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 2009-2010
President - Dr. Terrance Brennan, Fredericton
Mr. Jean Daigle, Dieppe
Dr. Robert J. Fisher, Hampton
Dr. François Guinard, Edmundston
Registrar - Dr. Ed Schollenberg
Mr. Paul Leger, Rothesay
Dr. Lachelle V. Noftall, Fredericton
Ms. Karla M. O'Regan, Fredericton
Dr. Lisa Jean C. Sutherland, Rothesay
Dr. Mark Whalen, Campbellton
At its meeting on 26 March 2010, Council considered the following matters.
Two unrelated complaints dealt with the obligation to follow up investigations. In general, the obligation to follow up a particular investigation falls on the physician who ordered it. However, this can be modified by the context. Both matters concerned follow-up to a positive chest CT scan. In the first case, the patient had been followed at a regional centre, with reports being forwarded to his family physician. The family physician presumed that the physicians at the regional centre were dealing with all matters arising from these investigations. The physician asserted that the patient himself had stated that this was the case. At one point, follow-up to an investigation did not appear to occur and there was an allegation that the family physician had failed to meet her obligations. In this context, the Committee felt it could not fault the family physician for presuming the patient was being appropriately looked after. The Committee did feel that greater communication between all involved could have avoided any confusion regarding the issue. In the second case, a CT scan was ordered by a consultant and the report forwarded to the family physician. The required follow-up was clearly beyond the scope of the consultant’s specialty. Nevertheless, there was no evidence that the family physician had responded in any way at all to a significant positive finding. Furthermore, the physician declined to provide any response or other explanation to the complaint. In considering the lack of explanation, and the failure to respond, the Committee felt it appropriate to issue a formal Censure to the physician.
A patient presented to a walk-in clinic with respiratory symptoms, which were felt to be an exacerbation of the patient’s asthma. However, the next day, the patient died suddenly. The cause of death was not established. There was an allegation that the physician had failed to assess the patient properly. In response, the physician asserted a number of negative findings suggesting no evidence of significant pathology. Absent any evidence of deficient care, the Committee could find no fault with the approach taken.
A patient without a family physician had been attending a local Emergency Department in follow-up to a work injury and her gradual return to her employment. She saw a series of physicians who each allowed her duties to gradually increase. However, the last physician seen asserted that she was not returning to work quickly enough and refused to provide for any significant relief from her duties. In this context, the Committee wondered whether the physician had prejudged the patient before providing an appropriate assessment regarding her status. In that light, and noting also a failure to respond to the complaint when requested, the Committee felt it was appropriate to warn the physician with a formal Caution.
A couple complained that they were improperly discharged from a physician’s practice. The patients’ original physician had retired and they had only seen the new physician for a short period of time. One of the patients was on a broad range of drugs which the new physician thought was unnecessary and made efforts to reduce. The patients objected and the relationship deteriorated quickly. In response, the physician felt that the departure of the patients was inevitable. She felt they had been properly warned about the possibility of terminating their care. In any case, there were also significant suspicions of them accessing medication from another source. As a consequence, she felt she had no alternative but to discontinue treating them. In reviewing the matter, the Committee noted that, in most circumstances, the physician is expected to provide a clear warning regarding any outstanding difficulties which could result in discharging the patient. One possible exception is where there is evidence of improper access to medication.
A patient died shortly after admission to a hospital. He had presented with respiratory distress and evidence of heart failure. Treatment was initiated after some delay, but a number of investigations, including a cardiogram, blood gases, as well as cardiac enzymes, were not done. The patient was not admitted to intensive care, nor monitored in any reasonable fashion. There were also concerns regarding the care provided by other professionals. The Committee felt it was the physician’s ultimate obligation to assess the patient appropriately and, if local services are insufficient, to arrange for transfer of the patient to another centre. The errors involved suggested the need for a formal Censure, expressing the Committee’s disapproval of the approach taken by this physician.
A child was taken to a clinic with an upper respiratory infection. In order for the child to return to daycare, it was necessary for her to have a note from a physician. The physician declined to provide any note, stating that it was the policy of the clinic to not do so. In response, the physician asserted that this was a policy imposed by the clinic, which was mainly to deal with influenza patients. In reviewing the matter, the Committee noted that any such policy would not apply to the case in question. There was no evidence that it would create any hardship to the physician to provide a brief note, as requested by the family. The Committee did not feel the physician’s response was appropriate.
There was a complaint concerning involuntary retention of a patient in a hospital, the Committee felt that the physician should be warned, through a formal Caution, that, in such circumstances, the procedural requirements of the Mental Health Act must be followed.
An Emergency Room physician complained that a specialist, who felt that a consult request was unnecessary, made several loud and disparaging comments in front of other physicians and staff regarding the physician’s competence. In response, the consultant asserted that the consult request was unnecessary based on the patient’s clinical condition and he felt it was appropriate to point this out. In reviewing this matter, the Committee felt that the consultant’s approach was inappropriate. Regardless of the merits of the issue, any such discussion should occur in a discreet and collegial manner.
An infant was taken to a clinic with a rash. No general examination was done, but topical treatment was prescribed. A few days later, the child was ill and seen by another physician who diagnosed an ear infection, and asserted that this had been present for several days. The mother complained that the initial assessment by the first physician was inadequate. In reviewing the matter, the Committee could find no specific fault with the care provided, but did note the benefits of a more thorough assessment beyond the presenting complaint in a very young child. The Committee also wondered whether it was appropriate for this second physician to state with any certainty that an infection could have been diagnosed a few days earlier.A patient suffered a chainsaw injury to his leg. When an infection developed two weeks later, he alleged that the initial treatment by the Emergency Room physician was inadequate. In response, the physician asserted that the wound had been appropriately cleaned, debrided, and sutured. In reviewing the matter, the Committee noted that, even with appropriate initial treatment, infections can occur. The Committee could find no fault with the care provided.
CONSULTATIONS AND REFERRALS
In response to input by members, Council has approved the following guideline:
The key element in the consultation process is communication. In this context, a physician, upon making a request for a consultation, should provide all reasonable information relevant to the matter. This should address both the urgency of the matter, as well as sufficient background information for the consultant to both assess the matter and later properly assess the patient. This generally would include copies of any reports or other documents relating to the specific situation. A request for consultation can be forwarded by any means. If there is a specific urgency, the documentation should be accompanied by a direct contact, at least with the consultant’s office, to ensure that the material will be received and read in a timely manner.
Upon receipt of the consultation request, the consultant should make every reasonable effort to acknowledge such with the referring physician. Ideally, this will include specific information regarding an eventual appointment, or at least some guidance as to when such will occur. The consultant should also take the opportunity to recommend additional investigations which could be completed by the referring physician prior to the appointment. If a timely appointment is unlikely, the consultant is encouraged to suggest alternative resources which may be more accessible.
After first assessing the patient, the consultant may feel the need for further investigations. Under most circumstances, they should be arranged directly by the consultant, as it is the consultant who will be relying on this information to make recommendations in the patient’s care. There are, however, circumstances where, in discussion with the patient, it may prove easier, from a distance or logistical point of view, for the investigations to be done closer to the patient’s residence. If these arrangements can be expedited by the family physician, such approach is acceptable. In any case, all efforts should be made to avoid any ambiguity as to how arrangements are being made and who will be responsible for the results and interpretation.
Updated guidelines on the use of narcotics in chronic non-malignant pain have been developed by a national committee. They will shortly be published. In order to get a “base line” of current practice, researchers are conducting a brief on-line survey. Physicians who prescribe narcotics are encouraged to participate. Please contact the Registrar at email@example.com to receive the co-ordinates of the survey.
NEW MEMBERS OF COUNCIL
Council welcomed new public members recently appointed by the government. They include Paul Leger of Rothesay, Ruth Lyons of Tide Head and Karla O’Regan of Fredericton. Reappointed for a second term was Dr. Teréz Rétfalvi (PhD) of Moncton.
FROM THE ARCHIVES
One hundred years ago
In 1910, Council decided to mandate that five years of undergraduate studies be required for licensure. They agreed to endorse the new credential from the Medical Council of Canada on the condition that exams would be held in Saint John. Council also determined to reject proposed reciprocity with Québec.
Seventy-five years ago
In 1935, Council discussed whether the LMCC should be sufficient for licensure, passed a resolution against all radio advertising, and noted that an illegal practitioner had served one month in jail for practising medicine without a licence. Council considered whether medical students should be allowed to act as hospital interns. Council reaffirmed that its main role was to “improve conditions for the medical profession in New Brunswick”.
Fifty years ago
In 1960, Council discussed an ongoing dispute with the New Brunswick Medical Society regarding sharing the cost of publishing a Directory, decided they would no longer charge a yearly fee for a physician to be listed as a specialist, and approved increasing the annual fee to $75, of which $12 was for licensing, $43 went to the Medical Society, and $20 went to the Canadian Medical Association.
Twenty-five years ago
In 1985, Council began looking for a full time registrar, decided to start a newsletter, and expressed reluctance at the government proposed amendment to the Medical Act regarding abortions performed outside of a hospital. Council was also troubled by a sudden and unexplained increase in complaints. There were 877 physicians licensed. The annual licensing fee was $200.