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.
Officers and Councillors 2007-2008
President - Dr. Robert E. Rae, Saint John
Mr. Jean Daigle, Dieppe
Dr. Santo Filice, Moncton
Registrar - Dr. Ed Schollenberg
Dr. Anthony London, Saint John
Dr. Lachelle V. Noftall, Fredericton
Dr. Teréz Rétfalvi (PhD), Moncton
Dr. Malcolm W. Smith, Tracadie-Sheila
At its meeting on 20 March, 2008, Council considered the following matters
A patient undergoing chemotherapy saw a specialist for an apparently unrelated condition. Over the course of several months, that condition deteriorated. The patient alleged that the physician failed to properly consider the impact of her complete medical situation in monitoring her. The Committee agreed. The Committee felt the physician should have been more cogniscent of the effects of certain aspects of the patient’s chemotherapy treatment. The Committee felt that the physician had been appropriately reminded of the issue, but felt a more extensive review of the physician’s practice may be necessary.
A patient had requested a particular type of investigation from a specialist. The physician determined that the patient’s clinical condition did not warrant such. The patient went out of province to have the investigation, which purportedly showed some abnormality. On reviewing the matter, the Committee noted that the patient had accessed certain physicians who had claimed expertise in a particular area, but such was open to question, as was their interpretation of the patient’s results. Physicians are reminded that, whether it is an investigation or treatment, such should only be offered in the patient’s best interests.
A patient presented to her local hospital with an apparent exacerbation of a chronic problem. She had been followed for this at a regional centre. The Emergency physician attempted to contact a consultant at that centre for assistance. The consultant refused to take the call. In response to the complaint, he stated he had no responsibility to respond to patients from the other hospital. This was a policy implemented by his department. In reviewing the matter, the Committee noted that physicians have been repeatedly reminded of their professional obligation in this regard. They are to accept calls from other physicians in order to determine what assistance, if any, may be offered. In this case, the patient was actually being followed by a colleague. The Committee reminded the physician that to simply refuse such a call did not meet his professional obligations.
There was an allegation that a physician had failed to actively intervene with a patient who was expressing self-destructive thoughts. Based on the specifics of the case, the Committee could find no fault with the care provided. However, the Committee wished to remind physicians to familiarize themselves with risk factors, such as access to weapons, which could warrant more active intervention.
A patient had made arrangements for a family member to pick up copies of her records from her former physician. The family member was unable to attend and sent an acquaintance. The records were handed to the acquaintance without clear verification that the person was entitled to receive such. In response, the physician acknowledged that this was an error on the part of his staff, which had been corrected.
Physicians are reminded that it is never considered ideal for records or other information to be passed directly to a patient, as opposed to another physician. Nevertheless, for practical reasons, this is done from time to time. In those circumstances, every effort should be made to ensure that the person receiving the information is authorized to do so.
In addition, the Executive Committee took interim action against two physicians. One was suspended due to acute incapacity. Another had restrictions placed on his ability to prescribe certain medications.
STORAGE OF RECORDS
This is to advise members that the guideline on records storage has been modified. Physicians will now be allowed to scan and keep electronic copies of all records, allowing the originals to be destroyed in an appropriate fashion. Copies can then be generated from the electronic version when necessary.
ENDING THE DOCTOR/PATIENT RELATIONSHIP
Council has amended the previous policy on this matter to provide somewhat clearer language. The basic intent remains unchanged. In any case, if physicians have any questions, or run into any difficulties, they are encouraged to contact the College office.
An important element of appropriate patient care is an ongoing, consistent, stable relationship between patient and physician. Because of the value of this relationship, and the significant harm that can follow to patients when alternate care is not available, the decision to terminate care to a patient should be a difficult one. Unless alternate care can be immediately arranged, such a decision should only be made in unusual circumstances and for the best of reasons. Otherwise, the physician could be subject to a complaint of abandonment.
It should first be noted that there are only a few circumstances where such a decision to terminate care could be made without advance notice to the patient. These would be generally limited to cases involving illegal activity or fraud, usually for the purpose of improperly obtaining controlled drugs or substances.
In contrast, there are also situations which should rarely, if at all, be considered as sufficient grounds to terminate care. These would be situations where a patient was asserting their rights to have the physician meet ethical obligations. Patients have the right to information, to ask questions, to insist on informed consent, and to make reasonable requests for second opinions. They also have the right to accept or reject any intervention or treatment offered by the physician. It is only when such a decision adversely affects the doctor/patient relationship in a fundamental way that the physician may consider the option of asking the patient to find care elsewhere.
Difficulties can arise in situations between these extremes. In those circumstances, the physician is obligated to communicate the nature of the problem directly to the patient, making it clear that there is a potential for the patient to be discharged from the practice. It is only if the situation does not resolve after such notice that the physician can formally advise the patient that the relationship is being concluded.
When such a final decision has been made, it should be communicated directly to the patient, preferably by registered mail. The patient should be advised that ongoing care will be provided for a reasonable period of time to allow them to make alternate arrangements. In some circumstances, a period of two to three months is considered appropriate. The patient should also be advised that relevant records will be forwarded to a new physician on request.