committee felt that, under the circumstances, wherein the patient had an unusual diagnosis, which took the expertise of several physicians to reach, no fault could be found with the initial process.
A patient was traveling from out of town and found herself needing a prescription renewal. She was directed by the Emergency Department to a walk-in clinic. There she was requested to discuss the nature of her condition with a receptionist. She advised the receptionist that she only wished to speak with the physician and was told that she, consequently, could not be seen. A discussion followed which deteriorated into an argument. The physician eventually intervened and, again, asserted that he would not see the patient unless such matters were disclosed to the receptionist. On reviewing the matter, the Committee noted that the situation created several risks. First of all, while it may be appropriate to determine whether the patient can be appropriately seen in such a facility, any denial of treatment on the basis of a particular medical condition could create the risk of a complaint of discrimination. Under these circumstances, since the physician had intervened, it would have been most appropriate for him to deal with the matter directly rather than continuing to insist on a particular approach.
A patient was seen at a walk-in clinic and, after discussion with the physician, certain investigations were ordered. However, when the patient presented to the hospital, it was determined that the requisitions had not been forwarded. In response the physician stated that, so far as he knew, he had made the necessary arrangements. In reviewing the matter, the issue appeared to be a clerical error at the clinic. The Committee could not fault the physician for such.
A physician had agreed to provide a physical examination in order for a patient to get a particular license. The Regulations involved required that the report be forwarded to the relevant agency within seven days of the examination. The physician failed to do so and, as a consequence, the patient was denied the right to apply for the license. The Committee noted that the physician was aware of the time requirements and should not have agreed to provide the service if he knew he was unable to meet them.
A family physician was following a child with an unusual diagnosis. Several consultants had recommended certain investigations be done on the child. When the family physician sought to order them, the family resisted. As the physician felt this placed the child at significant risk, the family was reported to Child Welfare authorities. The family complained that the physician had acted inappropriately. In reviewing the matter, the Committee felt that the physician had, in contrast, acted completely properly. The recommendations from the consultants were very clear. The child was at significant risk if the recommendations were not followed.
There was a complaint regarding the communication difficulties between the family of an elderly patient and her physician. This was one of a series of similar such matters wherein difficulties in communication arise, particularly when the physician is dealing with a large family, or when dealing with a family member at a distance from the location of the patient. The dispute concerned the resuscitation status of the patient. These are matters which can easily be the source of difficulty. Physicians need to be mindful of the risks involved in these discussions, appreciating the stressful nature of this situation.
PHYSICIANS AND THE PHARMACEUTICAL INDUSTRY
After receiving some follow-up to the issue raised in the last Bulletin, Council has decided not to develop a specific policy in this regard. As members will recall, the issue concerned whether members could be improperly influenced in prescribing when they are compensated directly for involvement in a company-sponsored post marketing survey. Council felt the existing guidelines should cover the matter, but will continue to monitor the situation. Members are reminded that, regardless of the circumstances, the only concern in decisions regarding therapy should be the patient's best interest.
SEAT BELT EXEMPTIONS
While the Motor Vehicle Act does allow individuals to be exempt from the requirement to wear a seat belt, members are reminded that the Canadian Medical Association Determining Medical Fitness to Drive guidelines make it very clear that there is no medical indication for such an exemption. As a consequence, the issuing of such a certificate is considered to be unacceptable practice. In addition, issuing such exemptions may create significant liability issues. To that end, when the College becomes aware that a physician has issued such a certificate, a reminder will be issued of the appropriate standard of care.
CO-SIGNING OF PRESCRIPTIONS
The College has become aware that physicians are being approached by various entities to provide their signatures to prescriptions issued in the United States, but which could then be filled by a Canadian pharmacy. While these approaches have mostly previously been aimed at members living in the United States, it now appears that physicians in New Brunswick are being approached as well. Physicians are reminded that the co-signing of a prescription, without the possibility of direct patient assessment, is considered improper and could result in a complaint and disciplinary action.
Council declined to adopt guidelines taken in several provinces on direct "after-hours availability" to patients. It was Council's view that these statements were of such vague language as to be unhelpful in defining any particular responsibility. Furthermore, situations obviously vary a great deal from community to community.
- Council approved a joint policy of the New Brunswick Pharmaceutical Society regarding prescription refills. Modeled on that taken in several other provinces, this would, in very limited circumstances, allow a pharmacist to renew certain prescriptions when they are critical to the patient's wellbeing and the patient's physician is temporarily unavailable.
FROM THE ARCHIVES
90 years ago
In 1913 Council approved reciprocity with the United Kingdom. There were 254 physicians registered in the province. Council approved an increase in the registration fee to $30., but decided to allow the annual license fee to remain at $1.
60 years ago
In 1943 Council passed a resolution suggesting that Canadian medical schools deny entry to all foreign-born applicants, and approved increasing the annual fee to $20., which was shared with the Medical Society.
30 Years ago
In 1973, Council was considering an approach to assessing foreign-trained specialists, considered increasing the annual fee to $42., and decided to remove psychiatry from the required content of a rotating internship, except in the case of foreign graduates.